Contenu du sommaire : La santé au centre : politiques publiques, territoires, centres de santé

The article deals with the transformation of the “mutualist medicine” practiced in the health centers of a departmental mutualist union of the Bouches-du-Rhône under the crossed effect, in the turmoil of liberalization, of the injunction to profitability and of the separation of the insurance and social missions of the mutual health insurance companies. This workers' mutual insurance company, which was inspired by the trade union and communist movements, created a network of health centers throughout the department at the end of the 1950s on the initiative of Marxist-oriented doctors, who were involved in the social struggle in search of new ways of practicing medicine, and cgt union activists, who were allied with mutual insurance company representatives and left-wing municipalities wishing to invest in the field of the right to health and its protection. From the 1980s onwards, in the face of the retreat of the Social Security system and under the effect of European competition regulations, management imperatives and alignment with the entrepreneurial rhetoric of the mutual benefit society gradually modified the solidarity-based ethos, the social vocation and the preventive orientation of the health centers. This profound evolution has pushed the mutuality, weakened by a decline in its membership following the rise of unemployment and precariousness, to adopt a more opaque and less democratic mode of governance, leading to an internal crisis in 2012, the catalyst of which was the switch to fee-for-service remuneration for the centers' doctors.

Municipal health centers are organizations halfway between the hospital and private sectors. They represent a quite old device that can be used to respond to certain (re)emerging public health issues. Based on an inquiry in two municipalities in the former Parisian “red suburbs”, this text attempts to show how these centers can allow for the territorialisation of actions while at the same time providing comprehensive care for patients, in the dual sense of long-term follow-up and attention to the multiple dimensions of health determinants. However, these privileged places for coordinating care and initiating experiments are also affected by the more general contradictions of current health policies, which attempt to do better with less. Strengthening and coordinating internal teams and external partnerships thus requires a great deal of work, but it is often invisible and therefore little valued, and it often clashes with existing professional cultures and work routines. The funding of actions is increasingly based on responding to calls for projects, which can be to the detriment of structural mechanisms that are nevertheless involved in the desire to develop prevention and health education beyond the curative approach alone.

The 1998 law against exclusion formalized the existence, at the national level, of health care access offices (pass) in hospitals. Since then, its professionals have been providing medical consultations, as well as social work to open social rights, to patients without social security coverage and without resources. This model, which links the health and social dimensions in the care of people who are far from the health system, has recently been taken up at the local level. In 2013, the Île-de-France Regional Health Agency set up an experiment of ambulatory pass. It decided to place them in primary care institutions located outside the hospital, in this case municipal health centers and associative health networks. Knowing that these structures were chosen because of their preexisting mobilization on the subject and that the ambulatory pass are a transposition of what happens in hospitals, this article questions the institutionalization of socio-medical assistance produced by this experimentation. If the latter brings out or reinforces the social dimension of patient care, by allowing the creation of posts dedicated to it, it does not contribute to the introduction of additional medical staff – sometimes necessary in these structures. Thus, this experimentation in health centers and networks results in different forms of institutionalization of the care of their patients.

The Tabado program aims to help high school students and apprentices quit smoking. Judged successful when it was first tested in 2009, it has been progressively deployed in metropolitan and overseas France since 2018. Its implementation, steered nationally by the inca (National Cancer Institute), is entrusted to various health prevention associations at the regional level in a logic of territorialization. In the light of a qualitative field survey carried out over three years as part of the evaluation of the program, the article analyzes the way in which the associations position themselves with respect to the relatively well-defined national framework of the program – which becomes more rigid as it is deployed – oscillating between compliance with the rules laid down by inca and negotiation of room for maneuver. More precisely, it highlights several types of resistance deployed by the latter, ranging from non-use of the program's animation supports to more substantial questioning of the control or intervention logics that embody it. In doing so, the case study shows the ambivalences in which the associations are placed. While seeking to enhance their own specific action registers and cultures, they also tend to be recognized as central actors of the public action of preventive health.

Although the government wishes to promote the development of therapeutic innovation and its access to all patients in the field of cancer, the fact remains that the elderly are still little beneficiaries. These patients are under-represented in clinical trials. Yet, we know that they represent the population most vulnerable to the occurrence of cancer. This paradoxical situation raises the question of health inequalities by age. This article proposes to question this medical problem and to highlight the logic behind its existence, from the point of view of 12 institutional and associative actors. The way they think about access to care and medical research is part of the complexity of defining and designating the elderly population. The causes they attribute to it are based on social, political and medical dimensions. The causes they attribute to it are based on social, political and medical dimensions, and reflect the interplay between the representation of the elderly, the inertia of public policies and pharmaceutical laboratories, and the lack of therapeutic activism by and/or for the elderly.