Contenu du sommaire : Les métamorphoses des politiques de santé

Les métamorphoses des politiques de santé

• Introduction - M. Didier TABUTEAU, Conseiller D'Etat, Dir. général de la Fondation Caisse d'épargne pour la solidar p. 7
  Over the last two decades, while our attention has focused on social and financial crises, the healthcare sector has been undergoing profound transformations, structural and otherwise. New actors have appeared, biology and genomics have opened up exciting prospects, the public's expectations have been renewed, public administration has been transformed. Indeed, it is not illegitimate to speak of metamorphoses in healthcare policies, the extent and repercussions of which are the subject of this issue of the RFAP.

• Les débats récurrents

  • Les trompe-l'oeil de la "gouvernance" de l'assurance maladie - Contrastes franco-allemands - MM. Patrick ASSENTEUFEL, Professeur à l'Univ. de Rennes 1, Bruno PALIER, Chargé de recherche CNRS p. 13
    Trompes-l'œil in the “Governance” of Health Insurance French-German Contrasts. The authors judge the relevance of the term governance — now the accepted term for the transformation of the regulation mode of the health insurance system — in relation to two basic issues : the horizontal relationships between state and non-state actors, and the importance given to negotiation between multiple actors. These two aspects of the system are then discussed in the framework of an analysis of the recent reforms in the French health insurance system. Finally, a comparison with Germany shows the limits of a governance unable to question the validity of the two essential elements constituting the identity of the French health system : the patient‘s freedom and the freedom of liberal practitioners (doctors practising outside the state healthcare system).
  • La régulation des dépenses de santé en Europe et dans certains pays membres de l'OCDE - M. Jean de KERVASDOUÉ, Professeur au Conservatoire national des arts et métiers p. 29
    `titreb
    The Regulation of Health Expenses in Europe and in some OECD Countries `/titreb The French healthcare system is in serious difficulty. But before introducing reforms, a study should be made of the experience of other countries — European countries as well as the United States, Canada, and Japan. Even if the various western health systems are complex and cannot be transposed as such from one country to the other, this comparative approach opens up avenues of thought that should be explored. In theory, it advocates increased control of health expenses and the implementation of a system which is more coherent and open to change.
  • Les réformes hospitalières - M. Gérard VINCENT, Ancien dir. des hôpitaux, Délégué général de la Fédération hospitalière de France p. 49
    Hospital Reforms. The successive hospital reforms put in place in the past 20 years have produced mixed results. Present reforms centred on modernisation and a more flexible organisation should allow hospitals to better deal with the issues they are confronted with today. Nonetheless, additional proposals could be formulated to ensure the efficient functioning of the hospital in the future. These would concern more efficient piloting and better hospital organisation, giving hospitals more means with which to carry out their work, strengthening the coordination between hospitals and the various healthcare providers, and enhancing the role of local hospitals.
  • Les enjeux du financement de la santé - M. Jean-François CHADELAT, Insp. général des affaires sociales, Dir. du Fonds de financement CMU p. 65
    Health Insurance Agreements Policy : its Aims and Limits. In this article, the President of the Caisse nationale d'assurance maladie des travailleurs salariés (Health insurance fund for salaried workers) and of the Union des caisses d'assurance maladie (Union of health insurance funds) describes the different stages of agreement policy in the field of health insurance. He sheds light on the ambiguity of a system considered “liberal”, but which functions essentially on the basis of agreements with the state authorities. As he points out, the bases of this policy, reconfirmed in the 2004 agreement, are : to serve the interests of those insured and of enterprises, to guarantee the best quality of healthcare at the lowest cost, to coordinate healthcare around the main doctor via the establishment of a “treatment plan” and finally, to respect the framework set by Parliament in the National Objective for Health Insurance Expenditure.
  • Témoignage : La politique conventionnelle : ses ambitions et ses limites - M. Michel REGEREAU, Président de la CNAMTS et de l'UNCAM p. 75
    Financing Healthcare : Major Issues, Obstacles, Tools. Can health insurance expenses be controlled without controlling healthcare expenses ? Political decision-makers in all countries today are confronted with this challenge, which involves seeing to it that healthcare expenses remain compatible with the economic situation. This is the central point of the August 2004 Act, based on the responsibility of actors. Other available sources for the financing of healthcare will also come into play : in the coming years, taxes and National Healthcare contributions will be increased, adjustments will be made between basic and complementary insurance, and certain expenses will be relegated to the household level.

