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Quatorzime congrs national de lAssociation Franaise de Science

Politique
Montpellier 2017
Projet de Section Thmatique
Marc SMYRL, MCF-HDR
(Universit de Montpellier, CEPEL)
marcsmyrl@yahoo.com
Marie MONCADA, doctorante et ingnieure dtudes CNRS
(Universit de Versailles Saint-Quentin-en-Yvelines, PRINTEMPS)
marie.moncada@ens.uvsq.fr
CONTROLE DES DEPENSES DE SANTE ET SELECTION DES INSTRUMENTS :
UNE COMPARAISON ENTRE ETATS MEMBRES DE LUNION EUROPEENNE
HEALTH EXPENDITURE CONTROL AND SELECTION OF INSTRUMENTS:
A COMPARISON AMONG MEMBER STATES OF THE EUROPEAN UNION
Prsentation scientifique
Mots-cls : Action publique, Union europenne, Comparaison, Sant, Budget,
Instrument.
Key words: Public policy, European Union, Comparison, Health, Budget,
Instrument.

En franais (8000 signes)

Comment comprendre la slection des instruments politiques visant contrler


les dpenses de sant dans lUnion europenne (UE) ? Les facteurs impactant sur
ces dpenses sont-ils les mmes que ceux relatifs aux politiques sociales ?
(WILENSKY et al. 1985, MORAN 2000, CLARK et McELDOWNEY 2000, BLAKE et
ADOLINO 2001)
Face laugmentation des dpenses de sant et la rcession conomique dans
lUE, diffrentes stratgies ont t mises en place depuis 2008. La modulation du
prix des soins pour les patients a constitu un premier type dinstrument. La
facture hospitalire a ainsi augment dans certains Etats (Rpublique Tchque,
Estonie, France, Irlande et Roumanie) au mme titre que celle des soins
ambulatoires (Grce, Italie et Roumanie). Pourtant, dautres pays ont diminu le
cot des mdicaments pour les personnes faible revenu (Autriche, France,
Irlande et Italie) et rendu gratuits certains soins (Italie et Hongrie) (MLADOVSKY
et al. 2012). Afin denrayer le cot des soins urgents, le maintien des couvertures
de sant a t un second instrument. Parmi les soins non rembourss se sont
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ajouts les soins dentaires (Estonie, Irlande, Slovnie) et les soins dispenss hors
de lUE (Pays-Bas). LIrlande et, dans une moindre mesure, la Rpublique
Tchque, ont t les seuls Etats exclure certains bnficiaires des couvertures
de sant. Lorganisation de loffre de soin reprsente un troisime instrument
prventif. Les hpitaux ont ainsi t ferms ou ont fusionn (Danemark, Grce,
Lettonie, Portugal, Slovnie). Dautres Etats ont dvelopp le-Sant (Lettonie)
ainsi quun nouveau systme dordonnances lectroniques (Croatie) (MLADOVSKY
et al. 2012). Enfin, le paiement des professionnels de sant est un dernier
instrument permettant, par des mesures incitatives, de contrler lefficacit des
soins. Des politiques de mesure de la performance ont ainsi t mises en place
avant la crise en Rpublique Tchque (2000), en Estonie (1998), en Irlande
(2001), en Lituanie (1998), en Norvge (1996) et au Royaume-Uni (1998) (SHAW
2005).
Daprs la littrature, la fabrique des politiques franaises seraient le fruit des
lites (GENIEYS et HASSENTEUFEL 2001), des conflits entre administrations
(PIERRU 2011) ou entre stratgies individuelles (HASSENTEUFEL 1997; PALIER et
BONOLI 1999). Dautres travaux insistent sur limpact des cooprations entre
associations de patients, professionnels de sant, groupes pharmaceutiques et
assurances de sant au Royaume-Uni (BAGGOTT et JONES 2014; MARSH et
RHODES 1992), en Finlande (TOIVIAINEN, VUORENKOSKI et HEMMINKI 2010), aux
Pays-Bas (VAN DE BOVENKAMP, TRAPPENBURG et GRIT 2010), en Autriche
(FORSTER, BRAUNEGGER-KALLINGER et KRAJIC 2011), en Allemagne (GEISSLER
2011), en Norvge et au Danemark (OPEDAL, ROMMETVEDT et VRANGBAEK
2012). Certaines tudes mettent galement en avant le rle des ides au niveau
europen (RUSSELL 2014). En ce sens, peu de travaux comparent linfluence de
ces paramtres entre eux au niveau des deux premiers cycles du processus de
laction publique (JONES 1970), soit lidentification du problme et le
dveloppement du programme.
Or, comment comprendre la slection de ces instruments dans lUE ? Des trois
i (PALIER et SUREL 2005), devrions-nous passer aux cinq i (PETERS et VAN
NISPEN 1998) ? A la poubelle (COHEN, MARCH et OLSEN 1972) ou la
logique accidentelle (TUOHY 1999), devrions-nous prfrer le choix
rationnel institutionnel (KISER et OSTROM 2000) ou lanalyse squentielle
(SCHNEIDER et INGRAM 2005) ? La littrature comparatiste doit-elle librer ces
modles des carcans nationaux (DEZALAY 2004) ? Notamment, quelle importance
accorder lhybridation des systmes de sant (SCHMID et al. 2010) ? Observe-ton un phnomne de convergence ou de divergence des instruments europens
(BENNETT 1991; CLAVIER et al. 2011; HEICHEL, PAPE et SOMMERER 2005;
HOLZINGER et KNILL 2005) ?
Parmi les rares travaux comparant ces paramtres en matire de sant dans lUE,
les travaux de Mike DENT (2003), Ellen IMMERGUT (1992), Johan MACKENBACH et
Martin McKEE (2013) doivent tre cits. Le premier auteur tablit une
comparaison binaire par chapitre : Pays-Bas/Sude, Royaume-Uni/France,
Allemagne/Italie et Pologne/Grce. Par exemple, en abordant la question du
contrle-qualit des soins au Pays-Bas et en Sude, Mike DENT constate que
labsence de mesure contraignante dans ce domaine est davantage la rsultante
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des conditions de vie aises et dune grande esprance de vie en Sude,


