Pilotage et mise en œuvre d’une réforme d’un système public de santé : dynamiques entre acteurs d’une gouverne pluraliste

Public health systems can be characterized in terms of pluralistic contexts, involving actors with diverging objectives, who remain linked through ties of interdependence. In such contexts, no formal authority can exercise complete control over the trajectory of collective action. In order to guide change, the State, who nonetheless occupies a particular position, has the obligation to insert itself in the ever evolving interactions of key actors. This thesis aims to analyze and understand the State’s governing capacities, and the dynamics between the concerned actors in piloting and implementing a public health system reform.  The thesis proposes a theoretical framework drawing upon the organizational analysis of Crozier & Friedberg (1987) and the policy instruments approach of Lascoumes & Le Galès (2004). In this perspective, the identified actors are motivated by their particular stake in the issue and mobilise strategies that effect the evolution of the collective action. In order to reach its objectives, the State calls upon instruments of various kinds, such as those based on formal authority or communication and information.   The theoretical framework is applied to a case study: the New-Brunswick health system reform launched in 2008. In terms of reorganisation, the eight existing regional health authorities (RHAs) were amalgamated in two (RHA A and RHA B). RHAs A and B thus represent two units of analysis. In addition, the analysis is informed by interviews with representatives of the State, such as health ministers, deputy ministers, and other relevant stakeholders, such as chief executive officers of health organizations, health professionals, and citizens. The analysis is also supported by a review of the grey literature, including media reports. The study period is characterized by three specific time points: the formulation of the reform (2006 to 2008), the grand launch and immediate response (2008 to 2010), and the implementation of the reform (2010 to 2015). During these phases, the stakeholders were compelled by various aspects of the reform that motivates them to change their behaviors, for example, access and coordination of care, performance and public participation. Moreover, factors present in the systemic context, such as language rights within the health care setting, provide further motivation, among certain actors, influencing change. This research demonstrates that as the context evolves the State must adapt to the dynamic interactions of the actors involved, and mobilizes various instruments to respond accordingly. The response to various strategic actions may be conceptualized as a continuous learning process.  In conclusion, practical recommendations are proposed, aimed at decision-makers when conducting public health system reforms. The recommendations proposed are also consistent with the modifications made to the theoretical framework. These relate to the objectives proposed by the State, the continuous learning process, the types of instruments that can be used to renew legitimacy, and regarding the citizen population, an influential group of actors in the pluralistic context. The recommendations emphasize the general idea that a reform takes place over a long period of time, and that its programming by the State can be very difficult.

Keyphrases: Governance instruments, Health system, Reform, Organizational approach, Pluralistic context, Case study