French local health contracts: A response for a centralised governance of the health system

Abstract

Since liberation from occupation in 1945, the French public health system has been dominated by a hospital-centred perspective and ruled within the straitjacket of central government planning and funding authority. This approach quickly showed its limitations in responding to the needs of local communities. Over the past few decades, the National Assembly has adopted a series of policies to implement solutions that better reflect the needs and realities of local communities, thus marking a shift towards a territory-based approach of health policies. Most of these solutions are typically targeted at disadvantaged communities. In 2009, a new policy was introduced that grant Regional Health Agencies the power to sign health contracts with local governments. In this presentation, drawing from the results of 4 research projects, we will outline the main features, strengths and limitations of this policy instrument for generating community health action. Local health contracts represent an attempt by policymakers to generate an intersectoral mobilisation of local stakeholders. The contracts are signed for up to 5 years and are managed by a coordinator (more than 80% of whom are women). Each contract is unique and defines a set of objectives based on a needs assessment of the population. They implement actions that address a wide range of health determinants, from access to health services to housing, nutrition, environmental health, gender-based violence, etc. While our research on local health contracts has shown their potential to develop solutions to complex problems, their funding model severely limits their ability to identify emerging threats to population health and mobilise the diverse resources available locally. We will conclude our presentation with an analysis of the skills and competencies needed to coordinate a local health contract - highlighting how boundary spanning professionals are crucial in the implementation of community health practice.