Embedding sustainableeffectiveness in decisionmaking within an ecosystem: Lessons from the health technology assessment program at the Lombardy Region, Italy

Purpose - Healthcare policy-makers are implementing practices based on the logic of cost-opportunity to rationalize investments and resource consumption. The successful implementation of these practices depends on policy-makers’ capacity to involve professionals dispersed in the ecosystem, and who are unaccustomed to cooperating. Our case studyinvestigates the institutional work pursued by the Lombardy Region to stimulate a Health Technology Assessment (HTA) program. Design/methodology/approach - This chapter is based on a longitudinal case study of institutional change linked with a HTA program in the Lombardy Region. The HTA program initiatives were implemented during the 20092012 period. The case study is based on triangulating data from archival data, contents of the assessment forms and interviews with regional staff and experts. Findings - The Lombardy Region implemented two distinct strategies, with mixed results. A strategy that was based on the formalization of the HTA program in a legislative direct through educational efforts did not obtain the commitment of the key actors in the relevant ecosystem. Subsequently, the Region implemented an ‘institutional work’ design strategy that included a combination of political, cultural, technical and structural work. This strategy stimulated local HTA experiments that might be used in the future to legitimize the full diffusion of the new practice in the ecosystem. Originality/value- This study highlights a viable strategy of change that policy-makers can use to manage processes of institutional change in a professional ecosystem. The ‘institutional work’ strategy can support the establishment of new practices that incorporate the logic of costopportunity, which might rationalize the use of resources and improve investment decisions.