allgeant ainsi la demande pour ce contrle et sopposant par la mme au cas
nerlandais. De mme, en Pologne et en Grce, le clientlisme et le familialisme
dominent en raison, notamment, dune industrialisation tardive et du faible
salaire des mdecins et des infirmires. Ellen M. IMMERGUT compare, en 1992,
diffrents paramtres dont les institutions, les intrts, lconomie, la technologie
et lidologie en Sude, en France et en Suisse. Selon elle, la structure
institutionnelle et les points de vto semblent tre finalement les variables les
plus lourdes pour expliquer le changement politique. Enfin, Johan MACKENBACH
et Martin McKEE observent quen Europe, les politiques de sant prventive
(tabac, alcool, nutrition, sant maternelle et infantile, maladies infectieuses,
hypertension, dpistage du cancer, scurit routire, pollution atmosphrique) se
dveloppent gnralement lorsquun gouvernement social-dmocrate est en
place depuis plusieurs annes.
Dautres paramtres mergent galement la lecture de la littrature
interactionniste . Herbert OBINGER, Carina SCHMITT et Peter STARKE (2013)
montrent ainsi que linteraction horizontale entre Etats membres peut conduire
un changement de politique sociale par apprentissage, imitation, concurrence ou
contrainte. Lapprentissage sinspire des meilleures pratiques dautres Etats afin
de rduire les consquences involontaires de nouvelles politiques tout en
adaptant ces pratiques la situation du pays qui les adopte. Limitation peut
rsulter
dune
tendance
politique
non
contraignante
supranationale
ou internationale. La concurrence renvoie au besoin, pour un Etat, dtre plus
attractif que dautres en contrlant, par exemple, le cot de sa main-duvre. La
contrainte, enfin, peut rsulter dune directive ou dun rglement europen
impratif.
Cette littrature interroge finalement la dfinition de leuropanisation de Claudio
RADAELLI (2002). Cette dernire est, selon lauteur, un processus de (a)
construction, (b) diffusion et (c) institutionnalisation de rgles formelles et
informelles, de procdures, de paradigmes politiques, de styles, de savoir-faire,
de normes et de croyances partages qui sont dabord dfinis et consolids dans
les dcisions de lUE puis incorpors dans la logique des discours, des identits,
des structures politiques et des politiques publiques lchelon national . Or, les
lments interactionnistes mentionns ci-dessus ne sont-ils pas galement un
marqueur deuropanisation ? Quel intrt y a-t-il maintenir cette sparation
entre instances europennes et convergence spontane des politiques
publiques ? Lauteur trouble lui-mme sa propre dfinition en estimant que le
mimtisme entre Etats doit galement tre un lment constitutif de
leuropanisation que ce mimtisme soit, ou non, initi par le triangle
institutionnel de l'UE (HASSENTEUFEL 2011, 279).
Les propositions prolongent donc cette littrature. Elles porteront sur le processus
de slection politique des instruments visant limiter les dpenses de sant dans
lUE. Ltude peut tre une comparaison transnationale portant sur un ou
plusieurs instruments dans au moins deux Etats membres. Elle peut galement
porter sur la slection de plusieurs instruments dans un mme Etat membre
des poques diffrentes.
3

