Comparative scholarship on health systems has largely relied on institutional approaches, based mainly on the public–private divide. This article argues that political dynamics are central to understanding the shaping and evolution of health systems. France offers a particularly instructive case due to the complexity of its system: intertwined public-private mix, changing modes of governance, persistence of historically rooted arrangements and institutional disjunctures. Drawing on policy tracing, with attention to critical realism, and conducting a contextual and historical analysis, the article shows how actor configurations, power resources, ideological conflicts and political crises have structured the French health system over time. The introduction presents the characteristics and paradoxes of the French system, which this article contributes to explain. The following two sections trace the separate institutionalisation of the two key policy actors: first, the nineteenth-century formation of the medical profession, structured as a national scientific elite, local political notability, and a corporatist organisation ; second, the belated and contingent construction of a national health insurance system, confronted with the resistance of organised medical liberalism. The third section analyses how the power relationship between the medical profession and the government have evolved after a major change of the political regime (Vth Republic) and pressure from economic and social challenges, such as modernizing hospital infrastructure, universalising access and containing expenditure. It shows growing government leadership, and yet limited statecraft over parts of health sector. The conclusion points to the interest of long-term policy tracing, as a method that allows to uncover underlying power structures and identify the causal factors of change, an approach applicable to other national cases.

Background
After encountering funding problems in the 1980s, the French healthcare system is now facing new types of public problems that trigger organizational responses. This is the case with the growing shortage of medical workforce since the 2000s—particularly GPs—leading to geographical inequalities in access to primary care. The expression “medical desert” has since flourished in political discourse and the press, contributing to the dramatization of the problem and pushing it to the top of the political agenda. At the same time, we are witnessing the development of a new repertoire of policy instruments that make primary care—and GPs in particular—the cornerstone of the healthcare system.
Objective
Based on an empirical qualitative analysis, this paper highlights the key role played by a new “instrument constituency” (Béland & Howlett, 2015; Voß & Simons, 2014) in the primary care reform process. This constituency consists of a small group of GPs —open to team-based practice, the integration of psychosocial dimensions of health, and changes in payment methods— playing the role of professional entrepreneurs, and the established “Welfare elite” —composed of political actors and civil servants who share reform objectives regarding health policies.
Approach
The paper adopts a processual approach, first focusing on the formation of this instrument constituency (around a specific organizational model: the multi-professional healthcare centers), then its gradual institutionalization through successive reforms (e.g., new financing methods and territorial integration of healthcare services) and the evolution of this instrument constituency (more specifically, the evolution of the roles and positions of its members).
Findings
The instrument constituency progressively institutionalized through new financing methods and territorial integration of healthcare services, extending to new professional and political actors. However, the persistence of the “medical deserts” problem and the proliferation of competing policy instruments have recently weakened this constituency.
Implications
The paper raises the question of the constituency’s sustainability in the current context of increasing conflicts in the French healthcare system, and opens a broader discussion on the role of instrument constituencies in policy change.

Citations

• Introducing Health Politics
  Haejoo Chung, Carles Muntaner
  Health Politics.2026; 1(1): e001.     CrossRef