The governance of the Italian health system is complex and ambiguous, as market and politics are strictly intertwined. The article deals with the conflicting logics of action which characterise the decision-making processes in the public health sector. Four logics are identified: bureaucratic, professional, of efficiency and political. These logics of action represent incompatible criteria the decision-makers must be accountable to. The health managers are forced to find out solutions which all the actors involved approve, and in leading the negotiation they act as politicians. The reputation and the fiduciary dynamics play an important role in the social care market. These conclusions are drawn through the exploration of an empirical case: a public tender for the supply of social services.