Are public health authorities able to "steer" rather than "row"? An empirical analysis in the Italian National Health Service.

The nature of the local health authorities (LHAs) in the Italian National Health Service has been deeply reformed during the 1990s by new public management (NPM) reforms that introduced decentralization, quasi-market and managerialism. These reforms implied that the main role of LHA is to govern the production of health services in their area (steer) rather than to only directly produce services (row). After more than 15 years from these reforms of Italian healthcare, we describe how much the steering versus rowing dichotomy made an impact on LHA activity, through an analysis of the management control systems they set up for themselves and the subsequent qualitative analysis of the opinions that a diverse group of managers expressed during 8 days of group discussion. Results show that managers of Italian LHAs, when only a small part of services is produced, tend to perceive their steering role as impossible to play and focus on production, leaving therefore ungoverned a significant part of the services offered to residents. NPM, therefore, was able to influence the reform of Italian healthcare but, as suggested by a postmodernist interpretation, left managers with a rhetoric change based on inconsistent assumptions instead of actionable ideas to manage the change process.