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“The reform of the governance of our health system must be the priority project for its overhaul”


AThen the overhaul of our health system is on the political agenda, the reform of the governance of this sector, undoubtedly the most consensual and the most restructuring of all, must be the priority project.

Governance refers to all the decisions, rules and practices aimed at ensuring the optimal functioning of an organization (here health), as well as the structural bodies responsible for formulating these decisions, rules and practices, for implementing them and for managing them. ensure control. We will focus our analysis on the big bang started in 1996 (Juppé orders) and finalized in 2009 (Bachelot law) which led to the establishment of regional health agencies (ARS).

One of the reasons for the creation of the ARS was to have a unified management of health, integrating health and medico-social through “regional health prefects”, outside the prefectural body established by Napoleon in 1800.

In addition to this desire for unification specific to health, the creation of the ARS was part of a desire to renew the modes of public action from Anglo-Saxon and Nordic countries. This wave, known as “agencification”, has experienced rapid expansion in France, leading to the creation of 1,244 public agencies, including the 19 ARS. It is the relevance of this pathway that is in question today for health.

The limits of the ARS model

With the establishment of the ARS in 2010, it is clear that we have gone from a decentralized and decentralized model of the State in health – around the former regional and departmental directorates of health and social affairs -, to a model that is not very decentralized and not at all decentralized.

Read the column: Article reserved for our subscribers Jean-Philippe Gallat: “The regional health agencies are only the heirs of an administration that has lost its sovereign mission in favor of a regulatory mission”

The Covid crisis crash-test revealed the limits of the ARS model, prisoner of its bureaucratic organization and not sufficiently connected to actors and territories. The prefects, in the regions and in the departments, were the real drivers of the coordination of actions and the transmission of national instructions from the State during the pandemic. To the point that they are now officially the only bosses in the management of future health crises.

The goal of unifying and strengthening state action to improve health management in the territories has also failed. The health state in agency mode is largely powerless to manage the crisis of the public hospital, the medical desertification, the deployment of digital, the fluidity of the paths of chronic patients…

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