France: A Public health system built on competing paradigms
Abstract Background Although France helped establish public health as a scientific discipline, it is well known that the country was slow to implement public health measures on a national scale. The central government played a limited role in public health until the second half of the 20th century. Public health became a privileged space for political action in the 1990s, as a direct outcome of the “blood crisis” and a series of other health “scandals”. Methods A comparative historical analysis (CHA) based on government documents, law, and secondary sources. Results Between the early 1990s and 2016, France saw the emergence of two competing understandings of public health. It was legally defined as a responsibility of the state to protect its population against disease risks and to ensure equal access to and representation in the healthcare system, captured by the notions of sécurité sanitaire (“health security”) and démocratie sanitaire (“health democracy”). Public health actions framed in the language of “security” changed its place in the hierarchical structure of the state. It both reinforced public health as a legitimate field of intervention (now presented as an important function of government, similarly to finance, foreign affairs, defense, etc.) and reinforced the central state, as the legitimate protector of population health and provider of public health services. The French public health arena also witnessed the (re)emergence of local and private actors, motivated by their own interests and competing understanding of public health.