Social protection, increasing medicalization of society, dynamics of the medical professions and the hospital institution: health is at the crossroads of multiple concerns. An inventory of empirical research and theoretical perspectives on this theme was necessary.
This book co-written by Henri Bergeron and Patrick Castel aims to fill a vacant place in the abundant literature on the sociology of health by attempting to link the latter to the analysis of social and health policies. To do this, it takes stock of the major explanatory models classically used to deal with this “ political sociology of health “. The work is organized around three main parts (health systems and their trajectories, care professions and organizations, public health policies) which place at the center of the subject the question of collective action and relationships between forces which appear structuring in each part of the book.
Health systems and their trajectories as a starting point
The genesis of health systems is at the heart of the 1D part which restores the way in which welfare states have designed and built their social protection systems as well as the way in which reforms work on them. However, several conceptions of the State and its role exist and lead to the development of different health systems.
The 1er chapter analyzes the principles and programs of Welfare, the question of the redistribution of social benefits, the thesis of social compromise, the diversity of national trajectories with regard to the degree of bureaucratization and centralization in the implementation of social programs. Based mainly on the work of Bruno Pallier, the analysis of social policies from a comparative point of view teaches us that the health system with a universal vocation is not a given, but has been constructed historically and according to modalities different in different countries. Three welfare state regimes, 1990) were identified and gave rise to a typology of health system trajectories which differentiate the various national health systems (broad coverage of the population, equitable but problem of quality and access to care), health insurance systems (quality of care but high level of expenditure and inequality of access to care) and liberal health systems (access to care conditional on the patient’s means, significant inequalities). The analysis of national trajectories of health systems makes it possible to study both the capacity of States, its institutional structure and its regime of government. Bergeron and Castel are particularly interested in the question of knowing “ why did the United States remain the only Western country without a universal health care system for a long time? ? “. They present the interest of the trajectory of the American health system (due to the Obama reform, its transformation into a universal health system, the resilience of institutions, the policies and socio-political determinants of health system reforms) .
In their chapter 2, the authors start from the crumbling of the consensus established, in the aftermath of the 2e World War, around the legitimacy of social policies to discuss health system reforms. This consensus required reforming health systems by mobilizing different public policy instruments, justifications and entrepreneurs for these reforms. Drawing on the work of Gosta Esping-Andersen and Bruno Pallier, this chapter offers an analysis of the controversy surrounding the increase in health costs and the perception of the welfare state other than as a sole burden. By studying the impact of the neo-liberal movement in States (described under the theme of efficiency in particular), the shrinking of the place of welfare States leaves more room for private insurance while requiring the intervention of the ‘State. Reforms in France would thus have led to the strengthening of the role of the State in the management of health establishments and policies, through massive recourse to the market (…). A process of economization is not incompatible with a process of state control » (p. 71). Among the various measures that promote health system reforms, the authors note governance measures (measures to modify the nature of relationships between stakeholders in the sector) ; control of health expenditure and improvement of quality. In the end, the link is very strong and very studied (or very strong because very studied ?) between the trajectories of health systems and Western welfare states allowed the authors of the manual to list several models of explanation of reforms: the institutionalist model (of path dependence and the way in which institutions favor certain groups to the detriment of others), the rational choice model (economic incentives and power relations between dominant actors) and the neo-institutionalist model.
The classic and well-known approach of the organization and healthcare professionals
The studies of the medical profession which has in all countries obtained protections ensuring it a monopoly and a right to self-control are at the heart of the “ traditional scope of health sociology » (p. 131) for the authors who devote two chapters to it.
Chapter 3 deals with the medical profession by questioning the specificities of the profession of doctor (p. 134) and wondering how to explain the protections that doctors benefit from (p. 141). The emergence of private medicine appears to be the advent of a classic professionalization process. Prestigious and established profession, enjoying professional autonomy reflecting a “ professional dominance » and carrying a “ professional project », doctors form a professional group recognized for their expertise and for which professional interests are legitimate to the extent that they participate in the defense of collective benefits (p. 157). The medical profession is, however, more segmented than it seems, the divergences and internal dynamics of the medical profession not preventing it from developing alliances within their “ system » professions.
