Physician zoning in France: the genesis of a public action instrument with a territorial dimension
- Cet article est une traduction de :
- Le zonage médecins en France : genèse d’un instrument d’action publique à dimension territoriale [fr]
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1As in other countries, territorial shortages in primary care provision has been a major issue for French public health policies for several years. Since 2005, regulatory “doctor zoning” has targeted areas with a shortage of general practitioners, where doctors are entitled to various public aids.
2In a socio-historical approach, this article aims to describe the genesis of this instrument of public action and to trace the process of its slow and hesitant emergence in a landscape of complex and contradictory interests. I propose to identify four successive periods. The first runs until the 1960s and 1970s, a period in which urban medicine escaped the process of territorial health planning that was gradually being put in place in France. The second period refers to the time when, in the face of the economic crisis and the challenges of controlling health expenditure in the 1970s, a global and a-spatial regulation of the number of independent health professionals was gradually taking shape, with the support of part of the medical profession. A third period can be identified towards the end of the 1980s, when the risks of a medical shortage emerged more and more markedly in the media, but when the stakes of controlling health expenditure still outweighed the demands of the public. Finally, the fourth period refers to the 2000s when, under increasingly virulent pressure from the public, the first steps were taken towards territorial regulation of liberal health professionals: the law n°2004-810 of August 13, 2004, relating to health insurance, created the Regional Health Missions (MRS) responsible for delimiting a zoning of doctors with regulatory status.
3This chronological presentation of the different stages leading to the genesis of the "physician zoning" instrument makes it possible to highlight that, like any other public policy, the introduction of physician zoning in 2005 seems to be the result of the meeting of three distinct processes. The first (problems stream) refers to the process that led to a "social fact" (the distribution of doctors over the territory) being promoted to the status of "object of social debate" (the existence of medical "deserts" calling into question the fundamental republican principle of equal access to health care), gradually supplanting the economic imperatives of controlling health care expenditure, the dominant paradigm until the 2000s. This gradual shift can be explained in particular by citizen pressure relayed by the media, which on the one hand led local elected officials to take up the problem, which on the other hand led medical bodies to prioritize their demands and public authorities to re-evaluate their decisions (political stream). Finally, the choice of instrument and the form it takes are part of a more general process of increasing territorialization of public policies, particularly health policies, as well as a process of development of territorialized positive discrimination policies (policy stream).
4Going back to the genesis of the instrument, and to the interplay of actors and interests, makes it easier to understand that current medical zoning, in its purely incentive form, is a tool of compromise shaped in part by pragmatic issues that cannot be ignored. In a context of redesigning physician zoning, of recurrent questioning of its relevance and of re-discussion of the measures to be adopted (between incentives and coercion, in particular) in France, this lays down certain bases for reflection that could be useful in any exercise of revising zoning and its associated public policies: has the balance of issues, constraints, interests, power relationships and capacities for action changed today? In a context of medical shortage, disaffection for general medicine and for private practice, isn't this pragmatic dimension all the more important?
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Référence électronique
Catherine Mangeney, « Physician zoning in France: the genesis of a public action instrument with a territorial dimension », Revue francophone sur la santé et les territoires [En ligne], Décentralisation et territorialisation sanitaire, mis en ligne le 29 janvier 2023, consulté le 07 mars 2026. URL : http://journals.openedition.org/rfst/1776
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