Healthcare at a Territorial Level: a French Imperative

In Germany, Medizinische Versogungzentren (MZV) are good examples of pluridisciplinary spaces of collaboration in the medical field, as they ask for at least two medical specialities to co-exist within the same space, all whilst promoting mixed status modes (a doctor can work both there and in the hospital). When it comes to France, it is necessary to continue investing more money in what is called médecine de ville ("city-care"), which encompasses GPs and specialized medicine in private clinics, as well as community health centers, known as maisons de santé. In 2018, the government suggested actors within the same area could coordinate to tackle specific health issues through groupings called Communautés professionnelles territoriales de santé ("Health professional territorial communities"): this was an opportunity to clearly articulate collaboration between health professionals within a local area. Other opportunities to transform primary care includes conferring GPs a public health mandate, or enabling pharmacists and nurses to complete more tasksthan they have previously been allowed. Essentially, the idea is to make the current health system structure, highly constrained by its silos, evolve.

Supporting the local level as a key force behind healthcare policies

Regained autonomy and freedom for healthcare actors also means increased responsibility at the local level. In 2007 in Denmark, a large structural reform was initiated, reducing the number of municipalities from 271 to 98, and the number of regions from 14 to 5. This led to a new division of tasks between states, regions and municipalities, as well as the implementation of a new financing system which made regions responsible for handling the health budget along with municipalities. In France, despite some legislative restructuring and reshuffling (which started as early as 2009) with the Hospital, Patients, Health, Territories law, which implemented "Agences Régionales de Santé'' (Regional Health Agencies) and "Groupements de coopération sanitaire" (Health Cooperation Groupments), transformation of the health system is far from being fully implemented. Now is the time to push this impulse further, notably by further involving politics in the governance of their local health systems, and vice-versa. 

This enables the healthcare system for smarter and more adequate handling. Institut Montaigne produced in association with start-up Kanopy Med a mapping of health needs and resources available in France, with the objective of highlighting departmental disparities in the allocation of health resources. This map additionally demonstrates that population health needs vary from regions to regions. For instance, populations from departments termed "bien portants" (healthy) showcase low levels of chronic diseases relative to the national mean. These observations are a starting-point for policy makers to reflect on different department's management of health expenditures. 

In this sense, the French system must better evaluate the effectiveness of innovation within the healthcare sector to promote evidence-based changes to current practices. If some fear such an approach might lead to a solely cost-effective approach to healthcare, it might be wiser, rather, to see it as an opportunity to further value patient-experience and voices, actively taking care of what researchers term "démocratie sanitaire" (health democracy - meaning the involvement of all individuals in the process). Typically, this can translate to implementing citizen health assemblies at the local level, as well as developing new tools to record patient experience. Recording patient experience is much less systemic in France than it is abroad in countries like the Netherlands, where for example, the Dutch Surgical Colorectal Audit, put in place in 2009, is used by all hospitals. 

Making public health a national concern

In the wake of a pandemic which has revealed how health can constitute a pillar for a country's stability, rethinking our French health system is also an opportunity to articulate a larger societal project: one which states public health as a key national objective. This is a tendency carried by world organizations like the WHO, which implemented in 2020 a Council on the Economics for All, aimed at attracting investment in healthcare, but also explicits how a healthy society also creates value in itself (i.e. value creation and economic growth). A similar line of thought is encompassed by the buzzword "One Health", which emerged in the 2000s. In light of current crises (climate, democratic), this approach is particularly meaningful: our health is dependent on that of our environment, and a healthy population is a key element of a functional democracy. Concretely, one way to implement it tangibly is by applying the concept of population-based responsibility. Born in Canada, this approach aims to make all health actors (public, private, medical, social) responsible for maintaining their population in a healthy state. Trials for implementation in 5 French regions are currently in place. 

We have thus seen how the local level is paramount to better managing citizens’ health. Yet public health knows no borders. A European response to current health threats will also be necessary in the years to come. Coordinated responses to the pandemic have highlighted what can be gained from collaboration, future projects are now in our hands. The current development of the European Health Data Space holds significant potential for both patient experience and future research. Institut Montaigne also believes our respective care systems have much to learn from one another. Last but not least, it cannot be forgotten: ensuring that citizen health sits at the crossroads of other geopolitical issues, whether building sovereignty in the pharma field, or safeguarding cybersecurity in general. 

Co-written with Laure Mourgue d’Algue, Assistant Policy Officer.

Copyright: Aris Oikonomou / AFP