L’influence de la gouvernance sur la capacité de changement du système de soins : l’exemple de l’implantation des groupes de médecine de famille

Cette thèse s’intéresse à la gouvernance de changements en contextes pluralistes. Nous souhaitons mieux comprendre l’exercice de gouvernance déployé pour développer et implanter un changement par le biais d’une politique publique visant la transformation d’organisations pluralistes. Pour ce faire, nous étudions l’émergence et l’implantation de la politique encadrant la création de groupes de médecine de famille (GMF) à l’aide d’études de cas correspondant à cinq GMF. Les cas sont informés par plus de cents entrevues réalisées en deux vagues ainsi que par une analyse documentaire et des questionnaires portant sur l’organisation du GMF. Trois articles constituent le cœur de la thèse. Dans le premier article, nous proposons une analyse de l’émergence et de l’implantation de la politique GMF à l’aide d’une perspective processuelle et contextuelle développée à partir du champ du changement organisationnel, tel qu’étudié en théorie des organisations. Les résultats démontrent que la gestion du changement en contexte pluraliste est liée à de multiples processus prescrits et construits. Nous avons qualifié ce phénomène de régulation de l’action social (regulation of collective action). La conceptualisation développée et les résultats de l’analyse permettent de mieux comprendre les interactions entre les processus, le contexte et la nature du changement. Le deuxième article propose une conceptualisation de la gouvernance permettant l’étude de la gouvernance en contextes pluralistes. La conceptualisation de la gouvernance proposée tire profit de plusieurs courants des sciences politiques et de l’administration publique. Elle considère la gouvernance comme un ensemble de processus auxquels participent plusieurs acteurs détenant des capacités variables de gouvernance. Ces processus émergent des actions des acteurs et des instruments qu’ils mobilisent. Ils permettent la réalisation des fonctions de la gouvernance (la prospective, la prise de décisions ainsi que la régulation) assurant la coordination de l’action collective. Le troisième article propose, comme le premier, une analyse de l’émergence et de l’implantation de la politique mais cette fois à l’aide de la conceptualisation de la gouvernance développée dans l’article précédent. Nos résultats permettent des apprentissages particuliers concernant les différentes fonctions de la gouvernance et les processus permettant leur réalisation. Ils révèlent l’influence du pluralisme sur les différentes fonctions de gouvernance. Dans un tel contexte, la fonction de régulation s’exerce de façon indirecte et est étroitement liée aux fonctions de prospective et de prise de décisions. Ces fonctions rendent possibles les apprentissages et le développement de consensus nécessaires à l’action collective. L’analyse des actions et des instruments a permis de mieux comprendre les multiples formes qu’ils prennent, en lien avec les contextes dans lesquels ils sont mobilisés. Les instruments indirects permettent les interactions (p. ex. commission d’étude, comité ou réunion) et la formalisation d’ententes entre acteurs (p. ex. des contrats ou des protocoles de soins). Ils se sont révélés fondamentaux pour coordonner les différents acteurs participant à la gouvernance, et ce tant aux niveaux organisationnel qu’inter organisationnel. Les résultats démontrent que les deux conceptualisations contribuent à l’étude de la gouvernance du changement. Nous avons développé deux perspectives inspirées par les sciences politiques, l’administration publique et la théorie des organisations et les analyses qu’elles ont permises ont révélé leur complémentarité. Les résultats permettent de mieux comprendre les processus impliqués dans un tel changement ainsi que leur lien avec les efforts déployés aux différents niveaux par les acteurs mobilisant leurs capacités de gouvernance pour influencer et construire la politique GMF.

Non-domination et collectivités : l'apport du républicanisme à une théorie des droits collectifs

L'objectif poursuivi dans ce mémoire est de montrer que le néo-républicanisme possède les outils les plus efficaces pour penser la réconciliation des droits individuels, fondement des États de droits occidentaux contemporains, et des droits collectifs que peuvent légitimement réclamer les collectivités nationales. Dans cette visée, et comme de nombreux auteurs libéraux se sont attaqués à cette question dans les dernières décennies, j'expose d'abord trois stratégies libérales pour traiter cette possible réconciliation tout en faisant ressortir leurs faiblesses respectives. J'avance qu'aucune de ces stratégies ne permet vraiment de comprendre comment un régime de droits collectifs et un régime de droits individuels peuvent être articulés de façon cohérente. J'argue ensuite que le néo-républicanisme, parce qu'il comprend la liberté non pas comme l'absence d'interférence, mais comme un statut de non-domination, permet de voir que les droits collectifs des groupes nationaux et les droits individuels sont nécessairement compatibles, parce qu'ils s'organisent en fonction du même idéal. Les droits d'un individu et ceux de sa collectivité nationale sont, d'une certaine manière, les deux faces d'une même médaille, la non-domination individuelle dépendant de la non-domination du groupe national auquel l'individu appartient. En dernier lieu, je soutiens que cette compréhension du rapport entre les deux régimes de droits devrait se traduire par un ensemble de mesures institutionnelles concrètes dont la plus importante est la reconnaissance d'un droit, pour les collectivités nationales, à l'autodétermination.

