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Digital technologies as a response to healthcare system crises: agenda-setting of digital health policies in France

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Abstract

Since the COVID-19 crisis, digital health or (‘eHealth’) technologies have been a prominent element of domestic political agendas. However, in France, their emergence on the political agenda had already been linked to another type of crisis: the continuous and enduring crisis concerning the financing of the French healthcare system between 1995 and 2004. The aim of this article is to shed light on the conditions under which digital health technologies may be adopted as ‘solutions’ amidst financial constraint and austerity, based on an in-depth study of the French case. Using the Multiple Streams Framework, combined with a comparative and qualitative methodology, this article explains why digital health technologies were adopted as a central instrument of the 2004 French healthcare reform (the Douste-Blazy reform), but not during the 1995 social welfare reforms (the Juppé plan). It shows that if the perceived political risk associated with a reform increases, political decision-makers are more likely to select economically ambivalent devices, such as the Electronic Health Record (EHR), in order to restore the balance between pursuing policies and retaining votes.

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Notes

  1. Chermann Elodie (2020). ‘La crise liée au coronavirus consacre la télémédecine [The COVID-19 crisis consecrates the use of telemedicine technologies]’, published on Le Monde website, available on: https://www.lemonde.fr/economie/article/2020/05/03/la-crise-liee-au-coronavirus-consacre-la-telemedecine_6038519_3234.html.

  2. Even though the effects of partisan politics on retrenchment policies is not as clear-cut as one would expect, especially in times of economic constraint (Brady et al. 2005).

  3. These interviews were conducted between 2017 and 2022 as part of two broader studies on digital public health policies.

  4. See the appendix at the end of the text for more details on this selection process. The coding of institutional speeches distinguished sentences that mentioned the deficit in relation to the social security, finance or economic measures (increase in contribution, decrease in benefits, social debt reimbursement, expected cost saving…). More general organisational measures (even if they were intended to contribute to the general objective of rebalancing the budget) were excluded from this coding. As regards TV interviews and speeches, the coding was mainly thematic, in order to show which measures were primarily highlighted by decision makers.

  5. Source: Eurostat, ‘Government deficits/surplus, debt and associated data’, code: gov_10dd_edpt1.

  6. Mission interministérielle de revue de projet sur le Dossier Médical Personnel (DMP) [Inter-ministerial review mission on the DMP]. Rapport sur le Dossier Médical Personnalisé (DMP) [Report on the French Electronic Health Record DMP]. Paris, Novembre 2007, p.49, see also p.64, translation by the authors.

  7. The Carte Vitale is an administrative health insurance card which is automatically given to French insured persons.

  8. Policy officer from the unit for electronic and new technologies in health, French Ministry for Health (1995–1999), 24.05.2018, 30.05.2018, see also: Loth, André (1996). ‘Systèmes d'information et cartes de santé’, Droit Social, special issue september–october, p.829.

  9. Source: Eurostat isoc_ci_in_h.

  10. Director of the Mission for the digitalisation of the health system, French Ministry for Health (1998-2005), 04.06.2018.

  11. Cohabitations refer to specific political periods within the French semi-presidential system during which the President belongs to a different political party than the majority in the French Parliament.

  12. Philippe Douste-Blazy’s speech on 16th june 2004: ‘The health insurance reform’, Available on: https://www.vie-publique.fr/discours/143188-declaration-de-m-philippe-douste-blazy-ministre-de-la-sante-et-de-la-p.

  13. Hearing of Mr. Philippe Douste-Blazy, Minister for Health and Social Protection, and Mr. Xavier Bertrand, Secretary for the Health insurance, by the special commission of the National Assembly charged with an examination of the bill on health insurance, 17th June 2004 (hearing opened to the media), Available on: http://www.assemblee-nationale.fr/12/cr-spec-assurance-maladie/03-04/c0304002.asp

  14. Interview with the Minister for Solidarity, Health and Family, Philippe Douste-Blazy on TF1, on 3rd may 2004.

  15. Advisor to the Minister for Solidarity, Health and Family, Philippe Douste-Blazy (2004–2005), 06.04.2017. Translations by the authors.

  16. Advisor to the Minister for Solidarity, Health and Family, Philippe Douste-Blazy (2004–2005), 08.06.2018. Translations by the authors.

  17. Advisor to the Minister for Solidarity, Health and Family, Philippe Douste-Blazy (2004-2005), 06.04.2017; Advisor to the Minister for Solidarity, Health and Family, Philippe Douste-Blazy (2004-2005), 20.07.2022 Translation by the authors.

  18. Interview with the Minister for Solidarity, Health and Family, Philippe Douste-Blazy on TF1, on 3rd may 2004.Translation by the authors.

  19. Hearing of Mr. Philippe Douste-Blazy, Minister for Health and Social Protection, and Mr. Xavier Bertrand, Secretary for Health insurance, by the special commission of the National Assembly charged with the examination of the bill on health insurance, 17th June 2004 (hearing opened to the media), Available on: http://www.assemblee-nationale.fr/12/cr-spec-assurance-maladie/03-04/c0304002.asp. Translation by the authors.

  20. The time span selected was from around six months before the reform to one month after the reform. The 20’clock TV news from the national channels TF1 and France 2 were selected and analysed when appropriate.

