Health system: getting out of the “endless crisis” is not just a question of means


On Friday January 6, the President of the Republic Emmanuel Macron presented, during his greetings to health actors, several avenues to try to get the French system out of “this day of endless crisis”. Additional means, such asaccelerated recruitment of medical assistants in order to achieve 10 creations by 000 (against 2024 currently), are therefore added to those already recorded during its first five-year term: 4 billion euros per year for the increase in the remuneration of caregivers and 000 billion of investments in hospitals.

In addition to these additional financial resources, human and organizational resources have been released: the end of the numerus clausus for medical students since the start of the 2021 school year pending the reorganization of work in the hospital announced on January 6.

On the morning of the President of the Republic's announcements, the economist Thomas Piketty called for a drastic increase in the resources allocated to health. He thus called on France Inter to spend up to 30% of GDP on health by financing the additional expenditure through tax increases, which then made him consider levies of up to 70% of GDP!

A simple question of money?

In 2021, France devoted 12,3% of its GDP to health expenditure, which is approximately the same as in Germany where the share is 12,8% (9,5% in Italy, 11,9% in the United Kingdom and 17,8% in the United States). The lack of resources is therefore not “glaring”. However, if France and Germany devote the same share of their resources to health, the use of these resources can be very different: by controlling in this way by the level of resources, we can then identify, by comparing France with Germany, the organizational changes that would make it possible to do better.


With nearly 8 beds per 1 inhabitants in Germany in 2020, the possibility of benefiting from hospital care is greater than in a country where there are only 5,7 beds per 1 inhabitants such as in France (there are 000 beds per 3,2 inhabitants in Italy, 1, 000 in the UK and 2,3 in the US). In addition, Germany invests more in the “quality” of care. The country has more doctors (4,5 per 1 inhabitants compared to 000 in France), but also more medical personnel (12,1 nurses compared to 11,3 per 1 inhabitants). This gap in human capital has widened, to the disadvantage of France, since 2000.


Moreover, German doctors and nurses are better paid than their French counterparts. A German GP earns around 4,4 times the average German salary, while his French counterpart earns only 3 times the average French salary. German nurse wins 1,1 times the average German salary whereas this factor is only 0,9 in France.

For the patient, access and quality of care can only be better across the Rhine: each German consults a doctor more than a French, he benefits from more x-rays, scanners, longer stays in hospital and more medical innovations.

Organizational inefficiencies can then explain why, for the same health expenditure, there are fewer beds in France, fewer nursing staff receiving lower salaries and fewer medical innovations. We are going to identify three of them, in the areas of Pharmacy, hospital and medical research.

The pharmacist can become a caregiver again

There are more pharmacists in France than in Germany (1,03 versus 0,67 per 1 inhabitants) and these health workers have high salaries without doing any treatment. This strong "French sales force" in drugs led the French share of health expenditure devoted to pharmaceutical products to be higher than that of Germany: before 2014, it peaked at 18% of health expenditure in France, while it has never exceeded 15% in Germany.

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To cope with an offer that does not allow all patients to be in contact with health personnel, pharmacists could carry out simple prescription tasks, and thus relieve general practitioners. This reallocation of tasks would allow generalists to focus on cases that require specific expertise. This would then partly justify the increase in fees they are asking for. Pharmacists would therefore contribute to the production of care.

Refocus French hospitals

If we focus on the hospital, which is today in the spotlight of the news, France devotes more resources to it than Germany, with 4,6% of its GDP against 3,6% (second in Europe after the United Kingdom). But what characterizes France is its very large number of hospitals: there are 4,42 hospitals per 100 inhabitants in France against only 000 hospitals per 3,62 inhabitants in Germany (there are 2,86 in the UK, 1,80 in Italy and 1,86 in the US).


As France also has a very large number of hospital beds (as a reminder, 6 beds per 1 inhabitants), there is therefore a phenomenon of fragmentation: the average number of beds in France per hospital remains lower than the situation in Germany. This fragmentation reduces the quality of care because it is strongly linked to the workload of its agents: the level of expertise increases sharply when multiple cases have been treated by the medical teams of an establishment. Patients take this on board by always asking to be treated by the most reputable hospital.