Chapter 4 addresses the organization of care and medical decisions. The evolution of the medical profession has led to the questioning today of the strong position of medicine vis-à-vis other actors in care, the hospital constituting an organization crossed by power relations which redistribute the legitimacy, the skills of each person. and modify the existing division of labor. Bergeron and Castel also study the way in which patients are placed at the center of the system with a therapeutic relationship which then appears as a heuristic focal point for understanding the care decision-making process. The authors of the manual then identify a growing rationalization which involves the predominance of managers in the hospital, a limitation of the autonomy of doctors, the showing ofEvidence Based Medicinea standardization of knowledge. From this point of view, it is a shame that the authors (Mike Saks and Ellen Kuhlmann in particular) who sought to study the medical profession and the organization of care with regard to national health systems implemented through the question of governance of the medical profession are unfortunately absent from this work.
Public health policies at the heart of the book
The third and final part of the work aims “ to measure the extent to which the struggles are strong and the knowledge and actors are even more numerous with regard to the definition of public health policies » (p. 266). The authors begin by defining public health policies as preventive health policies and “ health safety “. It is organized around the last three chapters.
Chapter 5, which focuses on knowledge (questions of epidemiology, risks, biomedicine) is the one in which the authors justify – surprisingly very late – the choice of the title of their book: “ A political sociology of health issues must give an important place to the study of medical and, more broadly, health knowledge, as well as those who participate in one way or another in the field(s). health » (p. 271). This chapter, the core of the authors’ skills, paradoxically almost leads to questioning the place of the other two parts.
Chapter 6 focuses on patient organizations, knowledge and health policies. The role of patient associations in the formation of health policies is explained there: their number, their form, their visibility and their mobilizations are studied, showing the diversity of the collectives and the power relationships that emerge from them. Very well documented, this chapter clearly shows that associations sometimes obtain a “ moral jurisdiction » (p. 350) but do not necessarily succeed in penetrating the concrete organization of work and exercising decision-making power there.
Chapter 7 concludes the book on public health policies. The authors recall the achievements of work on public health policies: the role of the State in driving public health policies, the emergence of a “ European health area », the history of knowledge and disciplines at the foundation of public health (confrontation of clinical medicine and social medicine), the influence of the Pasteurian revolution on the development of care, the democratization of access to it, investment health, the evaluation of medicines by health agencies, social inequalities in health. By studying how public health policies increasingly work on the relationship to risks (epidemics, chronic pathologies, particular lifestyles, etc.), the authors show how medicalization acts as a framing of problems. public » by a medical definition and form of social control. For example, to take up the work of Abigail Saguy, to speak of obesity rather than corpulence constitutes a medical framing (p. 367). Bergeron and Castel are also interested in how certain social problems are put on the agenda rather than others. The latter makes it possible to analyze public health instruments from the angle of definitional struggles and socio-political processes which authorize or prevent the inclusion on the agenda and the publicization of social problems. Actors, such as European observatories, can thus produce expertise and, as Bergeron has shown on the issue of drugs and drug addiction, contribute to the construction of a public health policy and sometimes to a convergence of national and to the circulation of knowledge. In the end, the authors explain, if public health has achieved some success (the normalization of AIDS by its inclusion in the jurisdiction of general preventive policies for example), it nevertheless remains dominated by the curative approach and struggles to resolve the problem of poor consideration of health inequalities (the agreement on the observation does not translate in practical measures, instruments and concrete actions).
This manual, which provides a complete overview and includes an impressive amount of work and references, emphasizes what persists in health practices, policies and systems and produces individualization and empowerment of individuals in the taking care of their health. Despite all its qualities, this work nevertheless has the drawback of being aimed more at the initiated. However, the usefulness of a manual is not obvious to those familiar with the field of health. The implications left by the authors are indeed damaging in that they do not always explain certain notions sufficiently for others, those for whom this type of work is ultimately intended, such as for example “ disease management ” Or “ clinical pathways » (p. 90). An additional effort at explanation would, however, have made this book essential by making it more accessible to non-specialists in the field of health.