CO-PRODUIRE ET PARTAGER DES CONNAISSANCES POUR DECLOISONNER ACTEURS ET NIVEAUX TERRITORIAUX ET AGIR SUR LES INEGALITES INFRA-COMMUNALES DE SANTE
Depuis 2011, un groupe de travail francilien dénommé « Plateforme Géodépistage » réunit des acteurs de différentes sphères professionnelles (chercheurs, acteurs institutionnels et de santé publique, élus locaux) agissant à différents niveaux territoriaux (de l’Etat à l’intra-communal) autour de la question des inégalités socio-territoriales de santé. Ce rapprochement s’opère autour de la production de connaissances sur les disparités d’accès au dépistage du cancer du sein dans des villes d’Ile-de-France.
L’article propose de décrire la démarche de co-production, partage et application des connaissances portée par ce groupe de travail régional et de mettre en évidence deux types d’effets produits par le décloisonnement d’acteurs qu’induit cette démarche, à la fois au sein de la plateforme elle-même et dans une ville, en s’appuyant sur l’exemple d’Argenteuil (Val d’Oise). La première expression de ce décloisonnement s’observe dans la création de références communes entre les acteurs de la plateforme autour de la notion de territoire et d’inégalités de santé. La seconde se révèle dans la mise en oeuvre au niveau local de collaborations avec de nouveaux acteurs qui n’étaient pas encore associés au processus de co-production de connaissances.
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Co-producing and transferring knowledge to decompartmentalise stakeholders and territorial levels and reducing health inequalities
“Territorialisation” can be considered as the contextualization of public action (Clavier, 2011). With this redefinition of the shape of public action, combined with the growing recognition of the holistic view of health determinants and social and spatial health inequalities, Public Health is not anymore a medical problem that would be solely addressed by health professionals. It rather becomes a social issue on which political actors (locally elected-officials, institutional and associative territory-based players, etc.) may legitimately take decisions (Clavier, 2011). Indeed, social and spatial determinants of health inequalities comprehend a wide array of factors that combine differently according to places. When being considered at various scales, these factors incorporate a range of stakeholders from various sectors and involved at different territorial levels. These stakeholders face the challenge to coordinate themselves to tackle the issue of reducing social and spatial health inequalities effectively.
“Territorialisation” of public action in regards to health implies changing the way local health policies are implemented and managed within the territories (territory being defined as “institutionalized geographical space”). This involves new practices based on new knowledge and new coordination patterns between actors (Torre & Vollet, 2016). Focusing at local level recombines the content of public policy. The State / national level is then required to authorize – whether it is acknowledged or not – a set of tasks set by a “lower” level of action. Locally-based actors redefine problems related to their territories (Thoenig, 1996). However, if locally-elected officials and local actors (from the health sector or not) are claiming proximity as a way to better adjust policies to local issues, optimal degree of proximity (city, district, region, and others), strategic choices and programs’ implementation still vary drastically depending on their own intervention area. Thus, linking and coordinating actors has become a major challenge to territorialize public action (Gumuchian et al., 2003). This coordination deals with connecting various actors working at different scales in order to act in a consistent, synergetic and integrated manner. In addition, defining issues and the objectives of the public policy meant to answer these questions require building the foundations of a collective intelligence (Clavier, 2011) and an increased capacity of territory-based information for action. Therefore, knowledge, including its production, sharing and transfer modalities and access, becomes a strong challenge for the players if they wish to be part of this public action territorialisation and influence it.
Since 2011, a French regional working group called “GeoScreening Platform” (“Plateforme Géodépistage”) brings together stakeholders from various professional spheres (scholars, public health and institutional stakeholders, local decision makers) working at different territorial levels (from State to intra-urban). The working group focuses on social and territorial health inequalities in the Paris Region. Bridging these stakeholders is done through production of local health diagnosis carried out by health geography students from Paris Nanterre University (UPN) as part of their academic training. These studies compile an inventory of disparities in accessing breast cancer screening in cities within the Paris Region. They also highlight the potential explanatory factors of these social and territorial inequalities.
“GeoScreening Platform” connects health geography scholars / lecturers from Paris Nanterre University (UPN), the National Association of Cities for Public Health (Elus, Santé publique et Territoires, ESPT), eight associations managing breast cancer screening programs at district level (structures départementales de gestion des dépistages), Health Insurance, Regional Health Agency (ARS- IdF) and the Regional Union of Health Practitioners (URPS-Médecins IdF).
The article aims at portraying the co-production, sharing and transfer of knowledge carried by the regional working group. It emphasizes two kind of effects resulting from stakeholder decompartmentalisation induced by this approach. This analysis will draw on the example of the city of Argenteuil (Val d’Oise) where several studies have been co-produced (four in geography and one in sociology, between 2012 to 2016).
The first proof of the decompartmentalisation is observed in the creation of common references among the Platform’s members. The collaborative working group gradually evolved into a true partnership and developed a cross-sectoral approach. From the initial motivation to investigate a technical issue (namely geocoding data to better target populations and identify intervention areas), the members gradually moved towards incorporating a health geography approach. This is shown through an evolution of language and the use of paradigms. The stakeholders adopt the concept of reducing social and territorial inequalities in health through their actions. By producing a common knowledge, the members themselves become owners of the approach as well as the results produced by the studies that they convey within their own spheres. Indeed, they contribute to their diffusion and dissemination.
A second proof of the decompartmentalisation is seen in the implementation at local level – in the city of Argenteuil – through collaboration with new stakeholders who had not yet been involved in the knowledge co-production process.
Argenteuil is a working class city where health has long been an important local agenda. The city is known to be socially and physically fragmented, marked by major social and health inequalities between neighborhoods. For these reasons, the local health policy does not only focus on access to health care but it also considers prevention interventions as well as programs tackling social and territorial inequalities. To develop this local policy, both in the implementation of actions and in its construction as a vision, the city needs to rely on knowledge
Since 2012, the platform collaborates with Argenteuil’s stakeholders and decision makers, who shared their interest in this partnership; a project bridging research to action. In a context of major political changes, the principle of the commitment on these health issues is not compromised. We observed how the studies carried out by the students in Argenteuil and other cities in the Paris Region first served the local stakeholders as a primarily foundation for further reflection. Then we saw the process of knowledge co-production and transfer. The way Argenteuil’s stakeholders integrated it, gives an opportunity to the local health department to work with new staff who have not been involved in actions related to health inequalities yet. These new players are from within the health department (eg. working in the City Health Centers) or from another department (eg. working in urban poor targeted areas, on sports, etc.).
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