Abstract EN:

Between 1995 and 2008 the reform of the health insurance system in France deeply transformed the social state. From the apex of the state downwards various apparatuses (institutional structures, training programs, work organization) induced new (or renewed) thought categories and practices that penetrated the representations and work of institutional agents. The role of the state was reinforced and managerial policies incorporating a new governance system were introduced. In the course of this transformation, the training programs aimed at different categories of agents were reformatted to fit both the new political orientations of the health system and the discourse of "quality service" with its managerial tools. The implementation in January 2000 of a universal health coverage programme called CMU (Couverture Maladie Universelle), the aim of wich was to protect precarious populations, has been empirically observed. The influx of "assisted" population groups claiming CMU or AME (state medical aid for certain foreign populations) benefits led to a reorganisation of the system, evidence in the way in wich users of the health system are treated at the reception at local level. The managerial rationalisation allowed a classification of users ranging from "good" insured clients to the "assisted" and the imposition of strictly quantitative objectives (norms of "quality"), rationalised work time and work organisation measuring such items as "client" time spent in waiting lines on the length of interviews. At the same time, however, arbitration over the attribution of conditional CMU or AME coverage was left to the discretionary appreciation of health service employees.