The complexities of negotiating governance change: introducing managerialism in Italy

Since the beginning of the 1990s, health policy in Italy has been characterised by continuous reform as reflected by the frequency of new measures. Importantly, the reforms have changed considerably many aspects of the health-care system, including the governance of medical performance. The new measures fall into two types: regionalisation and transformation of local providers into ‘health-care enterprises’. In relation to the governance of medical performance, more specifically, the reforms have entailed the introduction of budgeting and quality assurance, the creation of new managerial roles, and the transformation of existing roles, as well as the introduction of new mechanisms for evaluating medical performance. In terms of the specific forms of governance, the reforms have reinforced hierarchy-based forms of governing intermeshed with party governance, and have re-defined professional selfregulation by strengthening collective forms of professional self-regulation. The design and implementation of the reforms are subject to a complex process of negotiation, which involves a wide range of actors spread across different levels of governance and takes place in relation to all aspects of the governance of medical performance.