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

• Date: 01 February 2020
• DOI: http://doi.org/10.1002/pa.1985
• Author: Daniel Simonet
• Published date: 01 February 2020

ACADEMIC PAPER

The quest for a better performing health system: Public

expertise and corporate management recipes in France

Daniel Simonet

Department of Management, School of

Business and Management, American

University of Sharjah, Sharjah, United Arab

Emirates

Correspondence

Daniel Simonet, Department of Management,

School of Business and Management,

American University of Sharjah, Sharjah,

United Arab Emirates, PO Box 26666.

Email: dsimonet@aus.edu

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 physi-

cians 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 deliv-

ery of health services.

1|INTRODUCTION

A sharp rise in both the deficit of the French Statutory Health

Insurance (from 4.5 billion Euros in 2008 to about 14.5 billion in

2010) and the Social Security deficit (from 10 to 24 billion between

2008 and 2009) triggered a restructuring of the health system. A

new regulatory framework led to a reassertion of the “centre.”The

administrative strategic apex promoted yardstick competition and

novel accounting mechanisms as a mean to govern at a distance

(Cole, 2008; Barry, Osborne, & Rose, 1996). These emphasized out-

put‐rather than outcome‐measurement and streamlined the delivery

of health services. The French welfare elite (Barsoux & Lawrence,

2013) pursued a hybrid strategy. It regulated quasi‐markets of care

providers, created supportive conditions for a vibrant private hospital

sector, but rejected privatization and outsourcing. Hence, reforms

highlight differences between Anglo‐Saxon and French NPM‐

modelled reforms. Did these novel policy instruments ease the public

management exercise? It appears that gaming strategies and opacity

remain in many areas. Reforms contributed to a drift in values. Speci-

ficities of the French medical profession shaped the path of reforms.

Expert power was reinstated, and a powerful French Welfare elite

emerged. However, this was at the detriment of public participation.

1.1 |The 2009 HPST Bill: Reasserting the centre

The French Welfare elite (Genieys, 2010) streamlined the vertical

chain of command to ensure effective execution of decisions, to reas-

sure the public that objectives are being met in a bid to be reelected,

List of Abbreviations: DRG, Diagnostic‐Related Group; EEC, European Economic Community;

NHS, National Health Service; RHA, Regional Health Agencies

Received: 13 April 2019 Accepted: 9 May 2019

DOI: 10.1002/pa.1985

J Public Affairs. 2020;20:e1985.

https://doi.org/10.1002/pa.1985

© 2019 John Wiley & Sons, Ltd.wileyonlinelibrary.com/journal/pa 1of9