Tackling wicked issues in performance management and governance of health prevention: an empirical analysis of vaccination strategies in Italy

Performance management (PM) in the public sector is a research stream that grasped much of the attention of public administration and management scholars in the last decade (Bouckaert & Halligan, 2007; Hall, 2017; Douglas & Ansell, 2020). This is mainly related to the ever-evolving context in which PM regimes apply. Our society and its current challenges are indeed growing in complexity so that these last have been defined by modern literature as “wicked” (Rittel & Weber, 1973; Head & Alford, 2015). Wicked does not mean “evil” but it refers to the impossibility to share an understanding of societal problems and their definition. According to Head & Alford (2015),“wickedness” depends on three key factors i.e., social pluralism, institutional complexity, and scientific uncertainty. The first one is related to the presence of multiple interests and values of stakeholders; institutional complexity refers to the horizontal fragmentation and multilevel governance characterizing the public administration; while scientific uncertainty describes the existence of gaps in reliable knowledge. To deal with wickedness and foster performance, one key solution proposed by the literature refers to the implementation of collaborative arrangements (Cristofoli et al., 2017; Bianchi, 2021). This solution has been proved to be successful in addressing the source of complexity deriving from institutional fragmentation and social pluralism. However, few scholars proposed solutions tackling also scientific uncertainty. Based on this gap, the article aims at exploring the contribution that simulation, and in particular System Dynamics (SD), may provide to performance management in wicked public contexts.SD is a methodological approach that allows analysts to model and simulate complex systems and to experiment with the models to design strategies for management and change (Forrester, 1958).The adoption of SD to tackle wicked problems finds its foundation in the methodological opportunity to explore with simulation and engage with stakeholders, thus providing more robust decision support to inter-institutional settings through the so-called Dynamic Performance Management (DPM) approach (Bianchi, 2016). As such, SD allows analysts to adopt a holistic perspective to frame social pluralism, institutional complexity and scientific uncertainty as the key factors characterizing wicked contexts and, as a result, to support collaborative PM systems fostering a shared understanding of their operating principles and processes. To explore and analyse the suggested solution, the research focuses on health prevention. Recently, health prevention is being considered fundamental in tackling the COVID-19 emergency. In particular, the process of planning and implementing vaccination campaigns in western Countries represents one of the most challenging wicked problems in the current era. In vaccination activities, we can find the three sources of wickedness. First, vaccination campaigns embrace multiple interests and values (social pluralism),e.g., this pandemic created trade-offs between public health and the competitiveness of economic activities due to lockdowns and restrictions. The prioritization of population targets, for instance, has specific impacts on the restart of productive activities. Second, health prevention services are provided through the collaboration of multiple public and private organizations (institutional complexity),e.g., vaccinations activities are delivered through the collaboration of supranational institutions (i.e. European Commission), regulatory agencies (i.e. FDA, EMA, national regulation agencies), national and regional governments, local health authorities, hospitals, private health providers, general practitioners, national armies, pharmaceutical companies, etc. Last, health prevention results are usually 5 obtained in the long term and it is not possible to univocally attribute these results to activities executed in the past (scientific uncertainty).Thus, it appears almost impossible to assess ex-ante the effectiveness of certain measures (i.e. vaccination strategy) as it depends on the behavior of the other actors involved (virus–and its variants –included).Therefore, policymakers and managers in the public healthcare sector can find more effective decision support by applying systemic approaches and simulation techniques for improving inter-institutional coordination, collaborative governance and performance. For the above purpose, the research process begins with the review of the literature on wicked problems and performance management in the public sector. This review is combined with an analysis of SD modelling principles aimed at explaining the practical and theoretical contribution of this approach to deal with social pluralism, institutional complexity and scientific uncertainty. Building on this literature review, the paper proposes and illustrates the DPM approach (Bianchi, 2016, 2021) as a systemic method to performance management and governance in wicked contexts. Then, the approach is tested on two case studies exploring the vaccination campaign in two different Italian regional health systems selected based on their performances and characteristics. The cases are developed through the collection of empirical data, active engagement and discussion with the experts involved. In the last section of the paper, the case study results enable us to discuss the main advantages and limitations of the proposed approach in comparison with the gaps found in the literature. Eventually, the paper outlines critical implications for theory and practice and concludes with future research perspectives.