Variables of performance governance model development: evidence from the Italian public healthcare

• Date: 15 July 2024
• Pages: 768-788
• DOI: https://doi.org/10.1108/IJPSM-12-2023-0354
• Published date: 15 July 2024
• Subject Matter: Public policy & environmental management,Politics,Public adminstration & management
• Author: Fabio De Matteis,Elio Borgonovi

Variables of performance

governance model development:

evidence from the Italian

public healthcare

Fabio De Matteis

University of Bari, Bari, Italy, and

Elio Borgonovi

Bocconi University, Milano, Italy

Abstract

Purpose –The performance governance model, based on the use of performance information to improve

governance, is particularly complex, considering the inter-institutional relationships and com munity

involvement that it requires. In order to contribute to the scientific debate on this model, the paper aims to

highlight what are the challenges in developing three variables of performance governance (operational

performance measurement tools, governance integration and citizen involvement) in the public health context.

Design/methodology/approach –Based on the previous literature, we identified three variables that

characterize the performance governance model. We then exploredthem through the case study methodology

applied to the Apulia Regional Health System.

Findings –The analysis allows us to conclude that the healthcare system under consideration is still far from

applying the performance governance model, but it highlights some factors that are preparatory to the same.

Moreover, starting from the empirical evidence, some considerations arise regarding managerial and policy

making implications for the variables investigated.

Originality/value–The paper contributes to a growingbody of critical literature on performance governance

contextualizing the analysis in a particularly relevant area of the public sector, namely public health.

Furthermore, the research also identifies some potential risks of the performance governance model (rigidity in

performance measurement tool, organization-objective-responsibility relationship, participatory illusion).

Keywords Performance governance, Public healthcare, Case study

Paper type Research paper

1. Introduction

According to Bouckaert and Halligan (2007), the concept of performance governance is based

on the possibility of using performance information for broader purposes related to

supporting the governance of an organization. Specifically, the intuition is to employ

quantitative or qualitative health performance information about health care workers (Rowe

et al., 2018;Agarwal et al., 2019) and their organizations in order to inform, define and develop

health system governance policies that address perceived needs and problems (Tenbensel

and Burau, 2017). This approach jointly considers performance and governance elements.

The topic of performance is broad especially in the healthcare sector, which is

characterized by relevant social and economic implications. It is a much debated topic by

scholars (among others: De Bruijn, 2007;Poister, 2010;Van Dooren et al., 2015;Borgonovi

et al., 2018a;Vainieri et al., 2020;French and Mollinger-Sahba, 2021;Noto et al., 2023). They

have highlighted numerous aspects of the concept of performance that denote its breadth: e.g.

multidimensionality, the number of actors involved that links performance to the notion of co-

production, the support of performance measurement to both quality improvement and

decision-making and accountability processes.

IJPSM

37,6

768

The current issue and full text archive of this journal is available on Emerald Insight at:

https://www.emerald.com/insight/0951-3558.htm

Received 5 December 2023

Revised 11 February 2024

6 April 2024

20 May 2024

Accepted 14 June 2024

International Journal of Public

Sector Management

Vol. 37 No. 6, 2024

pp. 768-788

© Emerald Publishing Limited

0951-3558

DOI 10.1108/IJPSM-12-2023-0354

Similarly, the concept of governance has also found a place in the literature that has hi ghlighted

its relevance and complexity (among others: Bevir et al., 2003;Martinsen and Vrangbaek, 2008,

Casady et al., 2020;Sharma et al., 2021), emphasizing the expansion of the perimeter of governance

towards inter-organizational linkages (Osborne, 2006;Ramadass et al., 2018).

Consequently, the model of performance governance (Bouckaert and Halligan, 2007)-

which combines the two concepts above mentioned - is equally complex and has seen the

production of scientific insights developed, essentially, over the last decade.

In order to contribute to the scientific debate on this model, this paper aims to highlight

how the three variables of the model (operational performance measurement tools,

governance integration and citizen involvement) - arising from the literature analysis - can

be developed in a specific context represented by public health. They are the operational tools

for measuring performance, the integration of governance and the involvement of citizens.

The case study methodology is used, choosing institutions of the Apulian health system for

each of the variables investigated and analyzing them in order to pursue the previously

stated objective. This methodology is particularly suitable in situations such as the one

considered in this paper, characterized by the large number of variables and a high degree of

conditioning by the reference context (Yin, 2009).

The paper is structured as follows. The next section, through the analysis of the literature,

frames the salient aspects of the model by identifying the three elements that characterize it

and coming to define the research question. The third section exposes the research

methodology, while the fourth section contains the analysis and the discussion of the selected

institutions. The fifth paragraph includes the managerial and policy making implications of

the analysis and, finally, in the sixth paragraph some concluding reflections are highlighted

together with some indications for further research.

2. Literature review and research question

In the past, public sector reforms were, above all, characterized by interventions on political

or legal rules. It is only in recent decades that they have increasingly been taking on a

managerial character, becoming the subject of study by management scholars (Hood, 1995).

The evolutionaryprocesses of public administrationin various countries have manifested

themselves through public sector reform interventions that have followed certain common

guidelines, including those of developing forms of decentralization of responsibilities,

operational flexibility, performance orientation and productivity development (Pollitt and

Bouckaert, 2002). In particular, modern reform processes have concerned the so-called New

Public Management (NPM) that has led to a push towards a focus on results and, more

generally, on the performance of public organizations (Palermo etal., 2010). Subsequently, the

post-NPMapproach led to an evolutionof public administrationtowards a focuson the impacts

of its activities and, at the same time, on the inter-organizational relations preparatory to

achieving those impacts. Hence the development of the concept of collaborative performance

(Cepiku, 2021). More recently, the emphasis is being placed on the value created for the

community through the delivery ofpublic services: a process of evolution is developingin the

public service delivery process involving the community. This implies the participation of

citizens with a viewto co-production and co-creation (Amorim Lopes and Alves, 2020).

In the light of these trajectories of public administration evolution, the main scientific

contributions on performance governance are analyzed below.

2.1 Performance

A fundamental role of public sector reform processes is represented by the search for better

performance, especially in the health sector, considering both the social relevance and the

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