COVID 19 and the healthcare policy process in France: between presidentialization and programmatic reform path

This paper starts with an analysis of the healthcare policy process in the context of the different COVID 19 waves in France. It can be characterized by the key role of presidential authority, especially during the first wave. The main decisions were taken by the Sanitary Defence Council directly headed by Emmanuel Macron and announced by him. The President also launched a scientific council directly working for the Executive. This centralization of the decision process, reinforcing the presidentialization of the French political system, has led to a strong politicization of the COVID 19 policy issues and to a bypassing of the programmatic group: the “welfare elite”, a narrow group of senior civil servants, characterized by a specialized career path in the Social Security administration, which holds a key position in the healthcare policy process since the end of the 20th century (Genieys, Hassenteufel, 2015). Their policy change program has been heavily contested in the context of the COVID 19 pandemic, especially in the hospital sector with the lack of intensive care beds shedding the light on the negative effects of strict budgetary constraint on healthcare provision. The organization of a large discussion forum with the main stakeholders in June 2020 (“Ségur de la Santé”) has led to the adoption of different policy measures: the reopening of hospitals beds, recruitment of healthcare workers and medical staff, wage increase hospitals (especially for nurses) and the weakening of managerial power in hospitals (Hassenteufel, 2020). Therefore the COVID 19 pandemic seems to play the role of a focusing event (Kingdon 1984, Birkland, 1997), punctuating the established policy equilibrium (Baumgartner, Jones, 1993) in French healthcare policies. The paper will discuss this interpretation by shedding the light on previous changes in these policies, especially the elaboration of a new policy program oriented towards the reorganization of healthcare provision based on territorialization and new modes of coordination. It is strongly related to the agenda setting of the issue of “medical deserts” (Hassenteufel et al., 2020), and the growing involvement of elected local authorities in healthcare issues, reinforced by the COVID 19 crisis. The paper analyzes the policy actors involved in the shaping of this policy change program which are related to the “welfare elite” and how they try to make a strategic use of the current crisis in order to push it forward, in new institutions created before the crises, especially the regional health (state) agencies (ARS). Finally, we stress that the French programmatic elite in healthcare policies has been able to maintain its position in the policy process, especially in policy implementation, in the context of the COVID 19 crisis and therefore to pursue the new reform path initiated before.