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Authors and Affiliations

  1. Univ. Grenoble Alpes, CNRS, Sciences Po Grenoble, Pacte, 38000, Grenoble, France

    Chloé Bérut & Sabine Saurugger

  2. UMR Pacte, Institut d’études politiques, BP 48, 38040, Grenoble Cedex 9, France

    Sabine Saurugger

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  1. Chloé Bérut
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  2. Sabine Saurugger
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Correspondence to Chloé Bérut.

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Appendix: Data

Appendix: Data

Semi-structured interviews

Questions were asked about eHealth in the two reforms, the issues that were raised, their supporters and opponents, and the policy formation process in general. Since there is a 15–25 years’ time span between the reforms themselves and the interviews, the risk of memories bias was very high. Nevertheless, interviews were mainly used as a way to deepen observations primarily made on institutional and media speeches, which can be considered as archives and do not suffer the same bias.

Policy officers from the Ministry of Health in charge of eHealth

For the period under study (1995–2004) we identified the main policy officers in charge of eHealth within the French Ministry for Health. For a long time, there was only few people in charge of these issues, who worked most of the time within small units with limited resources. These interviews were central in gathering data about eHealth activities in the central administration during these periods of time.

References

  • Policy officer of the unit for electronic and new technologies in health, French Ministry for Health (1995–1999), 24.05.2018, 30.05.2018.

  • Director of the Mission for the digitalization of the health system, French Ministry for Health (1998–2005), 04.06.2018.

Members of the Minister for Health’s office in charge of eHealth (2004)

Generally, only one person within Ministers for Health cabinets is in charge of dealing with eHealth. Hence, data are often obtained using a unique interview. In our case, a second interview was performed with a more senior-level member of the cabinet, in order to triangulate the information gathered during the first interview. Two other interviews were conducted with external advisors of the Minister.

References

  • Advisor to the Minister for Solidarity, Health and Family Philippe Douste-Blazy (2004–2005), 06.04.2017.

  • Advisor to the Minister for Solidarity, Health and Family Philippe Douste-Blazy (2004–2005), 21.02.2019.

  • Advisor to the Minister for Solidarity, Health and Family Philippe Douste-Blazy (2004–2005), 08.06.2018.

  • Advisor to the Minister for Solidarity, Health and Family Philippe Douste-Blazy (2004–2005), 20.07.2022.

Institutional and TV speeches

To understand decision-makers’ initial intentions when communicating about their reforms, we selected the main institutional speeches gave by the relevant ministers in 1995 and in 2004. We chose to complete this first selection with interviews performed to present the respective reforms on TV news. Indeed, if the institutional setting of the 1995 reform made the institutional speech of Alain Juppé before the National Assembly very visible in the media (as it was a General Policy Statement), the same cannot be said for the 2004 reform. In this case, it is likely that the TV intervention constituted the main channel of communication from the Minister to the public. The choice to focus specifically on TV speeches relies on two elements: first, oral interviews are not partially transcribed or rewritten as it can be the case in the newspapers, and can therefore be analysed as a whole. Then, the choice of TV as opposed to radio is due to its prominent status within the French audience.

Institutional speeches

The selection of the relevant institutional speech with regard to the Juppé plan was based on its status as a General Policy Statement (Déclaration de Politique Générale). Due to its particular role in French politics, this type of speech is generally heavily reported in the media, and can therefore be considered as the main channel of communication of the Prime Minister on the reform. In the case of the Douste-Blazy reform, various and less visible channels of institutional communication have been used. The speech following the Council of Ministers on the 16 June 2004 has been reported in the media, as it took place at the beginning of the parliamentary decision-making process of this law. The other main channel of institutional communication was the speeches given by the Minister for Health Philippe Douste-Blazy’s and its Secretary for the Health insurance Xavier Bertrand’s before the National Assembly on the 17 June 2004. If these two institutional speeches may have been less influential in the media than the 1995 General Policy Statement, they can nevertheless be considered as a functional equivalent. All these speeches were found already transcribed on official websites from the public service and the French National Assembly.

References

TV interviews and speeches

To complete institutional speeches, all televised speeches and interviews about the two reforms were gathered. The selection process of which speeches and interviews we included in our selection was dependent on the materials found on the National Audio-visual Institute (INA) database, which is the main source of data on this matter in France. A keyword research (name of Ministers and sorting by date and media type)Footnote 20 was performed. Finding the main TV intervention by Philippe Douste-Blazy was easily possible, mainly because its intervention on France 2 in May 2004 was regularly mentioned by French eHealth actors we interviewed. In the case of the Juppe plan, the Minister did not specifically present its reform on the TV, as the General Policy Statement was heavily taken up by the media. However, several aspects of the social security reform were announced about a week before the General Policy Statement, during a televised speech about the Ministerial reshuffle.

References

  • Televised speech of Prime Minister Alain Juppé on the Ministerial reshuffle, on France 2, on the 7.th November 1995.

  • Interview with Minister for Solidarity, Health and Family Philippe Douste-Blazy on TF1, on 3.rd may 2004.

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Bérut, C., Saurugger, S. Digital technologies as a response to healthcare system crises: agenda-setting of digital health policies in France. Fr Polit 21, 227–248 (2023). https://doi.org/10.1057/s41253-023-00223-2

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