Thus, part of the means devoted to the hospital does not improve care. Moreover, this atomization is very costly because hospital activity is characterized by threshold effects: whatever the volume of care provided by a hospital, minimum means in terms of equipment and personnel are required (fixed operating costs). The scattering of resources over too many hospital structures then leads to the same fixed costs being paid several times over, whereas in some hospitals, the use of this equipment and personnel remains too low to guarantee good quality of care.

Finally, this proliferation of hospitals has led the share of health expenditure devoted toadministration du health system to be stronger in France: it was 8% in the 1990s and 7% in the 2000s against 5,5% during these 20 years in Germany.


This should lead to the rapid transformation of some of the local acute care hospitals into local hospitals. This will ensure better economic rationality in the management of the means granted to hospitals (reduction of fixed costs), will better satisfy the quality requirement of acute hospital care, while maintaining a local network of primary care care .

Finally, it should be noted that the very large number of hospitals on our territory does not guarantee the population better care in the event of an accident: the mortality rate within 30 days after an admission for a heart attack is 7,05% in France against 5,5% in Germany (6,6% in the United States and 7,25% in Italy). Health and therefore the hospital are “public goods”, not tools for the local development of a territory!

Reallocate research resources

The Covid-19 episode alerted the general public to the shortcomings of French medical research. Germany, with BioNTech and the University of Mainz, the United Kingdom, with AstraZeneca and the University of Oxford, and the United States with Moderna and the funds committed by Pfizer to support BioNTech are the countries that have developing a vaccine.

Is it a surprise? The quality of research and development (R & D) of countries is particularly put to the test when it comes to finding a solution to a new problem: resources must be reallocated to "create" these new products, and these resources must be placed in hands that have the very strong skills necessary to produce a good of international standard.

However, the lack of means of French R&D is known. It results in a lower number of patents filed each year (approximately 110 patents per million inhabitants in France against 350 in Germany). But, if we disregard the level of resources, France is characterized by a lower share of these R&D resources devoted to the medical and pharmaceutical field: this share is three times greater in Germany (and twice as United States).


Here again, it is not necessarily the "lack of resources" that explains France's poor results, but rather their misuse. Thus, a study conducted by the Economic Analysis Council (CAE) published in 2021 analyzed in detail the French delay in the field of medical research. Firstly, the means granted to R&D in health are low and decreasing: public credits in R&D for health are decreased from 3,5 billion dollars in 2011 to 2,5 in 2018 (i.e. -28,5%), whereas during the same period they increased by 11% in Germany (+16% in the United Kingdom).

Second, funding is not used for research that meets international scientific standards. More specifically, out of 19 clinical trials conducted in France, only 287 were randomized trials (statistical tools recognized in medical sciences as the best means of evaluating the beneficial and harmful effects of a therapy), i.e. 5910%, while 30 % were in Germany (75% in the UK). It should also be noted that 68% of French non-randomized trials were funded by public research (only 75% in Germany, and 20% in the United Kingdom).

If a large part of public health R&D funds are allocated to experiments that will never have any international recognition, because they use outdated methods, then French health R&D will never be in a leadership position. It is therefore not surprising that France could not find, over the same period of time, the vaccination protocols found in Germany, the United Kingdom or the United States.

Reduce health inequalities

Improving the use of the skills of healthcare personnel, rationalizing the management of our hospitals by avoiding fragmentation, and finally aligning French healthcare research with international standards are priorities for advancing our healthcare system.

The changes needed to achieve this should not be held back by the belief that these reforms would increase health inequalities: with a different system in Germany, the probability of being healthy for someone in the richest 25% is 1,07 .25 times greater than for a person among the poorest 1,08%, whereas this figure is XNUMX in France, as we showed in a research recent.

By reforming ourselves, we can therefore also reduce health inequalities!

Francois Langot, Professor of Economics, Researcher at the Macro Observatory of CEPREMAP, Le Mans University

This article is republished from The Conversation under Creative Commons license. Read theoriginal article.


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