Théorie des jeux expérimentale & action motrice

How do sportspeople succeed in a non-collaborative game? An illustration of a perverse side effect of altruism Are team sports specialists predisposed to collaboration? The scientific literature on this topic is divided. The present article attempts to end this debate by applying experimental game theory. We constituted three groups of volunteers (all students aged around 20): 25 team sports specialists; 23 individual sports specialists (gymnasts, track & field athletes and swimmers) and a control group of 24 non-sportspeople. Each subgroup was divided into 3 teams that played against each other in turn (and not against teams from other subgroups). The teams played a game based on the well-known Prisoner's Dilemma (Tucker, 1950) - the paradoxical "Bluegill Sunbass Game" (Binmore, 1999) with three Nash equilibria (two suboptimal equilibria with a pure strategy and an optimal equilibrium with a mixed, egotistical strategy (p= 1/2)). This game also features a Harsanyi equilibrium (based on constant compliance with a moral code and altruism by empathy: "do not unto others that which you would not have them do unto you"). How, then, was the game played? Two teams of 8 competed on a handball court. Each team wore a distinctive jersey. The game lasted 15 minutes and the players were allowed to touch the handball ball with their feet or hands. After each goal, each team had to return to its own half of the court. Players were allowed to score in either goal and thus cooperate with their teammates or not, as they saw fit. A goal against the nominally opposing team (a "guardian" strategy, by analogy with the Bluegill Sunbass Game) earned a point for everyone in the team. For an own goal (a "sneaker" strategy), only the scorer earned a point - hence the paradox. If all the members of a team work together to score a goal, everyone is happy (the Harsanyi solution). However, the situation was not balanced in the Nashian sense: each player had a reason to be disloyal to his/her team at the merest opportunity. But if everyone adopts a "sneaker" strategy, the game becomes a free-for-all and the chances of scoring become much slimmer. In a context in which doubt reigns as to the honesty of team members and "legal betrayals", what type of sportsperson will score the most goals? By analogy with the Bluegill Sunbass Game, we recorded direct motor interactions (passes and shots) based on either a "guardian" tactic (i.e. collaboration within the team) or a "sneaker" tactic (shots and passes against the player's designated team). So, was the group of team sports specialist more collaborative than the other two groups? The answer was no. A statistical analysis (difference from chance in a logistic regression) enabled us to draw three conclusions: ?For the team sports specialists, the Nash equilibrium (1950) was stronger than the Harsanyi equilibrium (1977). ?The sporting principles of equilibrium and exclusivity are not appropriate in the Bluegill Sunbass Game and are quickly abandoned by the team sports specialists. The latter are opportunists who focus solely on winning and do well out of it. ?The most altruistic players are the main losers in the Bluegill Sunbass Game: they keep the game alive but contribute to their own defeat. In our experiment, the most altruistic players tended to be the females and the individual sports specialists

