This article investigates how regional health systems in Italy have responded to the COVID -19 pandemic. In particular, we explore the extent to which the strategies adopted by the four most affected regions – namely Lombardy, Veneto, Emilia-Romagna and Piedmont – have been similar or dissimilar. While the prevailing media narrative has emphasized the differences between two (opposing) organizational models established in Lombardy and Veneto, little attention has been paid to the
policy actions undertaken in Piedmont and Emilia-Romagna. By focusing on the first three months of the emergency, we show that the (pre-)existing organizational characteristics of the regional health systems have been crucial in determining the adoption of different response strategies along three dimensions: containment measures for outbreaks control, hospital and community-based care, and diagnostic testing.