Contenu du sommaire : La santé est-elle sous-administrée ?

Government Initiative and public health objectives. Being the health of a population and its study, public health has an ongoing need for epidemiology, economies, social sciences and, ethics. Government activity in public health extends beyond lawmaking and regulation. However, said activity is uncoordinated and lacks a System of priorities. Above ail, public health ought to enjoy greater attention in public debate. To remedy the lack of true policy and insufficient government typical to public health, the author recommends starting by rigorously taking stock of the nation's health and drawing up a list of objectives and priorities based on coherent policy, thereby making debate irrelevant on preventive vs. acute care and giving way to economic and technical evaluations. This rather negative observation ought not to be a discouragement, but a challenge. The role of government should be all the more stimulating as it is unconventional.

Headway and handicaps in health care statistics. In-house statistical services for social security and guardianship administration have shown strong sustained growth in the past decade. Such services were started decades after comparable services for business, industry and agriculture. Quality has improved and the scope of investigation has broadened despite recent budget restrictions. However : 1. Statistical services grew in specific directions that served the purposes of the sponsoring institutions : the regulation of health care made available, and hospital management and, on the other hand, a detailed knowledge of private practice to lay the groundwork for fee-setting negotiations. Such institutional thinking has not monopolized ail statistical investigation for the past 10 years, yet it does predominate. 2. French physicians enjoy privileged social status that prevents any outside body from exerting true control over the profession. For example, the NGAP standard fees list acts as a buffer that mediates transactions between the profession and the social security administration. The jurisdiction of the Medical Association is yet another way the medical community polices itself and prevents intervention from external societal bodies. For these reasons, it remains very difficult to collect some data certain statisticians consider useful to forming a representative picture of health care institution clienteles, especially the most ‘medical' of all data : diagnoses.

Current information needs for the allocation of medical equipment (The case of medical image equipment in France). There is an ever-closer relationship between the allocation of medical equipment, cost-cutting objectives and a policy of upholding quality health care. However, health services are very difficult to evaluate comprehensively and no serious observer would apply the very general indicators of national health available to such an end. General indicators have taken on a symbolic value that has a magnetic effect on health care professionals and the general public alike. This is especially true of statistics on hi-tech medical equipment. The 1970 Hospital Act extends «carte sanitaire» allocation procedures to such so-called ‘heavy-duty' equipment. However, procedural inadequacies later arose while the information and evaluation tools at hand proved too modest for policymaking. Medical image equipment is an excellent example. This domaine has witnessed an impressive number of major and costly innovations over a short period : an examination of this period will yield a general statement about how allocation ought to be planned. Thus, this analysis and resulting recommendations remain somewhat general, at least insofar as they concern multipurpose diagnostic equipment, for which it seems impossible to define ‘needs' objectively. Therapeutic equipment ‘need' is obviously easier to define ; sector-by-sector policy can be set using relatively accurate epidemiological data. Any future attempt to improve allocation procedures would require the prior creation of a data bank on installed equipment and dispensed medical care. The article shows how the «region» is a convenient administrative unit for coping with equipment allocation and encouraging more concerted action between health care professional and government bodies.

What are senior personnel needs for public health and social services administration ? Why do public health and social services have a poor reputation ? Where do their weaknesses lie ? This falling prestige concerns neither the competence nor the dedication of civil servants, but the weak appeal of civil servant status and the limited degree of independence that departments enjoy vis-à-vis Prefects. These weaknesses stem from ministerial and institutional organizational structures whose history has been affected by mutual societies, business associations and individual initiative. The State, as tutor and guardian of law, has been intervening with limited means only since recently through disjointed external structures and centralized structures with changing duties. Specialized schooling was instituted only recently and Public Health physicians have not set up new career paths. The tradition of volunteer work has inhibited unionization and modernized management. The image of public health and social services could be improved by (1) strengthening decision-making mechanisms, (2) enhancing senior personnel training and (3) improving working conditions through greater decompartmentalization, job and geographical mobility. Although job mobility depends on standardized statutes of service, the difficulties facing the Ministry of Social Affairs include its current teething problems. Its recent creation, lack of tradition and statutes may prove to be strong points in facing the challenges of growth and modernization.

