At the turn of the millennium, France had the best healthcare system in the world, according to the World Health Organisation (WHO), and it became a Global Health leader by contributing to setting up and funding key Global Health initiatives, such as UNITAID and the Global Fund to Fight AIDS, Tuberculosis and Malaria. Almost two decades later, the government faces an unprecedented strike in the emergency services, while experts worried about the decrease in French expertise and influence in Global Health. France’s health leadership thus seems to be challenged both at the national and international level. This parallel is quite striking because, traditionally, the Global Health literature is blind to health development in donors’ countries. Rather it studies primarily interventions by high-income countries in the Global South. In this blog post, I want to understand how these domestic and foreign health issues can be related through an analysis of the French case.
In spite of its denomination, Global Health concentrates much more on how to address health issues in the Global South than on how to ensure universal access to healthcare worldwide. Indeed, the vast majority of Global Research focuses on state aid agencies’ and international NGOs’ endeavour to fight infectious diseases in low- and middle-income countries (Packard 2016). Yet this is an incomplete representation of the field: Global Health also happens in the Global North. For instance, during medical studies in the US, students opting for a Global Health Elective acquire field experience either in low-income countries or in poor American neighbourhoods (Hanrieder 2019). In a post on this blog, Luis Aue and Tine Hanrieder show how the dental therapists, who are providers of basic dental care, practice in underserved areas from both the Global South and the Global North (2018). These two examples suggest that there is no strict boundary between the health problems and technologies of rich countries versus the ones in poor countries (Izambert 2019).
The foreign and domestic health care challenges faced by France
What are the implications for the French case? At the international level, France remains a key actor in Global Health but should not rest on its laurels, as the failure to get its candidate selected for the succession of Margaret Chan at the head of the WHO demonstrates. More fundamentally, the French Global Health strategy is mostly decided at the presidential level and implemented by the Foreign Ministry, with little involvement of the Health Ministry and other relevant Global Health actors, such as humanitarian organisations. As a result, the strategy is not widely known and lacks coherence. In addition, French Global Health experts are not numerous enough – both in France and in international organisations – to guide and influence policy-making.
At the national level, even if France still has one of the best healthcare systems in the world, a recent series of strikes and reports indicates that the system is under great pressure. Despite the fact that France has an effective universal healthcare coverage, discrimination and socio-geographic disparities in access to healthcare remain, as well as health inequalities: recently the French Ombudsman denounced that foreigners are more likely to face barriers to healthcare, while there are wide gaps in life expectancy across the country. Even more worrying, several emergency services have been on strikes since the beginning of the year to protest against their increasing work load and the lack of human and material resources.
Explaining decline at the international and national levels
These parallel phenomena can partly be explained by a deficit in investment, notably with regards to research, infrastructures, training and professionals. For instance, there is no Global Health institute in France, and only two higher-education institutions offer some training in Global Health. As for domestic issues, the causes of the crisis in French hospitals are numerous, but it can be mostly explained by a non-adaptation and an under-provision of alternative healthcare solutions outside of the hospitals, and the financial pressure exerted on hospitals. From the late 1970s up to the early 2000s, the number of medical students trained each year has indeed been halved. Even if the movement has been reversed since, the effects of the decrease are severely felt today not only because of the length of medical studies, but also because of the growing medical needs of an aging population and the rise in non-communicable diseases. Moreover, public hospitals lack human, financial and material resources because of the austerity politics they face (Juven 2019). Hence, we see that at both levels, the means allocated do not match the needs and ambitions of the country.
Linking national and international levels
Beyond investment in people, research and infrastructures, future reflections about the state of the French healthcare system should take into account discussions about France’s health diplomacy and vice versa. Indeed, the strict demarcation between healthcare efforts at home and abroad undermines both fields of intervention. In 1999, France adopted the universal healthcare coverage law; it was a landmark reform since it ensured that any regular resident in France would get access to healthcare coverage (Sopena 2012). By contrast, most of efforts dedicated to improve health abroad consist in fighting against epidemics, while cholera, tuberculosis or malaria cannot be eradicated without universal access to healthcare, backed by strong healthcare systems. In this regard, the expertise of the Social Affairs and Health Ministry could be useful for the work of Foreign Ministry. Alternately, it would be misleading for the French government to think that illnesses of poverty are only to be found in low-income countries. For instance, there are still cases of tuberculosis in France, which mostly affect people living in precarious housing conditions. France shows the highest rate in health and mortality inequalities in Western Europe (Lang 2014), which implies that a strong healthcare system and a universal healthcare coverage are not sufficient to ensure equality before health.
In this respect, the Health Ministry could learn from humanitarian NGOs, which intervene not only in the Global South, but also in social spaces of exclusion in Europe, as it successfully did in the past (Izambert 2019). More broadly, the French case suggests that the Global Health literature would probably gain from expanding its geographical focus to the Global North so as to allow for a fruitful exchange of expertise and techniques: there is no a-priori ground for setting up public healthcare coverage solely in high-income countries and caring about the price of medicine solely in low-income countries.