Has the establishment of regional health agencies achieved its objectives?
In 2014, the Social Security Evaluation and Control Mission (Mecss) drew up an initial assessment of the ARS “a major innovation, a lack of trust”. The parliamentarians pointed out dysfunctions in the national management of health and medico-social policies as well as insufficient coordination of the different administrations (functioning like “organ pipes”). The mission recommended in particular balancing the powers around the director of the ARS, by assigning more powers to the supervisory board and by strengthening health democracy within the framework of the regional health and autonomy conferences and the territorial conferences, but also granting more autonomy of action to the agencies and trusting the actors on the ground. It also insisted on the need to give more financial resources to the agencies for community care.
Four years later, a report from the General Inspectorate of Social Affairs (IGAS) on “Steering the transformation of healthcare provision by the ARS” studies the implementation of the national strategy My health 2022. This strategy, included in the law on the “organization and transformation of the health system” of July 24, 2019, sets new objectives for the territorial management of healthcare provision. The IGAS warns of the following elements:
- analysis of the population’s needs does not always lead to better accessibility and quality of care;
- Agencies must have sufficient human and budgetary resources for greater autonomy of action. Their supervisory authority must therefore “refocus on objectives and results and not on means”.
Claude Evin, former Minister of Health and former director of the ARS of Ile-de-France for six years, published on March 31, 2020, on the occasion of the tenth anniversary of the ARS, an overall assessment of this “regional decentralization”. He highlights the following advances:
- the establishment of unified regional governance;
- the importance of “bringing together State services and health insurance in the regions” (regional multi-year plan for risk management and efficiency of the healthcare system);
- a “strengthening of health democracy” through consultation;
- the success of the departmental ARS delegations, strongly requested by health professionals;
- a better analysis of local needs.
For Claude Evin, the assessment of the agencies is rather positive. The management of the health system at the regional level has been strengthened. On the other hand, this new organization has not been taken into account at the national level. To complete the territorialization of health policy, the central departments of the Ministry of Health still need to evolve “in their culture, their organization and their functioning, which are still very much marked by an approach top down with decentralized services.”
The ARS are often perceived as “technocratic behemoths” far removed from the field, notes a parliamentary report in June 2021. The assessment that the rapporteurs draw from the action of the ARS is mixed. The agencies have a vast scope of competences but the question that now arises is that of their capacity to carry out all of their missions. The missions of regulation and structuring of the health offer seem, for example, to mobilize the ARS much more than their public health missions, of which the health crisis has nevertheless served to remind us how essential they are.
While the report does not question the logic behind the creation of the ARS or their status, it does recommend rethinking their governance in order to remedy the feeling of distance between the ARS and the field. In particular, it suggests strengthening the departmental delegations of the ARS and giving more weight to the regional counter-powers that control the action of the agencies.
On this last point, the rapporteurs propose in particular to transform the supervisory board of the ARS into a board of directors co-chaired by the president of the regional council and the regional prefect. They also insist on the importance of granting more autonomy to the agencies and of strengthening their financial and human resources.
Reforming the governance of ARS by strengthening the weight of local elected officials is one of the objectives set by the law of February 21, 2022 (known as “3DS”), which transformed the supervisory board of agencies into a board of directors. Following a health crisis that has shown the importance of local action, this measure should allow greater involvement of local authorities in the implementation of health policy. A decree of June 19, 2024which comes into force on October 1, 2024, modifies the composition and operation of the body for this purpose.
Operational mechanisms, which aim to facilitate the practice of health professionals and improve the organization of patient care, in which local authorities are involved, already exist. For example, the territorial professional health communities (CPTS)bringing together health professionals in a territory, are supported by the departments or municipalities. Installation assistance is in place in areas lacking in doctors, in collaboration with the communities.