The instruments of national health policy (Equipment allocation plan and conventional tariffs). The State acts on national health by regulating the health care System. Its regulations and procedures are based on a theoretical model of reality. Analyzing two instruments of policy, conventional tariffs for medical services and the medical equipment allocation plan, reveals that the authorities have very limited capacity to deal with the two-tier complexity of health care, i.e. it is difficult to establish a relationship between means and results, and French care is marked by institutional pluralism.

The Powers and limits of local health authorities over hospitals. The local health authorities (DDASS) are a favorite target of criticism when discussing public health. But what are their duties, limits and operating mechanisms ? They oversee and coordinate the establishment of new facilities, and approve annual budgets and long-term policy for hospitals. They stand between two opposing forces, i.e. central government trying to hold down hospital costs through the national equipment allocation plan plus various rules and procedures, and local interests seeking to maintain and even expand hospital facilities. This has given rise to a policy of “ inching along” and compromise that bows to quantitative targets set by central government without openly opposing local demands. Likewise, they exercise their authority very cautiously, interplaying with a number of organizational factors internal to hospitals, e.g. no indicators to account for hospital activity, bookkeeping unrepresentative of institutional operations, long and unwieldy reports, insufficient staffing with bureaucratizing training and hermetic career paths. The underlying conflict between national objectives and local demands will not be resolved in the medium term. The only bridle possible would be management and evaluation tools to re-orient hospital activities towards specifie objectives.

Health care and health insurance. The author shows how health care austerity policy and the social security crisis have given rise to an added mission for national health insurance (NHI) bodies which, since 1980, have had to evaluate the functioning of the health care System and contribute to improving its efficiency in addition to their current tasks. She describes the history of NHI duties and recent developments in various health care sectors, including private practise and hospital care, public and private. The missions of ail bodies are given. The new powers vested in Social Security are part of long-term government policy ; government instruments of self-regulation are analyzed ; the specific role of Social Security is described in detail, i.e. how it maintains ongoing dialogue towards negotiated change with health care professionals, over and above authoritarian regulations and economic restrictions. In fact, the State relies on NHI to adjust societal regulations so as to try to build a consensus for its policy. The proper execution of this new function assumes a re-distribution of roles among individuals and bodies active in NHI. This would modify the configuration of an already complex power structure. The article also describes the problems arising within NHI from the growing importance of Consulting physicians.

Hospitals. However great the efforts of the past 40 years to improve the management and control of the hospital System, dissatisfaction is obvious among users, health care personnel, the administration, social security and private enterprise. Hospitals served as locally-administered lodgings until the 19th Century. They have gradually evolved into complex centres of differentiated production that compete with other partners of the health care System and are increasingly dependent on socio-economic developments. Thus the hospital has become a matter for national government without really losing its local connections and has become a meeting ground for many partners. The time is ripe for long-term decisions that are needed for a coherent, viable System, i.e. socially — concerted effort for a new definition of national health, the role and functions of hospitals ; a streamlining of State intervention with its many contradictions ; making citizens play an active role in hospital System, optimizing complementarity between different role players ; giving hospitals appropriate tools to evaluate costs and production ; and the adoption of fixed-term contracts with means and objectives between hospitals, Social Security, the State and other public bodies so as to give hospitals a solid framework and better control over their future, and make them responsible entreprises.