Théorie des jeux expérimentale & action motrice

How do sportspeople succeed in a non-collaborative game? An illustration of a perverse side effect of altruism Are team sports specialists predisposed to collaboration? The scientific literature on this topic is divided. The present article attempts to end this debate by applying experimental game theory. We constituted three groups of volunteers (all students aged around 20): 25 team sports specialists; 23 individual sports specialists (gymnasts, track & field athletes and swimmers) and a control group of 24 non-sportspeople. Each subgroup was divided into 3 teams that played against each other in turn (and not against teams from other subgroups). The teams played a game based on the well-known Prisoner's Dilemma (Tucker, 1950) - the paradoxical "Bluegill Sunbass Game" (Binmore, 1999) with three Nash equilibria (two suboptimal equilibria with a pure strategy and an optimal equilibrium with a mixed, egotistical strategy (p= 1/2)). This game also features a Harsanyi equilibrium (based on constant compliance with a moral code and altruism by empathy: "do not unto others that which you would not have them do unto you"). How, then, was the game played? Two teams of 8 competed on a handball court. Each team wore a distinctive jersey. The game lasted 15 minutes and the players were allowed to touch the handball ball with their feet or hands. After each goal, each team had to return to its own half of the court. Players were allowed to score in either goal and thus cooperate with their teammates or not, as they saw fit. A goal against the nominally opposing team (a "guardian" strategy, by analogy with the Bluegill Sunbass Game) earned a point for everyone in the team. For an own goal (a "sneaker" strategy), only the scorer earned a point - hence the paradox. If all the members of a team work together to score a goal, everyone is happy (the Harsanyi solution). However, the situation was not balanced in the Nashian sense: each player had a reason to be disloyal to his/her team at the merest opportunity. But if everyone adopts a "sneaker" strategy, the game becomes a free-for-all and the chances of scoring become much slimmer. In a context in which doubt reigns as to the honesty of team members and "legal betrayals", what type of sportsperson will score the most goals? By analogy with the Bluegill Sunbass Game, we recorded direct motor interactions (passes and shots) based on either a "guardian" tactic (i.e. collaboration within the team) or a "sneaker" tactic (shots and passes against the player's designated team). So, was the group of team sports specialist more collaborative than the other two groups? The answer was no. A statistical analysis (difference from chance in a logistic regression) enabled us to draw three conclusions: ?For the team sports specialists, the Nash equilibrium (1950) was stronger than the Harsanyi equilibrium (1977). ?The sporting principles of equilibrium and exclusivity are not appropriate in the Bluegill Sunbass Game and are quickly abandoned by the team sports specialists. The latter are opportunists who focus solely on winning and do well out of it. ?The most altruistic players are the main losers in the Bluegill Sunbass Game: they keep the game alive but contribute to their own defeat. In our experiment, the most altruistic players tended to be the females and the individual sports specialists

Théorie des jeux expérimentale & action motrice

How do sportspeople succeed in a non-collaborative game? An illustration of a perverse side effect of altruism Are team sports specialists predisposed to collaboration? The scientific literature on this topic is divided. The present article attempts to end this debate by applying experimental game theory. We constituted three groups of volunteers (all students aged around 20): 25 team sports specialists; 23 individual sports specialists (gymnasts, track & field athletes and swimmers) and a control group of 24 non-sportspeople. Each subgroup was divided into 3 teams that played against each other in turn (and not against teams from other subgroups). The teams played a game based on the well-known Prisoner's Dilemma (Tucker, 1950) - the paradoxical "Bluegill Sunbass Game" (Binmore, 1999) with three Nash equilibria (two suboptimal equilibria with a pure strategy and an optimal equilibrium with a mixed, egotistical strategy (p= 1/2)). This game also features a Harsanyi equilibrium (based on constant compliance with a moral code and altruism by empathy: "do not unto others that which you would not have them do unto you"). How, then, was the game played? Two teams of 8 competed on a handball court. Each team wore a distinctive jersey. The game lasted 15 minutes and the players were allowed to touch the handball ball with their feet or hands. After each goal, each team had to return to its own half of the court. Players were allowed to score in either goal and thus cooperate with their teammates or not, as they saw fit. A goal against the nominally opposing team (a "guardian" strategy, by analogy with the Bluegill Sunbass Game) earned a point for everyone in the team. For an own goal (a "sneaker" strategy), only the scorer earned a point - hence the paradox. If all the members of a team work together to score a goal, everyone is happy (the Harsanyi solution). However, the situation was not balanced in the Nashian sense: each player had a reason to be disloyal to his/her team at the merest opportunity. But if everyone adopts a "sneaker" strategy, the game becomes a free-for-all and the chances of scoring become much slimmer. In a context in which doubt reigns as to the honesty of team members and "legal betrayals", what type of sportsperson will score the most goals? By analogy with the Bluegill Sunbass Game, we recorded direct motor interactions (passes and shots) based on either a "guardian" tactic (i.e. collaboration within the team) or a "sneaker" tactic (shots and passes against the player's designated team). So, was the group of team sports specialist more collaborative than the other two groups? The answer was no. A statistical analysis (difference from chance in a logistic regression) enabled us to draw three conclusions: ?For the team sports specialists, the Nash equilibrium (1950) was stronger than the Harsanyi equilibrium (1977). ?The sporting principles of equilibrium and exclusivity are not appropriate in the Bluegill Sunbass Game and are quickly abandoned by the team sports specialists. The latter are opportunists who focus solely on winning and do well out of it. ?The most altruistic players are the main losers in the Bluegill Sunbass Game: they keep the game alive but contribute to their own defeat. In our experiment, the most altruistic players tended to be the females and the individual sports specialists