The Chapter analyses the external audit readiness process (Percorsi di Certificabilità, PAC) of Italian Local Health Authorities (LHAs), providing an up-to-date overview of their diffusion and implementation, and analyzing the strategic and/or managerial approaches developed by Italian regions. PACs were part of a wider accounting harmonization process, which involved Italian Public Administrations (D.lgs 118/2014) and required a uniform classification of the reports and accounting principles at Central, Regional and Local level, so to have comparable and clear documents. In this perspective, PAC were oriented toward achieving more transparent information system and an efficient internal control and external audit for public accounting. A deep desk analysis of normative and official documents was conducted for providing an overview of the current state of the art of the PACs’ diffusion. Then, authors conducted a comparative analysis among regional models, also with an in-depth case studies analysis on three selected Regions. According to ministerial decrees (D.M. September 17, 2012 and D.M. March 1, 2013), all Regions (with the exception of PA Trento, Val d’Aosta and Friuli-Venezia Giulia) started the PAC’s process between 2013 and 2017, also introducing various local adjustments. Regional PACs turn out to be heterogeneous in terms of accountability and governance of the process; the integration with information system or other internal control and external audit systems; the development of Regional Guidelines or Manuals, dedicated training path, and local pilot projects. The study provides evidence for two different Regional approaches: some Regions adopted a technical approach, focusing on accounting principles and administrative procedures. Others focused on organizational principles and development of a managerial culture, according to a strategic approach. The Regional case studies (Lazio, Liguria and Umbria) point out a different attitude between the Regional and LHAs’ level towards the PAC’s process. Regions can play a lead role in accordance with a top-down management strategy (if aiming at increasing LHA orientation towards more accountability and transparency). Conversely, Regions played a direction and coordination role, encouraging a bottom-down process and giving at LHAs the responsibility to monitor and entirely manage the process.