"Issues of public governance in the Italian Local Health Care Authorities: empirical evidences from the management actors' perceptions"

The etymological origins of the term “governance” derived from the Latin “gubernare” that referred to the ancient skippers and was then linked to the art of steering and governing. As the literature has not identified a common agreement on the boundaries of this concept (see Van Kersbergen and Van Waarden, 2004, Kooiman, 1993), the public governance remains a blurred model whose concrete or empirical application gives rise to new concepts and criticalities. In the Anglo-Saxon literature “governance” is associated to legitimacy (governance as a set of institutional issues) and accountability (governance as the responsibility of an organization to tackle and satisfy public needs, see also Stocker, 1998). Furthermore, Rhodes (from 1992 to 2000) recognizes a tricky passage “from government to governance”. He reads the governance as the delegation of public power and functions upwards (to international institutions) and downwards to local and regional governments. In the Italian literature, that passage is discussed by Borgonovi (2002) with reference to the exercise of public authority in services choices. Specifically, according to the government model, the decision-making comes from a legitimized public authority with a top-down approach, while in the governance model the same public authority renounces to this compulsory intervention in favour of a bottom-up consensus approach to the decision-making. The described passage “from government to governance” is subtly connected to the theory of rationality both from an organizational (March and Simon, 1958) and an economics perspective (Williamson, 1975). The divide between “absolute” and “bounded” rationality and between the “economic” and the “administrative” man is implied in the comparison between government and governance but it does not run dry the possibility of a third form of rationality (Grandori, 2000): the “programmed” man who obeys to norms and rules, he applies a logic of appropriate action, constrained by the past experience of self and others (March, 1994, Wrong, 1961, Hofstede, 1991, Ouchi, 1977). For these reason, Huse (2003, p. 211) stresses that «governance is not only control, incentive and ownership structure. It is also the allocation of decision rights, as well as normative and value based control». Furthermore, Frederickson (2005, p. 8) points out that «it is difficult to conceive of anything involving government, politics or administration that is not governance». Following the important public sector reforms of the Nineties, the Italian literature has recently focussed the attention on the difference between New Public Management and public governance, where the first one is interested in the micro perspective of Public Administration functioning conditions while the latter concept is tied to the capacity of managing and steering systems of public and private actors (Cepiku, 2008). Trying to synthesize the different literature perspectives on governance, Cepiku (2008) sketches a common framework that implies, at the micro level (each public administration), an outward-oriented public management and a problem-solving role of the public administration itself with the involvement of its stakeholders’ capacities. Some of the questions tied to the corporate governance issues in the public sector regard the mechanisms and conditions that contribute or guarantee the institutional functions of the public administrations, thus to be governed and managed in the public interest. Obviously, in the public sector it is impossible to neglect the role played by the institutional set of rules and organizational structure because of their intertwined linkages with the political discretion and the power balance. The evolution towards the autonomy of many public administrations (like the Local Health Care Authorities) represented both the result and the cause of a weakening role of the institutional sets. The autonomy is a fundamental pre-requisite to strengthen the responsibility mechanisms but it also imposes a bigger “accountability” weight to the individual public administrations than the traditional one. The autonomy weakens the mechanisms of the political accountability, for instance the sole LHCA General Director is nowadays chosen by the political organs of the Region. In this context, the economical rationality becomes one of the most significant and “neutral” logic of action and decision making (Del Vecchio, 2001). The power shift from the political organs to the administrative ones has enlightened the role and responsibilities of the public top-management. The complexity of a public administration is evident from its sensitivity to the multiple stakeholders’ interests that insist and affect its sources of legitimacy and modes of functioning. In this new perspective, the space for the redefinition of the relationship between political and managerial issues becomes conceptually identifiable but the central issue shifts on the tools, mechanisms and conditions that allow the operative fulfilment of that space. Stick (1999, pp. 12-13) argues: «one area of concern is the link between “letting” and “making” managers manage. It is much easier to fulfil the first part of the bargain than the second, It is much easier to remove control than to enforce accountability. In fact, accountability frameworks – the specification of targets, reporting on results, and audit of performance – still are relatively undeveloped». The recent Italian health care reforms have emphasized the role of the management and the responsibility sense-making appeared as a governance tools in couple with the adoption of some managerial tools. Nevertheless the real governance issue is “how does the health care management perceive its renewed role?” and “how does the management use the managerial tools?”. The present work aims at tightening up and focusing the concept of public governance among the Local Health Care Authorities (LHCAs) of an Italian Region, through the perception of their internal governance actors . The paper is structured in the following sections: the first section will try to shed light upon the concept of public governance for the Italian LHCAs and it will focus on the slight equilibrium between political and managerial issues to emphasize the role of the strategy definition. The second section will summarize the evolution of the Italian Health Care system and on the specific choices of the Emilia Romagna Region. The third section will discuss the empirical research design and the following 4, 5 and 6 sections will display the main results as read by each of the governance actors involved. The final section will purpose a more specific definition of public governance in light of the empirical evidences.