Recentralization and vertical alignment in the French health‐care system

• DOI: http://doi.org/10.1002/pa.1640
• Date: 01 November 2017
• Published date: 01 November 2017
• Author: Daniel Simonet

PRACTITIONER PAPER

Recentralization and vertical alignment in the French health‐

care system

Daniel Simonet

School of Business and Administration,

American University of Sharjah, Sharjah,

United Arab Emirates

Correspondence

Daniel Simonet, School of Business and

American University of Sharjah, PO Box

26666, Sharjah, United Arab Emirates.

Email: dsimonet@aus.edu

Abstract

In foreign exemplars, key new public management (NPM) features such as decentralization and

devolution of health‐care responsibilities had outcomes below expectations. Other NPM traits

such as the patient as overseer of reforms or the empowerment of patient remained elusive. In

France, the integration of public values such as greater participation of patients and local actors

(NGOs and elected officials) and NPM‐driven private values such as performance evaluation

has yet to be seen. Taking advantage of NPM’s failings and austerity agenda, a French welfare

elite regained control over health‐care policy decisions at the expense of regions and other local

actors. NPM outcomes were below expectations. Austerity cures led to weakening of the regional

decision spaces, which can be explained under the principal–agent relationship. Accountability

shifted to managerial (the professionalization of hospital managers) and legal (governance via

regulations) forms in a bid to restore central government control. A democratic recess results

from the lack of public engagement in recent health reforms.

1|INTRODUCTION

New public management (NPM)‐driven administrative restructuring in

France sought to improve performance management and efficiency

rather than citizen empowerment or public participation. NPM unsatis-

factory outcomes, the need to prevent goal dispersion and to rein in

spendthrift regions, further accelerated the strengthening of the center.

A new centrally driven apparatus that endeavored to “govern at a dis-

tance”via regulations and other managerial tools (Ciborra, 2005; de

Kervasdoué, 2015) rearranged responsibilities among powerful stake-

holders to reinstate the French nomenklatura. Despite the hybridization

of managerial and professional values and practical advances in some

areas such as evaluation, normalization, and epidemiological studies

(these help understand disease prevalence and changes in surgical prac-

tices), regions are increasingly subjected to austerity measures, the

medical profession expresses rising discontent, and public engagement

is weaker.

2|DECENTRALIZATION’S PITFALLS IN

OVERSEAS EXEMPLARS AND IN FRANCE

There has been an international movement toward focal agencies run

at arm’s length of the government. The British National Health Service

(NHS) embraced spin‐outs for the delivery of more responsive welfare

services (Hall, Miller, & Millar, 2015) and opted for a greater reliance on

community‐based planning for its devolved policies (Pemberton, Peel,

& Lloyd, 2015). Limitations were naturally reached. Although safe-

guards have ensured that devolved approaches do not contradict cen-

trally defined policies (MacKinnon, 2015), there were many instances

of policy divergences in the UK. The Italian competitive model too

advocated decentralization (Palermo & Wilson, 2014) and a diminution

of the state role in health care (Fedele, Galli, & Ongaro, 2007). Away

from the “progressive opportunity”’ public value criterion that look at

social inequities (Bozeman & Johnson, 2015), Italian decentralization

increased territorial disparities regarding access (Ferrario & Zanardi,

2011; Pavolini & Vicarelli, 2012) and public expenditures for local

infrastructure, but generated little or no economies of scale due to a

lack of bargaining power that a single buyer such as a central govern-

ment could produce. Moreover, the transparency of the local govern-

ments was not necessarily higher (da Cruz, Tavares, Marques, Jorge,

& de Sousa, 2015). Spain, the most decentralized nation within the

Organization for Economic Cooperation and Development (OECD),

experienced a rise in health‐care expenditures (Joumard, André, &

Nicq, 2010). While citizens benefited from better services in regions

with greater fiscal autonomy (Alves, Peralta, & Perelman, 2013), decen-

tralization was undermined by the inability of the local levels to tackle

public issues, by fraud, political polarization, differences in accountabil-

ity levels (Durán, 2015), and rising municipal debts (Cuadrado‐

Ballesteros, García‐Sánchez, & Prado‐Lorenzo, 2013) that required

central‐level bailouts. Powerful local representatives distributed funds

Received: 22 September 2016 Accepted: 16 November 2016

DOI: 10.1002/pa.1640

J Public Affairs 2017;17:e1640.

https://doi.org/10.1002/pa.1640

Copyright © 2017 John Wiley & Sons, Ltd.wileyonlinelibrary.com/journal/pa 1of8