Clinical governance of healthcare and community services by healthcare organizations requires the use of validated tools for identifying the specific healthcare needs of the local population. The population served by a local health organization may be large and although data regarding this population as a whole is useful for a preliminary evaluation, it may be too generic for an accurate estimation of the healthcare needs at the district level since different districts may face different challenges and have profoundly different realities. In this context, it can be strategically useful to use a system of indicators targeted at districts, the latter regarded as the basic unit of the health care system and characterized by a relatively constant structure and size.A set of district indicators has been developed and adopted by a local health authority in Rome (Italy) "ASL Roma B", as part of a collaborative project with the Public Health Agency of the Lazio region. In this paper, we present the main results of the first four years of implementation of the system (from 2007 to 2010).The data shows that even within a metropolitan health organization serving an apparently homogeneous population, health needs, provision of services and outcomes may vary greatly between different districts suggesting the adoption of diverse operational strategies.