Table 4 Differences between Veneto and Tuscany Model about Provan & Kenis Trade offs

Efficiency vs. Inclusiveness

The new provincial-level LHOs have enhanced institutional inclusiveness through a better definition of the network structure and a better identification of the role played by each node.

The shift of some functions from the network to Azienda Zero has had the positive effect of increasing the efficiency of the network by unburdening it from non-mission related tasks, even though an initial sense of expropriation may have occurred.

The merger reform extensively reduced the number of LHOs and the need for lower level coordination, simplifying the decision-making process. However, broad inclusiveness has disadvantages in terms of decision-making processes and efficiency because of the risks of bureaucratization.

The coordination of nodes inside new sub-regional LHOs previously under the network responsibility passed on to the LHOs (network of networks).

Internal vs. External Legitimacy

The LHOs’ merger had not altered previous competition patterns among nodes, which maintain distinct roles in the network. Most of the competition is still played out among UHOs. The roles of the lead organization and the network broker have not changed after healthcare system reforms and remain fundamental for the network’s internal and external legitimacy.

The merger determined a more homogeneous distribution of power among participant organizations and increased the level of competition. Most of the competition is perceived to operate between an LHO and its respective UHO. The role of the network broker tends to be identified with regional authority. This has become more evident after the merger of LHOs and the lengthening of the chain of command.

Flexibility vs. Stability

A lower degree of formalization of the network, coherent with the LO form of governance, made it possible to absorb the impact of external changes without any detectable modification to the network’s structure. The flexibility of an LO can be in part explained by the specific role of a lead organization (opposite to NAO forms) in determining the responsivity of the network against external change and the use of informal mechanisms.

Tuscany has gradually strengthened the formal structure of the network to improve its sustainability.

The system replicated the same governance structure despite increased size and weight of the members, changing the balance of the power in the network.