The relevance of non-institutional practice in health care steering at local level in Italy.What has been learnt in pandemic times?

The Covid-19 pandemic has been a stress-test on Health Care Systems across Europe, but particularly in Italy, that has been the first European country hit by the outbreak in 2020. This fact triggered the need for learning a management of the crisis because of the lack of resources, the long-time policy of spending cuts and a shortage of doctors and nurses, specifically due to a short-sighted education policy over a long time. Territorial health services suffered a lack of investment more than hospitals. That's why primary has been completely unable to cope with the outbreak. Front-line actors (doctors, managers and local authorities) were consequently called for managing emergency by inventing extemporaneous solutions in steering capacity and instrument selection. Several scientific contributions have recently explained the pandemic outbreak in Italy looking at the national governance of the health system and its specific institutional framework that decentralizes tasks and functions to the Regions, also with a certain degree of managerial autonomy for local authorities. It means that the most part of the capacity of steering and coordinating the emergency was transferred to local level and to the capabilities of the street level bureaucrats. Indeed, although the National Health system had a National Pandemic Plan since 2006 (while only some Regions enacted a regional one since 2009-2010), pandemic strategies both at clinical and at managerial level were completely missing. When territorial health services, including hospitals, were hit by the first wave in March 2020, they were lacking tools, staffs and knowledge, but were simultaneously forced to steer (alone and quickly) an ‘ad hoc’ governance of emergency by adopting new plans and new instruments. Then, when the second wave came in November 2020, the local capacity to cope with the emergency was improved thanks to the practice learnt during the first one. It means that beyond the institutional frame, the local level achieved a capacity of steering grounded on the informal practice made of tacit knowledge, shared competence and networking. These practices allowed the operators to go over the crisis and were gradually institutionalized around different contexts. The paper focuses on the strategies in steering the pandemic the front-liners adopted to face the crisis through the adoption of new choices and instruments. The contribution is aimed at putting in evidence the pivotal role of shared innovative practices of coordination among doctors, managers and councillors to face in the national system and to assess to what extent it has allowed a policy learning in the Health system in Italy. Empirical evidence is provided from a comparison between two case studies corresponding to two different health districts (Pesaro and Florence), respectively stressed by the first and the second wave of the pandemic. Evidence will be provided by document analysis and through a set of in-depth interviews to practitioners: managers of hospitals, territorial coordinators, doctors and local councillors. The paper will provide evidence on the conditions in which these actors were obliged to operate and it will try to account decisions they made: their cognitive perspective will be assumed as a potential explanation of the choices of instruments, the allocation of resources and the strategies to cope with an innovative and successful territorial governance.