En anglais (4000 signes)

How can we understand the choice of policy instruments intended to control


health care spending in EU member states? Faced with an increase in healthrelated spending and an economic recession in the EU, various strategies have
been attempted since 2008. Adjusting the cost of care for patients is one type of
instrument. Overall payments for hospital care have thus increased in states such
as the Czech Republic, Estonia, France, Ireland, and Rumania as have payments
for out-patient care in Greece, Italy and Rumania. At the same time, however,
other countries have reduced the cost of prescription drugs for lower-income
persons (Austria, France, Ireland, Italy) and eliminated all charge for certain types
of care (Italy and Hungary) (MLADOVSKY and al. 2012). Adjusting payments to
health professionals is another instrument that seeks to control costs by inducing
efficiency. Policies assessing performance were put in place before the recession
in the Czech Republic (2000), Estonia (1998), Ireland (2001), Lithuania (1998),
Norway (1996) and the UK (1998) (SHAW 2005).
Policy literature suggests that French policies are the result of dominance by elite
decision-makers (GENIEYS and HASSENTEUFEL 2001), and conflicts among policymaking units or individual strategies (HASSENTEUFEL 1997; PALIER and BONOLI
1999). In other cases, such as Finland (TOIVIAINEN, VUORENKOSKI, and
HEMMINKI 2010), the Netherlands (VAN DE BOVENKAMP, TRAPPENBURG, and
GRIT 2010), the UK (BAGGOTT and JONES 2014; MARSH and RHODES 1992),
Austria (FORSTER, BRAUNEGGER-KALLINGER, and KRAJIC 2011), Germany
(GEISSLER 2011), Norway and Denmark (OPEDAL, ROMMETVEDT, and
VRANGBAEK 2012), greater emphasis is placed on the impact of cooperation
among patients associations, health professionals, insurers and the
pharmaceutical industry. Other studies put more emphasis on the role of ideas at
the European level (RUSSELL 2014). Beyond this, however, we note a general
lack of research comparing the influence of these parameters with respect either
to the identification of problems or the development of policy responses (JONES
1970, 230231). Should we move from the 3 Is (PALIER and SUREL 2005) of
the new institutionalism to a broader approach such as that of the 5 Is,
(PETERS and VAN NISPEN 1998) to models of temporal sorting such as the
infamous garbage can, (COHEN, MARCH, and OLSEN 1972) or to more
contextual explanations such as Tuohys accidental logic (TUOHY 1999). Should
we privilege an institutional version of rational choice (KISER and OSTROM
2000) or a sequential analysis (SCHNEIDER and INGRAM 2005)? Are national
systems even the appropriate unit of comparison (DEZALAY 2004)? How much
importance should we give to the hybridization of instruments and systems
(SCHMID and al. 2010)? Looking more generally, do we observe convergence or
divergence of instruments in Europe (BENNETT 1991; CLAVIER and al. 2011;
HEICHEL, PAPE, and SOMMERER 2005; HOLZINGER and KNILL 2005)?
Among the rare works that seek to evaluate the impact of these parameters, we
find those of Mike DENT (2003), Ellen IMMERGUT (1992), or of Johan
MACKENBACH and Martin McKEE (2013). The first of these compares successive
pairs of cases: Netherlands/Sweden; UK/France; Germany/Italy ; and finally
4

Poland/Greece. By addressing the question of quality control in Sweden and the


Netherlands, for example, Dent notes that the absence of constraints in this area
is more the result of better quality of life than of longer life expectance in
Sweden. He concludes accordingly that the demand for controls is thus lessened,
in contrast to the situation obtaining in the Netherlands. In Greece and Poland,
clientelism and familialism are dominant forces due to late industrialization but
also the relatively low salaries of doctors and nurses. Writing in 1992, Ellen M.
IMMERGUT compared a set of parameters such as institutions, the structure of
interests, economic organization, ideology, and the level of technology in France,
Switzerland, and Sweden. She concluded that institutional structure and the
existence of veto points were the variables offering the most direct explanation of
observed systemic changes.
Contributions will wonder how instruments are selected to combat the increase in
health care costs in the member states of the EU. Approaches will include
transnational comparisons focusing on one or more instruments in at least two
national cases, or on the choice among two or more instruments in a given
national case. We will welcome as well proposals focused on the role of
supranational bodies such as the EU.
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