• Les transformations structurelles

  • Les enjeux du vieillissement de la population - M. Alain PARANT, Démographe, Institut national d'études démographiques et Futuribles p. 83
    Ageing of the Population Issues. The author reviews the main issues arising from the ageing of the French population, pointing out the challenge they represent to society as a whole. Future problems concerning the family, employment, space, etc., as well as the “democratic risk” are considered in the light of this demographic analysis. The author discusses the dogma of the “longevity revolution” and shows the importance of the demographic approach, particularly when determining the orientation of public policy. He points out the virtues of an approach which not only gives priority to the fight against senility (by definition individual), but also takes into consideration demographic necessities (by definition collective).
  • La révolution silencieuse des professions de santé : démographie, compétences, responsabilités - MM. Edouard COUTY, Conseiller-Maître à la Cour des comptes, Marc DUPONT, Directeur d'hôpital p. 97
    The Silent Revolution of Healthcare Providers : Demography, Competencies, Responsibilities. The authors highlight the primordial role played by healthcare providers in the implementation and success of public policy in healthcare matters. They then review healthcare professions as a whole and underline the growing malaise caused primarily by : fear of increasingly insufficient staff, changes liable to undermine traditional modes of organisation, and the increase of their personal and professional responsibilities. In the end, the result of recent transformations is that healthcare providers seem more and more exposed and vulnerable, whereas they bear the responsibility for health policy as a whole. According to the authors, if we wish to avoid a lack of healthcare providers in the future, there must be an overall clarification of issues relating to this major sector of our social lives.
  • Les médecins et les malades face au droit - Mme Anne LAUDE, Agrégée des facultés de droit, Professeur à l'Université René Descartes-Paris V p. 113
    Doctors, Patients, and the Law. The author discusses the historical evolution of the doctor-patient relationship, showing how progress in science has played a role in limiting the prestige and power of the medical profession. One part is devoted to the emergence of law in the doctor-patient relation. It points out how recognition of the doctor's responsibility has increased parallel to the affirmation of the patient's rights. A second part is devoted to the analysis of changes in the doctor-patient relation due to law, commercial law in particular. The author concludes with a discussion of the issues, notably financial, which these transformations will raise for future medical policy.
  • Témoignage : Les perspectives de la médecine préventive et prédictive - M. Didier SICARD, Président Comité consult. national d'éthique pour les sciences vie et santé p. 121
    The Future of Preventive and Predicitive Medicine. In light of his own experience, the president of the National Advisory Committee on Ethics in the Life Sciences and Healthcare (Comité consultatif national d'éthique pour les sciences de la vie et de la santé) discusses the “divinatory function” of medicine. He tries to analyse what can be attributed solely to rationality in preventive medicine and warns against the possible dangers of a behavioural prediction which stigmatises individuals.

• Les voies nouvelles

  • Les nouveaux horizons de la politique de santé - M. Gilles BRÜCKER, Directeur général de l'Institut de veille sanitaire p. 127
    New Horizons in Healthcare Policy. In this article, the Director General of the Health Watch Institute (Institut de veille sanitaire) analyses the main issues on which French healthcare policy will depend in the future. He underlines the need to conciliate aims which are becoming more and more contradictory : control of public spending and equitable access to increasingly efficient but costly medical progress. In a critical analysis of the implications of these needs, he describes how recent reforms have tried to achieve such a synthesis. On the issue of “health democracy”, the article underlines the societal dimension of an area of public action, the importance of which increases along with the demands of an ageing population.
  • Les territoires de la santé, maillon clé de l'organisation sanitaire - M. François BOURDILLON, Service de santé publique, CHU Pitié-Salpétrière p. 139
    Territories, a Key Link in Healthcare Organization. Since the decision of September 4,2003 concerning the simplification of the organisation and functioning of the healthcare system, the former healthcare sectors have been replaced by health territories, which take into account where people live, their state of health, and the places where healthcare is dispensed. This new geography, which often chooses to overlook French administrative borders, is based on epidemiological data bases and socio-economic indicators and makes it possible to describe populations, their state of health and the healthcare offer. It also favours the comparison of geographic zones, serving as a basis for the discussion of issues concerning health inequalities and the measures that should be taken to remedy them.
  • Les ambitions européennes en matière de santé - M. Fernand SAUER, Directeur de la santé publique à la Commission européenne p. 147
    Healthcare European Ambitions The European Commission's Director of Public Health describes the main tendencies of Union policy in this important domain. He stresses the fact that European action is essential for the future of healthcare, not only in Europe but in the entire world. Following a presentation of the administrative and legislative instruments and as well as programmes put in place by the Union, he outlines the main elements of health strategy for the coming years. Finally, he states the importance of this area of community action in the future European constitution.

• Chroniques

  • Chronique de l'administration - Bénédicte DELAUNAY, Michel Le CLAINCHE, Hervé RIHAL et Luc ROUBAN p. 159
  • Chronique du secteur public économique - André G. DELION et Michel DURUPTY p. 175
• Informations bibliographiques - Coordonnées par Sandra DÉTRIE-LAVROFF