Reforming the French health-care system: the quest for accountability
| Published date | 01 September 2018 |
| Date | 01 September 2018 |
| DOI | http://doi.org/10.1177/0020852316648226 |
| Subject Matter | Articles |
International Review of
Administrative Sciences
2018, Vol. 84(3) 503–519
!The Author(s) 2016
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DOI: 10.1177/0020852316648226
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International
Review of
Administrative
Sciences
Article
Reforming the French health-care
system: the quest for
accountability
Daniel Simonet
American University of Sharjah, United Arab Emirates
Abstract
The resurgence of New Right politics in the late 1970s and 1980s (e.g. ‘Reaganomics’
and ‘Thatcherism’), which were pro-market and pro-private sector (Lorenz, 2012), has
increased the reliance on the private sector for the provision of public services.
In France, the support for the private sector is no longer a partisan or ideological
issue, but rather a pragmatic and increasingly routine approach to the delivery of
public services. Whether this will improve the efficiency of the health-care system is
still open to question. The article: investigates the use of the New Public Management
toolbox (Goldfinch and Wallis, 2009: 151) in the French health-care system; examines
its selective adoption; and assesses its impact on the accountability and transparency of
the medical profession. The French government eventually opted for a re-centralization
of the health-care system for monitoring purposes. The reforms antagonized the
medical profession and strengthened private care providers.
Point for practitioners
Despite reiterated calls for devolution, the implementation of New Public Management
in the French health-care system led to a greater re-centralization and rising regulations
for efficiency purposes. It also allowed the French administrative elite to regain its
prerogatives and regional health agencies to reform more rapidly than a multitude of
local public organizations. The quest for greater accountability remains an ongoing
process.
Keywords
accountability, health care, health system, public administration, public management,
public sector reform
Corresponding author:
Daniel Simonet, American University of Sharjah, School of Business and Management, Management
Department, University City, PO Box 26666, Sharjah, United Arab Emirates.
Email: dsimonet@aus.edu
Introduction
Studies of administrative reforms have often almost exclusively focused on man-
agerial accountability (Aucoin and Heintzman, 2000), performance management
(Moynihan and Pandey, 2010; Walker et al., 2011) and organizational autonomy
(Rotberg, 2014), while other equally legitimate issues such as accountability and
democratic participation have retreated. Corruption is an important determinant
of the quality of the public sector (Jackson, 2013) because it undermines public
trust and the effectiveness of public services (Fritzen et al., 2014). Stakeholder
representation, political legitimacy (Mattei, 2009) and the democratization of the
decision-making process also ensure a working public service. A top-down initia-
tive, New Public Management (NPM), in France was intended to improve the
accountability and transparency that were lacking in the former global budgeting
system since funding depended on care providers’ bargaining power rather than on
their actual activity. Accountability can be either: ‘democratic’, therefore viewing
the public as reform overseer, even though it may not have the capacity to under-
stand policy; ‘institutional’ in a bid to prevent abuse of public authority by civil
servants; or ‘managerial’ in order to ensure efficiency in public service delivery,
as evidenced by reiterated calls for ‘value for money’ or ‘paying for outcomes’.
What accountability model did the French government pursue in NPM implemen-
tation in health care? Did accountability improve, or did the lack of it trigger a re-
concentration of the decision-making process that eventually benefited a welfare
elite? What was the NPM impact on the medical profession and on private care
providers? Bureaucratic dysfunctions affected the former while the latter took
advantage of an uneven playing field. The article contributes to the earlier
stream of research on the variety of NPM (Bach and Bordogna, 2011; Bordogna
and Neri, 2011), highlighting contrasting elements between French and Anglo-
Saxon NPM. These also reflect differing administrative traditions in France.
NPM as a fait accompli
Public demand for better-working public services prompted the French public elite
to undertake bold reforms. In areas such as air transportation or communication
services, NPM was adopted with relative ease (Simonet, 2011). The unpopularity of
strikes made the French population supportive of the privatization of Air France in
the mid-1990s. Citizens also favoured the denationalization of France Telecom.
Communication costs were subsequently lowered for users. Deregulation extended
to other public services such as utilities that were traditionally delivered by state-
owned monopolies, for example, the E
´lectricite
´de France (EDF) company. Since
2007, French citizens can buy electricity and gas from private suppliers. In health
care, however, NPM did not benefit from the same public support, for citizens
feared higher co-payments and barriers in access to care. Hence, compared to other
public sectors, NPM implementation in health care occurred later and with limited
depth (for instance, it did not go as far as privatizing public hospitals). As
504 International Review of Administrative Sciences 84(3)
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