Issues and challenges of prescriptive zoning for public action

The example of the general practitioners zoning in France

Catherine Mangeney (Géographie-cités / Université Paris Cité) will present her thesis supervised by Julie Vallée and entitled: entitled: “The issues and challenges of delimiting prescriptive zoning for public action. L’exemple du zonage déficitaire en médecins généralistes en France et plus spécifiquement en Île-de-France”on

Thursday 7 December
at 2 pm
Université Paris Cité
Grands Moulins Campus
Halle aux Farines Building,
Esplanade Pierre Vidal-Naquet
75013 Paris, France
Thesis room (room n°580, sector F, 5th floor)

Composition of the jury

Claude GRASLAND (examinateur) – Professeur de géographie – Université Paris Cité
Patrick HASSENTEUFEL (examinateur) – Professeur de science politique – Université Paris Saclay (UVSQ) et Sciences Po Saint-Germain-en-Laye
Gladys IBANEZ (examinatrice) – Professeure de médecine générale – Sorbonne Université
Sophie de RUFFRAY (rapportrice) – Professeure de géographie – Université de Rouen
Julie VALLÉE (directrice de thèse) – Directrice de recherche CNRS – UMR Géographie-cités
Bruno VENTELOU (rapporteur) – Directeur de recherche CNRS – Ecole d’économie Aix-Marseille

Summary

Since 2005, French legislation has provided for the delimitation of geographical areas where populations lack spatial accessibility to general practitioners and in which doctors can receive public aid. The objective of this thesis is to discuss the methodology for delimiting this “doctor zoning”.
After having described in the preamble the process of the advent of doctor zoning as an instrument of public action, I devote the first part of this thesis to the interplay of interests and constraints which weighed on the methodology of delimitation of doctor zoning currently in force in France.

I also come back to the link between lack of spatial accessibility to general practitioners and poverty which turns out to be more fantasized than proven. I maintain that, as an instrument serving a public policy of positive discrimination with a territorial dimension, medical zoning must be delimited taking into account the objectives of social and spatial justice but also budgetary, pragmatic and political constraints.

In the second part of the thesis, I question the method of measuring levels of accessibility to general practitioners. To do this, I rely on the APL indicator (localized potential accessibility) and I evolve the initial parameters: geographical scale, mathematical model, quantification of the care offer (minimum and maximum thresholds of activity of doctors, age limit), quantification of the needs of the populations (according to their levels of consumption of care and non-recourse or according to the consultation durations necessary for prevention and health education actions) and configuration of the function decreasing the probability of appeal depending on the distance.

The idea is to test different settings of the APL in order to integrate the social dimension of needs. For Île-de-France, I observe that the changes made to the APL indicator lead to very significant variations of the geography of the areas of residence in which we measure low spatial accessibility to general practitioners. I also observe that the link between accessibility deficit and social disadvantage is strengthening but that it remains tenuous and is expressed differently depending on the types of spaces: it is more marked in the heart of the Parisian metropolitan area and in the rural areas of the Ile-de-France region.

In the third and final part of this thesis, I model what the situation in Ile-de-France could be in 3 and 5 years if the new doctor facilities were not subject to any zoning, if they were organized according to the current incentive zoning or according to more coercive zoning. I also test the impact of alternative zoning based on a paradigm shift, namely encouraging doctors to settle within urban polarities which correspond to their aspirations in terms of living environment while serving the greatest number of populations lacking of spatial accessibility to care. I show that this last principle is promising, particularly if doctors are mobile and agree to carry out part of their activity in secondary practices located in rural areas.
Through all of this research, I highlight the extent to which the geography of levels of spatial accessibility to general practitioners varies depending on the parameters integrated into the measurement. I show that, in a situation of medical shortage, each zoning principle leads to improving the spatial accessibility to care of certain categories of the population to the detriment of others. This research thus underlines the importance of leaving it to politicians to determine which categories of population and territories they wish to support as a priority. The way in which experts then delimit the zoning depends on this.