This article was developed based on testimonies from CEOs Livio Tranchida (CEO of Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino), Ida Ramponi (CEO of ASST Valtellina e Alto Lario), Vincenzo Petronella and Teresa Foini (CEO and Administrative Director of Fondazione IRCCS Policlinico San Matteo in Pavia), shared during the Master in Management della Sanità (MiMS) at SDA Bocconi School of Management.
Over the past thirty years, the healthcare system has changed more rapidly than the categories we continue to use to describe and govern it.
Healthcare organizations are often interpreted as complex administrative apparatuses; in reality, they operate as hybrid organizations with high professional, institutional, and technological intensity.
The gap between their actual nature and their conceptual representation is not a theoretical issue. It is one of the reasons why governing these organizations is becoming increasingly difficult.
A real-life episode makes this clear. A department head of international renown, trained in a major public hospital, receives an offer from a leading private institution: organizational autonomy, academic recognition, and working conditions that are difficult to replicate in the public sector.
In the public sector, there are no comparable financial levers. Yet the CEO does not simply accept an inevitable loss. The conversation he initiates is not about salary or benefits, but about the professional path that has been built, the conditions for working at one’s best, and responsibility toward the team. The professional decides to stay.
This is not an episode of individual negotiation. It is an example of a deep understanding of how a professional organization functions. And it is from here that one can begin to reflect on what it means, today, to govern healthcare.
Where hierarchy is not enough
Organizational theory describes hospitals as professional bureaucracies, systems in which coordination relies more on professional autonomy than on hierarchy. In these contexts, formal position does not automatically guarantee the ability to shape behavior. Alignment is not produced by decree, but through coherence of objectives, clarity of responsibilities, and quality of relationships. In a professional organization, coordination is a relational process before it is a hierarchical one.
For those training today in healthcare management, this is a decisive point: power does not coincide with position, but with the ability to generate systemic coherence.
The problem is not only resources
Public debate tends to interpret healthcare challenges as almost exclusively the result of resource scarcity. Scarcity is a structural fact, but it does not exhaust the problem.
The issue is not to balance the books ex post, but to design organizations that make them sustainable ex ante.
Performance depends on the alignment between strategy, organizational design, and accountability systems. Incoherent configurations produce inefficiency even when resources are adequate; coherent configurations generate value with given resources. Governing healthcare today requires design capability: intervening in the structure of processes, not merely overseeing the budget.
What excellence in healthcare really means
International evidence shows that, for many high-complexity activities, quality and outcomes improve with the concentration and integration of care pathways. Fragmentation does not produce excellence; it weakens it. Duplication without critical mass, non-integrated technologies, and overlapping responsibilities rigidify the system and increase risk. Excellence does not coincide with expanding supply, but with coherence between institutional mandate, organizational configuration, and the needs of the population served.
Organizational decisions directly affect how care is delivered.
Governing within an institutional ecosystem
Healthcare organizations do not operate as isolated entities, but as nodes within an ecosystem where care, prevention, research, and territorial governance intersect. Integration is not a formal feature; it is a structural condition of the system. The balance between missions and levels of governance requires continuous institutional mediation.
Management operates within a public mandate and engages with a plurality of legitimate stakeholders. Governing means maintaining coherence between technical objectives and institutional responsibilities, preserving margins of autonomy compatible with the overall design of the system.
In this sense, it is a form of health policy: not the pursuit of immediate consensus, but the construction of integration over time.
The system is changing. Those who govern it must change first.
The epidemiological transition calls for integrated models and the overcoming of silos. Technological innovation redefines roles and decision-making processes. Economic sustainability makes every allocation choice also an ethical decision.
In this context, tensions emerge that cannot be resolved solely through recruitment policies.
Reorganizing healthcare does not mean increasing resources or structures, but rethinking operating models in light of profoundly changed needs.
A matter of responsibility
The new generations now training in healthcare management will encounter a system marked by structural constraints and rising expectations. A system that cannot be governed by decree—nor by clinical or economic expertise alone. It is governed by understanding its professional, organizational, and institutional interdependencies, and by developing the ability to read from within the dynamics that shape decisions.
This systemic competence does not concern only those who aspire to lead a public organization: it is essential for anyone working in healthcare—whether in the private sector, industry, consulting, or policymaking—because everywhere decisions must contend with the same complexity.
By promoting debates such as the one that inspired this article, the Master in Healthcare Management (MiMS) at SDA Bocconi moves beyond a purely specialist approach and proposes an intentional educational design that exposes students to real complexity from the outset.
Direct engagement with those who, by profession, exercise systemic competence on a daily basis—CEOs and senior executives—makes decision-making processes, ambivalences, mediations, and priority-setting visible. Students learn not only what decisions are made, but how decisions are made within a complex system.
Exposure to a plurality of clinical, economic, institutional, and organizational perspectives, within a coherent educational framework, becomes a training ground for integration. This is how one learns to look at complexity—made up of constraints, tensions, and ambivalences—with perspective.
