Integrating beyond hierarchy: managerial practices of health and social district directors in Italy through a Mintzbergian lens

Background: The health and social district (Distretto Socio-Sanitario – DSS) has gained renewed strategic importance in Italy following the Ministerial Decree 77/2022 and the Mission 6 of the National Recovery and Resilience Plan (Piano Nazionale di Ripresa e Resilienza – PNRR). The decree redefines the organisation of territorial care, promoting integration between health and social services through new territorial settings and operational solutions.

These changes challenge the traditional division of responsibilities within the Local Health Authorities (LHAs) and call for renewed managerial and institutional coordination at the district level. Within this transformation, district directors play a pivotal role as integrators and boundary spanners, connecting services, professionals, and institutions.

 

Approach: The study investigates how health and social district directors interpret and enact their managerial role in this reform context, where - unlike other managerial positions - they rarely hold direct hierarchical levers. Adopting Mintzberg’s classic framework on managerial work, the research analyses the weekly agendas of 16 district directors from various Italian regions. Activities were classified according to Mintzberg’s managerial roles into interpersonal, informational, and decisional role. Each agenda was independently coded by three researchers to ensure interpretative consistency.

Quantitative analysis was complemented by a validation workshop with participating directors. Stakeholder involvement was central to the research design: district directors actively contributed by testing the agenda-collection tools, validating findings, and reflecting on implications – making the research both analytical and participatory.

 

Results: District directors work an average of 44 hours per week. Their work is characterised by fragmented, fast-paced, and interaction-intensive activities – consistent with Mintzberg’s description of managerial work. Approximately 38% of their time is devoted to informational roles, 36% to decisional, and 23% to interpersonal ones.

 

However, when analysing the ultimate purpose of their actions, decisional roles (especially resource allocation, 34%) dominate, suggesting that communication and information-gathering activities primarily serve decision-making needs. Directors act as both internal and external brokers: 46% of interactions involve internal stakeholders, 26% external ones (such as municipalities and third-sector organisations), and 28% mixed groups. This dual interface reinforces the DSS’s strategic role as an institutional bridge between the LHA and the community. Differences across regions and professional backgrounds reflect diverse interpretation of this integrative function.

 

Implications: The study sheds light on the evolving identity of district management in the Italian healthcare system. The findings illustrate how district directors enact a non-hierarchical form of leadership that relies on negotiation, facilitation, and connection rather than command. Their role epitomises territorial governance, balancing operational management with institutional representation and community interface.

 

Heavy workload and fragmented routines risk constraining strategic vision; nonetheless, training and peer-learning initiatives—increasingly frequent in their agendas—serve as crucial tools for capability building and mutual support. Strengthening organisational backing and recognising the integrative, non-hierarchical nature of their work are essential to fully realise the goals of the DM77/22 reform. Ultimately, district directors embody a key lesson for integrated care: effective integration depends less on formal authority and more on the ability to connect people, services, and institutions across boundaries.