The Consequences of Performance Measurement Systems in Multilevel Governance Health Systems: The Case of the Italian National Healthcare Service

Background: Performance measurement systems (PMSs) have become an essential component of health system reforms globally and are increasingly used to assess, reward and improve provider performance. While PMSs can be valuable tools for achieving desired health outcomes, their effectiveness depends on how they are designed, implemented, and used within complex multilevel governance structures. There is evidence that PMSs may also have unintended negative consequences. Drawing on new empirical evidence, the present study examines the consequences of PMSs implemented in multi-level governance systems through the analysis of the Italian National Healthcare Service (INHS), which exemplifies a decentralised health system with multiple levels of governance. Methods: The study employed a mixed methods approach combining quantitative and qualitative methods to examine the functional and dysfunctional consequences of PMSs in the INHS across three governance levels: (i) State-Regions, (ii) Regions-healthcare organisations, and (iii) Healthcare organisations-healthcare professionals. Results: We identified three key functional consequences. First, PMSs drive improvement by facilitating benchmarking, advocacy, and collaboration. Second, quantifying activities and services improves objectivity and transparency. Third, national PMSs provide a comprehensive view of performance across multiple dimensions and provide a more holistic understanding of how different aspects of the system interact. We confirmed previously reported dysfunctional consequences of PMSs found in other health systems and identified three new dysfunctional consequences in the INHS: Measurement Overload, Misconsideration, and Exploitation. Conclusion: Based on our analysis and existing literature, we propose ten key factors for strengthening performance measurement in the INHS. While this study offers novel evidence on the functional and dysfunctional consequences of PMSs in the Italian system, our research is context-specific, and the applicability of these factors to other multi-level health systems remains an area for future empirical testing.