Comparative public policy research has traditionally focused on cross-national policy variation. Over the past two decades, research interest on cross-regional policy variation within decentralized state has also expanded. However, while the former scholar effort looked into the explanatory factors of policy variation, the latter gathered evidence for the impact of policy variation on territorial equity. This paper proposal applies the research interest for explanatory factors to the analysis of cross-regional policy variation. It analyzes how decision-making by sub-central governments in Spain, within a similar institutional setting, leads to different policy outcomes in the same policy sector –namely, public management in the health sector. The case studies include the analysis of the health management policy trajectory in Andalusia and in Catalonia. Both regions have consistently pursued different health management models since the early 80’s, but the study focuses on the past decade, when important external shocks posed new challenges and created a new scenario for policymaking. Our hypotheses compel us to give a special attention to both ideological and economic factors, as well as to the particular quasi-federal institutional dynamics in Spain, and integrate them in the process explanation.

We place the study of public management reform under new institutionalism. This line of research has widely shared an  interest about the politics of public management, which has translated into different research issues, such as cross-national patterns in the content of reform policies and the role of particular factors in explaining policy variation. A commonplace argument is that cultural and institutional aspects, such as administrative traditions or institutional design, explain the fate of reform initiatives and, therefore, of policy outcomes. However, scholars have recently reflected on the explanatory pitfall involved in assuming a causality link between institutional factors and policy outcomes just because they appear repeatedly associated. They argue that such missing explanation link needs to rely on evidence from policy variables (Radaelli, Dente, Dossi 2012). This paper pursues this explanatory interest, with a shift to cross-regional policy variation, and from an integrative institutional approach elaborated by Barzelay and Gallego (2006) under the label of “Institutional Processualism”, and which has developed through analytical and empirical studies over the past decade. Explanation of policy change integrates agency, structural and contextual factors into an event-causation approach.