L’influence de la gouvernance sur la capacité de changement du système de soins : l’exemple de l’implantation des groupes de médecine de famille

This thesis is concerned with the governance of change in pluralistic contexts. We wanted to gain a better understanding of the governance processes utilised to develop and implement a public policy aimed at transforming pluralistic organisations. To this end, we conducted a multiple-case study of the emergence and implementation of a policy supporting the creation of family medicine groups (FMG) as it unfolded in five FMGs. The case studies were informed by over 100 interviews conducted in two periods in time as well as from an analysis of documents and questionnaires relating to the organisation of the FMGs. This thesis is essentially composed of three articles.  In the first article, we propose an analysis of the emergence and implementation of the FMG policy based on a combined processual-contextual perspective, which has its roots in the field of organisational change, as studied in organisational theory. The results demonstrated that the management of change in a pluralistic context is associated with multiple prescribed and constructed processes. We termed this phenomenon a regulation of collective action. The conceptual framework we developed enabled an analysis which in turn fostered a more enlightened understanding of the interactions that take place between processes, the context and the nature of change. The second article proposes a conceptualisation of governance that enables it to be studied in pluralistic contexts. This framework draws from several branches of political science and public administration. It considers governance as the set of processes involving the participation of many actors, who possess varying degrees of governance capacities. These governance processes are manifested in actors’ actions and the instruments they mobilise. Furthermore, the governance processes consist of three types of functions—avenue-prospecting, decision-making and regulation—which together serve to coordinate collective action. Like the first article, the third proposes an analysis of the emergence and implementation of a policy; however this article incorporates the framework of governance developed in the preceding article. Our analyses yielded some novel findings about the various functions of governance and the processes that lead to their realisation. Specifically, they revealed how the pluralistic context influences and shapes governance functions. In such contexts, the regulation function was found to be carried out in an indirect manner and to be closely tied to the functions of avenue-prospectings and decision making. These functions fostered the knowledge gathering and the consensus building needed to mobilise collective action and were manifested in the use of governance instruments. An analysis of actors’ actions and the instruments they used gave us insight into the many forms that such actions and instruments can take as well as the contexts in which they may be mobilised. Indirect instruments allowed for interactions (e.g. task force, committee or meeting) and the formalisation of agreements between actors (e.g. contracts, care protocols). These instruments proved to be fundamental to the coordination of the various actors participating in governance, both within organisations and between them. Our results demonstrate that the two frameworks contribute significantly to the study of change governance. We developed two conceptualisations inspired from political science, public administration and organisational theory, and the analyses they enabled revealed how the two frameworks complement each other. These results have given us a more clarified understanding of the processes involved in such a systemic change as well as the relationship between these processes and the efforts deployed at various levels of governance by actors exercising their capacity to influence or shape a far-reaching public policy.

Keyphrases: governance, change, governance instruments, process research, case studies, pluralist context