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Conference

French

ID: <

10670/1.gt6kzf

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Where these data come from
Govern by contract. The proofs of the cooperative territorialisation of health

Abstract

Local and regional authorities and their groups took advantage of the opportunity of ‘shrinking the verrous of the state’ (Le Galès, 1999) to mobilise in the field of health, while legal powers do not define and distribute the respective roles between the different levels of government (Monnereau, 2015). While some local elected representatives have been slow to engage, state actors are now seeing their domination challenged by public entrepreneurs blaming parts of the sovereign health power (Clavier, 2007). Although some communities and groupings of municipalities are seeking, in a context of globalisation and political competition between regions, to build themselves as a model (Bergeron et al., 2011), local health policies are scarcely spared by fragmentation, institutional and organisational competition, the distance between the various levels of government and, in their own right, by a form of fragmentation that takes place horizontally and vertically (Hassenteufel et al., 1998). The territorialisation of public health policies is thus debated (Amat-Rose, 2011) because it questions the legitimacy of the authority responsible for coordinating the various layers of government. If the “territory” is dedicated to the scale where public problems emerge and deal with them through the mobilisation and coordination of the responsible authorities (Schweyer, 2004; Haschar-Noé, Salamo and Honta, 2016), political regulation in this area requires the production of negotiated exchanges aimed at organising collective action. In the region, this role of coordinating and integrating health policies is entrusted to the Regional Health Agencies (ARS). Their creation formalises the ‘sovereign regulatory ambition’ (Tabuteau, 2013) and, to this end, they have a contractual public policy instrument — the Local Health Contract (CLS) — through which they must organise cooperative territorialisation and link their regional project to local actions. “Central Evidence” (Gaudin, 1995; (1999) enabling the State to ensure territorial regulation of health, this instrument comes in addition to the provisions of the Hôpital, Health and Territories (HPST) laws of 2009 and of the 2016 Modernisation of our health system, in order to signal its willingness to take over the levers of decision-making in the face of the counter-power of local elected representatives (Pierru, 2010). The comparative analysis of this contractual health factory in Nouvelle Aquitaine and Occitanie is a good analyst of how the State, through the ARS, tries to control the dual process of territorialisation and institutionalisation of collective action (Duran, Thoenig, 1996). The study is based on almost 50 semi-directional interviews conducted in these two regions with local elected representatives, staff of the ARS, decentralised state departments (Departmental Directorate for Social Cohesion, Regional Directorate for Youth, Sport and Social Cohesion, Regional Directorate for Food, Agriculture and Forestry) and representatives of organisations in the health and social sectors who have been involved in the preparation of CLS. The momentum shows that the way in which representatives of the ARS, local and regional authorities, their groups and local health operators take part in and respond to this commitment is a constant struggle to define and legitimise the relevant intervention scales, the actors and practices which they establish and which give them meaning and, in so doing, the territorial and sectoral boundaries of the territorial government of health.

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