Ces dernières décennies, les transformations des systèmes de santé dans le monde se traduisent par des processus de territorialisation, sous-tendus par trois tendances principales : la régulation financière, le développement des partenariats et le transfert des compétences. Dans ce papier, nous resituons tout d’abord le processus de territorialisation dans le cadre plus général des questions de décentralisation, de gouvernance et de gouvernement. En se focalisant sur le cas français, nous analysons ensuite l’articulation entre la décentralisation dite fonctionnelle en santé et les processus plus généraux de décentralisation des institutions. Pour conclure, nous questionnons les enjeux opérationnels et organisationnels qui en découlent.
In this paper, we focus on the common trends of transformations of health care systems in the world. Based on the identification of three logics that root these evolutions (financial regulation, development of cooperation and skill/power transfers), we define territorialization as a process. It refers to projects of planning for which actors implement strategies to produce controlled and bounded spaces. In this process, scales, distances enacted through instruments are involved for putting public policy into practice and space. These actions give rise to different forms of territorialization in which different modes of governance, government and uses are embedded. In a second part, we focus on the case of France and the ways instruments have been used to develop public policies. We insist on the disconnections between the political and administrative decentralization with the evolution of the health sector. The general trend of decentralization of French administration during the eighties is characterized by a greater proximity of public decision with citizen, which involves more action for local authorities. A structured vision of decentralization appears only at the beginning of 2010s based on potential differentiation of standard on the territory and the possibility for regions to provide guidance to others local authorities. During these periods, health sector remains on the sidelines of the legislative evolution. Although regional level was defined as the structuring level of organization for health care in the hospital law of 1991, regionalization of public health policy really operated in 2009 with the Patients, Health and Territories Law (HPST) creating regional health agencies. These ones, with the legal personality are a type of functional decentralization, which are submitted to state monitoring. Concentrating the decision-making power at the regional level and breaking down barriers between sectoral policies, this law simplified local organization of health sector governance. It is operated in a regional health plan which relies on contractual partnerships with a lot of actors including local authorities which became a major actor to decline the plan at the local level. In a third part, we discuss the stakes, options and problems that actors have to face in the current stage of decentralization. Combined with deconcentration of others services, overlapping, cross-financing occurred and involved lower clarity of administrative organization. Two major stakes are identified. Firstly, the capabilities for actors to form a wide coalition sharing objectives and keeping up with changes in stakeholder’s dynamics, like political changeovers and budget cuts. Secondly, a better coordination of actors, in order to create favorable conditions for cooperation and complementarities.
