Not just managers: this is why general managers of health care are called upon to play increasingly political roles

The relationship between politics and management is a theme at least as old as democracy and studied by different disciplines, from jurisprudence to sociology, passing through political, organisational and managerial studies. The device that has caught the attention more than others within this debate is the system of selection of top management, between spoils or merit system logics. As if, once the rules of access to top management roles had been resolved, the question of how the relationship between politics and management works could be exhausted. But this is not the case. Proof of this can be found in public health and in the work of the general managers of health companies, as emerged from a recent research carried out as part of the SDA Bocconi's DASP Network (Directors of Public Health Companies) dedicated to members of the strategic top management of public health companies.

The reforms that have followed one another over the last twenty years have progressively regulated the professional and managerial requirements for access to the role of director general, introducing regional and national registers, thus tightening - as a result - the space for political choice. Yet, as documented by the DASP Network, the term of office of the DGs has not increased (about 3.5 years) and careers - despite the introduction of a national register - are increasingly local. Perhaps too much is expected from the appointment systems of directors-general and too little from the skills of public managers, who are called upon to build a solid alliance of trust with a policy that - regardless of reforms - is changing its practices.

We asked a panel of health DGs with at least 10 years in the role how the relationship between management and politics has changed in recent years and what enables this relationship to work. The outcomes are less obvious than one would expect.

Of course, politics has changed: the structures for organising consensus have progressively dispersed and, today, the fact that the president of a region and the mayor of an area are from the same political party is no longer a guarantee of alignment of intentions between the centre and the periphery. With the consequence - for the CEO who, for example, has to close an inefficient and unsafe birthplace - of struggling to find the political backing for a difficult management choice. Thus, the company itself becomes the instrument for building local consensus and those who lead it interpret it. But, say the DGs interviewed, what has changed above all are the demands that society makes of public institutions, which politics is called upon to interpret and public management to transform into services: the management of Covid has brought new health needs to the forefront of public debate. This has resulted in a renewed political focus on an area, that of health, which for years was dominated by technical rationality. This is neither good nor bad news. It is a fact of how democracy works today. How, then, does the work of the DG change in this renewed scenario?

Three key points emerged from the research. Firstly, the work of the CEO is increasingly also a job of building the conditions for political sustainability of management choices, not only in the halls of power, but also in the territory and in relations with stakeholders.