The Differentiated Governance of Local Health Contracts

Abstract

According to a political sociology considering public action as a collective construction of interacting public and private players, our research focuses on the “new” governance of the “health territories” promoted by the Regional Health Authorities (ARS), and looks into the ways in which Local Health Contracts (CLS) have been produced. In the study area, the ARS launched its first two CLS in October 2010, as a sort of live experiment before rolling them out more generally in the future. The results of a comparative analysis of the seven CLS signed in 2014 show first that their negotiated governance gives rise to significant territorial variations, although a populational approach does dominate, legitimising the action of local elected office holders. Next, through a socio-ethnographic survey of two CLS in their formation process, we show that the way they are negotiated by the ARS oscillates between two different approaches to governance, top-down or bottom up, “hard or soft”, and that there are a certain number of favourable conditions that contribute to the construction of agreements and compromises that are acceptable to the various stakeholders. Far from taking the form of one “unified” governance, the production of CLS tends to be more “customised”. The stakeholders that take part therefore have no choice but to come to an agreement in order to respond, through a process of mutual instrumentalisation, not only to the specific issues of the sub-regional territories, but also to the objectives of the Regional Health Plan.