Territorialisation as an answer to the crises of the health system: healthcare territorialisation programs in France

The notion of territorialisation, which can be defined as a “combination of symbolic definition activities and material organizations aiming to make a delimited space the object of a political activity” (Segas, 2020), goes beyond those of regionalization, decentralisation or federalism, more used in the literature on subnational levels of public policies, for instance in healthcare (Costa-Font, Greer, 2013). Corresponding to the collective construction of public policies at subnational levels, territorialisation includes the main dimensions of the policy process (Mazeaud and al., 2022). More precisely territorialisation is related to three intertwined political activities characterising the policy process and involving programmatic actors: ▪️ The first one is the territorial definition of problems corresponding to the localised construction of policy issues and their contextualisation (Segas 2021). The spatial framing of public problems is the condition of the formulation of territorial policy programs and for the mobilisation of actors at different levels to support them. ▪️ The second one is precisely the formulation process of localised policy programs proposing policy orientations, arguments and policy instruments to tackle spatially framed problems in a policy domain. ▪️ The third one is the transformation of the territorial policy program into a territorial policy, fitting to a local context, through interactions involving different kind of policy actors with different resources, mobilized for the program at different policy levels. Territorialisation as an analytical approach has to be distinguished from territorialisation as a policy content and goal. In healthcare territorialisation as a policy program refers to the following dimensions: ▪️ increasing the policy capacities in healthcare to different subnational policy actors, public and private (and not only elected local authorities as in the regionalization, decentralization or federalism approaches), through the allocation of different kind of resources (institutional, financial, administrative, healthcare workforce and equipments…); ▪️ taking into account the spatial differences in health (especially territorial inequalities for healthcare provision and the state of heath of the population; i.e territorial social inequalities) and giving the possibility to define and produce territorially differentiated health policies adapted to specific needs and problems of a local population; ▪️ increasing the local coordination and integration of the different healthcare services (especially between in-and out-patient care); ▪️ involving the local population in the policy process through political participation and patient empowerment. This paper is focused empirically on France and shows how territorialisation has been put forward as a key policy orientation by programmatic actors. This new policy program aims to tackle issues related to the multiple crises of the French healthcare system, especially territorial inequalities of healthcare provision and more generally lack of workforce and organizational failures, reinforced by the COVID 19 crisis (Hassenteufel, 2020).