Inside the Autonomous State: Programmatic Elites in the Reform of French Health Policy

Genieys, William; Smyrl, Marc

doi:10.1111/j.1468-0491.2007.00386.x

Cited by 39 publications

(33 citation statements)

References 12 publications

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“…The French welfare elite and other high‐ranking civil servants forming a programmatic elite have for long pursued a strategy of power consolidation. None of its restructuring decisions were purely technical (though they may occasionally be represented as such) but served a specific agenda: a regrouping of power decision making within the RHAs in a bid to restore fiscal discipline with the RHA acting as an agent .…”

Section: The French Welfare Elitementioning

confidence: 99%

Technocratic recentralization in the French health care system: A critical evaluation

Simonet

2019

Health Planning & Management

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Summary The French health care system implemented several corporate management recipes such as diagnostic‐related groups (DRGs), benchmarking, and activity‐based management in a bid to restore fiscal discipline and to “reassert the center.” The government also regrouped health policy decisions with the Regional Health Agencies and opted for a top‐down line of command to ensure policy implementation. Though reforms emphasized evidenced‐based policy and outputs measurement, outcomes were below expectations in many areas and led to a shift in values. Professional autonomy and patient engagement receded. This leads us to a critical evaluation of the French audit society.

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Section: The French Welfare Elitementioning

confidence: 99%

Technocratic recentralization in the French health care system: A critical evaluation

Simonet

2019

Health Planning & Management

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“…. specialization in the social welfare sector was long considered a professional dead end’ (Genieys and Smyrl 2008: 78). Finally, an important change of ministerial portfolios occurred after 1970, when Sécurité sociale became a joint responsibility of the Ministry of Work and the Ministry of Health (Friot 1996: 153).…”

Section: Health Within the French Ministerial Portfoliosmentioning

confidence: 99%

“…The fiscal strain that affected mature welfare states from the mid‐1970s was just as salient in health care as it was in other branches of social security, and in parallel to the development of an expert knowledge of cost containment through health economics (Serré 2002; Benamouzig 2005), ministerial ‘welfare elites’ within the Ministry also started to incorporate the cognitive principles of dealing with permanent austerity in health affairs, aligning themselves with the policy paradigm advocated by ‘expenditure elites’ at the Ministry of Finance (Genieys 2005). Intergenerational ties and professional longevity in health affairs among the senior civil service, along with the creation of statistics and research bureaus (Marrot 1995: 47–8), enabled the development of a technical capacity on cost containment in health care within the Ministry, as its bureaucratic elites ‘gradually rallied around the notion that it was imperative for any new social welfare policy to be constructed so as to preserve a central role for the state, even while also taking into account the new financial constraints’ (Genieys and Smyrl 2008: 81). The presence among these elites of a shared belief in favour of controlling health expenditure led the Ministry to craft its own rationale and expertise for programming health‐care reform, hence allowing its Direction de la Sécurité Sociale to compete with other departmental influences (most prominent of which was the Direction du Budget at the Ministry of Finance) on that issue, rendering it a possibly determinant source of influence over policy formulation in the recent period (Hassenteufel 1999; Genieys and Smyrl 2008).…”

Section: Health Within the French Ministerial Portfoliosmentioning

confidence: 99%

“…Intergenerational ties and professional longevity in health affairs among the senior civil service, along with the creation of statistics and research bureaus (Marrot 1995: 47–8), enabled the development of a technical capacity on cost containment in health care within the Ministry, as its bureaucratic elites ‘gradually rallied around the notion that it was imperative for any new social welfare policy to be constructed so as to preserve a central role for the state, even while also taking into account the new financial constraints’ (Genieys and Smyrl 2008: 81). The presence among these elites of a shared belief in favour of controlling health expenditure led the Ministry to craft its own rationale and expertise for programming health‐care reform, hence allowing its Direction de la Sécurité Sociale to compete with other departmental influences (most prominent of which was the Direction du Budget at the Ministry of Finance) on that issue, rendering it a possibly determinant source of influence over policy formulation in the recent period (Hassenteufel 1999; Genieys and Smyrl 2008). The most recent configuration of ministerial power shows, however, that the Ministry has not acquired a definite leadership over the fiscal regulation of health care, and that other actors within the core executive are still leading the most substantial aspects of health system reform in France (Hassenteufel 2009: 375).…”

Section: Health Within the French Ministerial Portfoliosmentioning

confidence: 99%

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A Case of Weak Architecture: The French Ministry of Health

Briatte

2010

Social Policy &Amp; Administration

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International audienceThis article asks whether the public administration of health in France fits the general description of French state institutions as autonomous, powerful bureaucracies. Existing sources on the French Ministry of Health indicate that three types of processes have shaped its institutional structure, its official mandate and its actual policy influence since its inception in the 1920s. Faced with the rise of private-practice medicine, the Ministry first emerged as a resource-poor institution, and still remains an endemically weak ministerial portfolio by virtue of institutional path dependence. Since the 1980s, it has aligned itself on cognitive influences from other ministries, and has been especially sensitive to the pressure exerted by spending ministries to control health expenditure. Finally, in the light of recent health scandals, the creation of several health agencies has contested its effective mandate over public health issues. As a result, the current Ministry struggles to redefine its role in the competitive landscape of French health policy formulation

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“…Moreover, powers of regional Prefects (the préfet ) were extended. That reconcentration of control restored the prerogatives of a programmatic (Hassenteufel, ) elite (Genieys & Smyrl, ; Martin, ) from the Ministry of Health at the expense of the public (Braeckman, ) and the medical profession. From now on, expert control is no longer the sole prerogative of hospital physicians but shared with centrally appointed bureaucrats (three representatives of the French state sit at the RHA board of directors and each of them has three voting bulletins) as well as powerful management controllers.…”

Section: Introductionmentioning

confidence: 98%

The quest for a better performing health system: Public expertise and corporate management recipes in France

Simonet

2019

Journal of Public Affairs

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Though the government pledged to cut the public deficit from 7.7% of the gross domestic product in 2010 to 3% by 2013, thereby responding to EU Normative power, health expenditures continue to rise, because public demands are higher and more social problems are handled in the health care setting. With French budget deficit threatening France's credit rating, novel instruments were needed. These included corporate management recipes (e.g., pay for performance contracts, patient volume targets, and management by objectives), new compensation mechanisms (e.g., activity‐based accounting and a nationwide scale of health care costs) and far‐reaching laws (e.g., the 2009 HPST bill). Our approach investigates some critical elements of the French health care system. We focus on primary (e.g., family physicians and General Practitioners) and secondary (e.g., hospital and specialty) care. We explore how policies such as the standardization of health services, the regrouping of health policy decisions within the larger Regional Health Agencies, affected citizens' engagement and physicians' autonomy. A French welfare elite pursued a hybrid strategy, regulating quasi‐markets of care providers in a postcompetitive government, while creating supportive conditions for a vibrant private hospital sector. Reforms also emphasized evidenced‐based policy, outputs‐rather than outcome‐measurement, and performance evaluation in a bid to streamline the delivery of health services.

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Inside the Autonomous State: Programmatic Elites in the Reform of French Health Policy

Cited by 39 publications

References 12 publications

Technocratic recentralization in the French health care system: A critical evaluation

Technocratic recentralization in the French health care system: A critical evaluation

A Case of Weak Architecture: The French Ministry of Health

The quest for a better performing health system: Public expertise and corporate management recipes in France

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