By Frederic Bizard (economist, professor affiliated with ESCP Europe and chairman of the Health Institute)
In an Ifop poll from March 2022, 76% of French people consider our health care system to be ‘weakened’ and even ‘in need’. We can understand it as the crisis of the system extends to all its components: medical desertification of many territories, crisis in public hospital, scandal with nursing home, chronic shortage of medicine, decline in French medical research and our health. This systemic crisis is now an irrefutable fact, but a fact that political leaders refuse to face. No presidential program deals with the restructuring of the system.
The reason is twofold. First, the regulations of 1945 (social security) and 1958 (known as Debré, the creation of the CHU) built a reference system in the world in the 20th century, which our political leaders glorified without adapting it to the new world. So, this system of the 20th century based on the healing and the hospital, on the access to care, the politicians do not manage to go beyond the medical-technical dimension to establish a political thought about health, which integrates the social dimensions, economically, democratic at the heart of 21st century health.
Health from a social and economic perspective
The health system to be rebuilt will have as its strategic line the management of citizens’ health from an early age. It will no longer wait for the individual to get sick to take care of it, but will invest in maintaining good health at all ages of life. Curative will be by default and good health in case of excess. The disease becomes the failure of the care process and not its starting point.
This shift in health risk management from downstream to upstream is a highly political strategic measure, as the new health policy must include all the economic, social, behavioral and environmental determinants of the future health system.
This is how local authorities, whose main tasks concern the quality of human life, become major players in health. In this way, health education and the working environment will be integrated into the heart of the health system and not outsourced as today (to the Ministry of Education and Labor, respectively).
Investment in human capital
Universalization of access to good health also requires a shift in policy software. From a budgetary policy based on the management of health expenditure, we are moving on to a policy of investing in human capital, which must be coordinated between all actors and evaluated on the basis of relevant public health indicators.
Health is no longer just synonymous with doing everything to treat the sick, but is becoming a matter of reducing social inequalities, improving the quality of life and economic development (health is a factor of production).
What could be more political than these issues? Over the next five-year period, social investment in health should be € 15 billion over 5 years, with a share of health expenditure on prevention increased to 10% of total expenditure. The aim will be to strengthen the individual’s ability to remain in good health, to reduce the need for care and to neutralize the inflation risk of the aging effect by prolonging the life expectancy in good health.
Health from a territorial perspective
To succeed in this strategic shift from disease to lasting good health, health must be managed from health areas (sanitary living areas), defined to meet the health needs of the inhabitants.
These territories with about 150,000 inhabitants will form the common geographical unit for all health professionals. This territorial management of health will be integrated into a national health strategy, adopted in Parliament through a 5-year law on orientation and health programming.
For this dichotomy between a strategic state and a territorial approach to function harmoniously, a territorial public health service must be built, which must replace the current public hospital system. This new public service will integrate all health actors, regardless of their form of exercise and their activity sector.
Conduct a political double operation
This legal concept of public service – which guarantees equality, continuity and changeability for all health services -, scaled to the scale of health areas, is the essential mechanism for guaranteeing citizens the proper exercise of their rights and duties in health at all ages. life.
Compared to the current system, it is necessary to succeed in a dual political operation: to create the conditions for a state strategist in health and to delegate the operational management of the needs of health to the local health actors in an effective function of local democracy.
To transform the health system
The health of tomorrow therefore requires a reconsideration of the articulation between representative democracy (the State) and new forms of participatory democracy that find expression even in the territories. This local democracy will report to another democratic body to be rebuilt, the health branch of social security. To this end, the latter must regain its autonomy vis-à-vis the state.
Health will remain absent in the political debate. To make health a political issue, the transition from a medical approach to health to an equally social, economic and democratic approach must succeed. Who should lead it if the politician does not?
“Man is naturally a political animal,” Aristotle said. Knowing that health is one of its main concerns, it is up to the citizens to lead this transition by transforming our health system. Political administration follows!
Frederic Bizard, economist specializing in social protection and health issues