Recentralization and vertical alignment in the French health‐care system

Date01 November 2017
Published date01 November 2017
AuthorDaniel Simonet
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
Daniel Simonet, School of Business and
American University of Sharjah, PO Box
26666, Sharjah, United Arab Emirates.
In foreign exemplars, key new public management (NPM) features such as decentralization and
devolution of healthcare 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 NPMdriven private values such as performance evaluation
has yet to be seen. Taking advantage of NPMs failings and austerity agenda, a French welfare
elite regained control over healthcare 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 principalagent 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.
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-
tancevia 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.
There has been an international movement toward focal agencies run
at arms length of the government. The British National Health Service
(NHS) embraced spinouts for the delivery of more responsive welfare
services (Hall, Miller, & Millar, 2015) and opted for a greater reliance on
communitybased 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 healthcare 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, GarcíaSánchez, & PradoLorenzo, 2013) that required
centrallevel 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.
Copyright © 2017 John Wiley & Sons, 1of8

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