National director of hospitals : decision maker, flak-catcher or scapegoat ? The Minister of Health has been losing his independence for several years now. He now reports to the « grand » Minister of Social Affairs. Given two superiors and his liaison duties between politicians and civil servants, the post of Director of Hospitals is a precarious appointment lacking adéquate management tools for the proper programming and objective évaluation of his activities. This lack complicates task-sharing and relations with the minister's staff. Furthermore, social and health services hold little prestige despite social and économie rôles of considérable importance : they do not attract young senior civil servants while buildings and operations hardly stimulate personnel. Recent reforms and the anti-civil service ideology that dominâtes French conservatism could aggravate the existing problems of the civil service, i.e., time-consuming recruitment, rigid career paths according to graduate schooling, department and position and the dire State of inter-ministerial and external relations. In addition, the simple rules of the Budget Office that apply automatically across the board must lead to inadéquate government which in turn will resuit in increased bureaucracy. Thus, efficiency should be sought at the expense of formalism, and empirical factors should override ideological thinking. Instead of central administration, the public limited company (« Société nationale ») with set objectives and independent means, flexible management and open to inspection would appear more suited to the tasks at hand.

The informal Opinions of Physicians. Two professors of medicine provide their views on the topics in this issue. Prof. Huriet feels the causes of the policy vacuum merit attention : objectives are difficult to define, appropriate means are almost impossible to implement and reliable indicators of performance are lacking. Determining one coherent global health policy is nearly impossible, so government has been content for years with cumulating policies. Prof. Terquem also underscores the incoherence and contradiction within the French health care system as well as a lack of overall long-term perspective by the authorities. Yet the matter urgently requires attention lest the entire social welfare system collapse.

National health administration in Canada. Ever since confederation in 1867, public health administration has undergone several phases of ever-increasing Federal intervention in what had begun as a provincial responsibility. An initial period in which Federal Government individually negotiated and subsidized provincial programmes gave way to massive participation in the field of health : 1957 and 1966 legislation enabled it to Finance medical care and hospitalization by reimbursing outlays. Both parties were satisfied since the provinces retained control of the health care System while Federal Government gave substance to its dream of increased centralization and national unification. The level and cost of health care to the public then showed spectacular growth. In the subsequent economic crisis, the Government reduced its share of rising cost through 1977 & 1984 legislation, thus provoking numerous conflicts in the provincial health care sector. Despite an uncertain future, national health has become a field for which the Constitution has effectively split responsibilities : provincial exercise of health care duties has contributed variety (e. g in administration, financing, quality of care) while the Federal Government has, through financing, gradually contributed greater coherence, and a common approach to problem-solving in public health.

Regional Health Authorities in the English ; National Health Service. The 14 Regional Health Authorities in England control the finance and service provision of the 192 subordinate districts. They are responsible through their appointed authority members for the implementation of government policies and the development of local strategies for the delivery of health care. They receive a budget from the government Department of Health and Social Security under a formula developed in 1976 by the Resource Allocation Working Party. Regions attempt to coordinate the services provided by districts and an annual review process has been introduced by the DHSS to monitor their success. Executive control of the regions rests with a Regional Management Board, headed by the Regional General Manager. They carry out the policies of the authority whose members are appointed, not elected, from local government and the general public under a part-time, salaried chairman. But although regions are nominally in direct control of the districts, the districts have their own appointed authorities which can attempt to alter regional decisions on the allocation of money and the location of services. Thus the power of the regions is tempered by the political weight of the Districts and by professional groups, particularly the doctors and nurses.

Private Financing and the regulation of health care : the United States experience. The United States health care System is distinguished by a relatively large share of expenditures made in the private sector. However, despite some popular beliefs, this large role for private financing has not been associated with freedom from regulation. Private purchasers of care, including businesses and unions, are increasingly concerned with controlling costs. This has transformed the private health insurance industry from a System whose major purpose was to raise revenues for hospitals to one whose principal product is an ability to control medical care utilization by monitoring and regulating physicians behavior. This change in the industry is related to four trends — the use of experience rating, the participation of private firms in government programs, the growth of self-insurance, and vertical integration of insurers and providers. In addition, the recent substantial increase in the supply of physicians has weakened the previously strong political and economic position of the medical profession and made doctors more vulnerable to competitive pressures.