Health, a matter of State
Press release of the French National Academy of Medicine*
January 25, 2022
Despite previous warnings, the health, social and economic crisis caused by Covid-19 has shaken a French health system weakened by restrictive reforms and abandonment of sovereignty, with regard in particular to masks, medicines and several medical devices that may have been missing for Covid-19 asphyxiating victims. Only emergency measures have been able to alleviate the shortages and fill the gaps thanks to the dedication and ingenuity of health professionals in conjunction with an administration that started to listen to them.
On March 20, 2020, the President of the Republic announced that the health system could not remain as it was and promised “a massive plan for investment and upgrading of all careers”. Despite a start of implementation, at the end of 2021, several hospital beds are closed due to a lack of staff, overcome by weariness and demoralization, and the number of “medical deserts” is increasing. Obviously, it is necessary to get the health system out of an entrepreneurial and financial logic.
Health protection, a state responsibility
Health is one of the primary concerns of French people, and while there is an undeniable individual responsibility, French people spontaneously and without hesitation turn to the State as soon as any health scandal, problem or uncertainty occurs. The Covid-19 pandemic is the most recent example.
Legally, they are right. The preamble to the 1946 French Constitution, still applicable, “proclaims that the Nation guarantees to all… the protection of health…”. In the same year, one of the principles of the World Health Organization Constitution stipulates that “Governments are responsible for the health of their people”; they can only cope with this responsibility by taking the appropriate sanitary and social measures.
The State therefore has eminent legal responsibilities in the area of health protection.
A Ministry of Health and Health Insurance
Health protection suffers from serious historical and structural handicaps that hinder its consideration at parliament, government and administration levels. The first ministry in charge of health only dates from 1920, without bearing this name, which appeared only with Simone Veil in 1974. Since then, it has been either a simple State Secretariat with limited powers, or a huge Ministry of Social Affairs which mainly manages numerous “cash benefits” (pensions, Family allowances, unemployment and soon dependency). Health is then only one of its components, but limited to an area of professional service provisions and therefore fundamentally different, which is a source of misunderstanding, conflict, and mistrust.
Health protection is therefore either relegated to a State Secretariat or diluted in a Ministry of Social Affairs. This situation brings back to the National Council of the Resistance, which established on 15 March 1944 “a comprehensive social security plan aimed at providing all citizens with livelihood in all cases where they are unable to obtain them by work. Hence the principle of social security whose health insurance is only one part. It may seem difficult to question such a historic, symbolic, prestigious, and generous heritage, but many of the initial principles are already no longer applied, such as the elections to the boards of directors and, today, most of ”the Health Insurance financing” is no longer based on contributions but on taxation. In order to ensure coherence of action and to exercise the full scope of its responsibilities, in particular the organization of care or the response to health crises, it would be logical and functional to establish a Ministry of Health with full control over the State budget devoted to health and the Health Insurance budget. The experiment of a Ministry of Public Health and Health Insurance was only tried once and did not last long, from May 18 to November 7 1995. This decision was probably considered too innovative or giving too much latitude to the medical world.
A unified health management system would make it possible:
– to highlight the place and visibility of health within the State and in all policies,
– to revalorize the position of health professionals,
– to strengthen the prevention policy, particularly for major health risks,
– to adjust health insurance expenditure to the needs of the population and to the expectations of health professionals,
– to contribute to strengthening European health security,
– to transform the French research and innovation system in light of the difficulties encountered during the Covid-19 pandemic.
An eminent responsibility such as that of health protection must be exercised by a minister endowed with all the budgets for health including that of the State and, through supervision, that of Health Insurance.
The revision of the health system, shaken by the Covid-19 pandemic, is a necessity recognized at the highest levels of the State.
The French National Academy of Medicine recommends that:
- Health protection be respected as an eminent responsibility of the State to guide an autonomous policy of full exercise.
- Health protection should be the responsibility of a Ministry of Health and Health Insurance endowed with a full health budget, including the budget managed directly by the State and the Health Insurance budget, under its supervision,
- Doctors, health workers and users are better associated with decisions and management of the health system at all levels.
– Communiqué written by Gérard DUBOIS, Renaud DENOIX DE SAINT MARC (Rapporteurs), Antoine DURRLEMAN, Didier HOUSSIN, Jacques CATON, Dominique BERTRAND and Jean-Paul TILLEMENT on behalf of the former Commission VIII (Financing of Health Expenditure, Health Insurance). At its meeting on Tuesday 1 February 2022, the Academy adopted the text of this report by 98 votes to 8 with 8 abstentions
Bull Acad Natl Med 2022;206:477-8. Doi : 10.1016/j.banm.2022.02.008