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Public Health Act passing and implementation

Country: 
France
Partner Institute: 
Institut de Recherche et Documentation en Economie de la Santé (IRDES), Paris
Survey no: 
(5)2005
Author(s): 
Valérie PARIS
Health Policy Issues: 
Public Health
Reform formerly reported in: 
Reform of the public health law
Current Process Stages
Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no no yes yes no no
Featured in half-yearly report: Health Policy Developments Issue 5

Abstract

In France a new Public Health Act was adopted in August 2004 with an aim to reshape public health policy. However, its slow implementation until now seems to compromise the achievement of its goals.

Purpose of health policy or idea

The most innovative aspect of the Act is the description of the elaboration of public health policy.

The act defines the role and the responsibility of the State in public health policy. It describes the scope, the process of elaboration and the instruments of implementation of this policy, at the national and regional levels. The Act presents in an annex report 'The public health objectives for 2004-2008'.

The Parliament will debate every five years on these objectives of the public health policy proposed by the Government. The implementation of the law will be monitored on a yearly basis and assessed after 5 years.

Regional public health plans are designed in line with the national objectives. A new regional institution is created as a joint venture of existing regional institutions to implement this plan.

The content of the report on public health objectives for 2004-2008

The reports sets out nine explicit 'principles' governing health objectives definition, which are: knowledge (objectives and programs are based on the best available knowledge), reduction of health inequalities; gender parity; youth protection; development of timely preventive intervention; economic efficiency; 'multi-sectoral' cooperation; consultations with all the stakeholders and regular assessment of the implementation.

Major health problems to be addressed are defined taking into account:

  • their repercussion on morbidity, avoidable mortality, functional limitations, activity restrictions or quality of life;
  • the social values (which have to be made explicit);
  • the existence of a gap between the French situation and the situation in other developed countries (as a marker of opportunity for improvement).

Five strategic plans are announced for the period 2004-2008:

  1. the national cancer plan;
  2. the national plan to reduce the health impact of violence (road violence being a priority defined by the President),
  3. the national plan on health and environment,
  4. the plan to improve the quality of life of persons with chronic diseases, and
  5.  the plan on rare diseases.



Moreover the annexed report sets out 100 national public health objectives to be achieved within 5 years. These so-called 'quantified objectives' address the following areas:  health determinants (tobacco (2), alcohol (2), nutrition (8) and physical activities (1)), health and work (4), health and environment (7), iatrogenic accidents (4), antibiotic resistance (1), pain treatment (2), deprivation and inequities (2), deficiency and disability (1), infectious diseases (8), maternal and perinatal health (4), cancer (6), endocrine diseases (2), neuropsychiatric diseases (10), diseases of sensory organs (3), cardio-vascular diseases (5), respiratory diseases (2), Inflammatory Bowel Diseases (1), gynaecological diseases (3), chronic renal failure (2), Diseases of the musculoskeletal system (6), diseases with antenatal origin (2), rare diseases (1), mouth and tooth diseases (5), problems in oral or written language (1), contraception and abortion (1), older persons' health (3).

Five types of objectives can be distinguished:

  • Reduction of mortality or morbidity for identified diseases (e.g. Objective 40: Reduce by 20% the mortality due to bowel infections of children <1 year and people > 65);
  • Reduction (increase) of the prevalence of risky (healthy) behaviour or reduce pollution (including noise) exposure (at workplace, at home or in atmosphere); e.g.: Objective 1: Reduce average alcohol consumption per inhabitant by 20% ;
  • Reduction of social inequalities in health care access and health status, reduction of activity restrictions due to disabilities (e.g.: Objective 34: Increase life expectancy of deprived groups to reduce the gap between life expectancies of different groups);
  • Improvement in health care process: reducing the prevalence of iatrogenic accidents and antibiotic resistance, improving pain care, increasing the participation in prevention programs (e.g. Objective 50: Reach a 80% participation rate for breast cancer screening), increasing compliance to guidelines for certain types of treatment (e.g. Objective 54: Reach 80% of diabetes' surveillance in line with official guidelines);
  • Increasing the public health knowledge, surveillance and expertise, for instance to define screening strategies (e.g. Objective 53: 'The strategy for colorectal cancer screening should be defined in 4 years').



These specific objectives and the new organisation set up to define and implement public health policy are the most important features of the Act. But this act also contains two important corpus of measures.

  • The first group of measures aims at improving the alert system to prevent and better manage public health threats. This part of the plan was influenced by the tragic consequences of the heat wave of August 2003 where a high number of elderly people have died.
  • The second group of measures modifies the rules applicable to the clinical trials in terms of patients' inclusions and information, mainly to comply with the European Directive 2001/20/CE.

Main points

Main objectives

Reshape public health policy elaboration and implementation and publicize quantified objectives, validated by the Parliament.

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Characteristics of this policy

Degree of Innovation traditional rather innovative innovative
Degree of Controversy consensual rather consensual highly controversial
Structural or Systemic Impact marginal rather marginal fundamental
Public Visibility very low low very high
Transferability strongly system-dependent neutral system-neutral

Political and economic background

See previous surveys

Complies with

EU regulations

Only for the part on patients' participation to clinical trials.

WTO/GATS

Ratification of the WHO framework Agreement on Tobacco, since the first section of this Act ratifies it.

Purpose and process analysis

Current Process Stages

Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no no yes yes no no

Origins of health policy idea

See previous surveys.

Stakeholder positions

See previous surveys.

Influences in policy making and legislation

The content of the Bill was presented in previous surveys (Public Health Plan preparations (1) 2003 and Reform of the public health Law (3) 2004). It was substantially amended during the Parliamentary debates, for several reasons:

  • Some deputies argued for the introduction of concrete measures related to nutrition, tobacco and alcohol consumption, some of these measures were adopted. For instance: sweets and drinks vending-machines are banned in schools. Food manufacturers are obliged to insert warnings about health risks of added sugar, salt or sugar substitute in their advertisements unlessthey accept to pay a 1,5%-tax on their promotion expenditure, which goes to the National Institute for Prevention and Health Education (INPES) . A new tax is introduced for 'Light alcohol' (between 1.2 and 12% of alcohol, such as beer , wine, etc.)
  • Some measures related to the environment were proposed by the government, which was preparing the Health and Environment Plan during the Parliamentary debates
  • Lastly, various measures were included relating to the organisations of health professionals and other subjects.



Main critics

Deputies criticised the fact that there were too many objectives (100), and no hierarchy among these priorities. They also stressed that the Bill did not contain enough concrete measures and did not inform about the human and financial means devoted to these objectives. They also pointed out that the legal status of the annexed report was not as 'binding' as a law, in the sense that it does not create rights likely to be invoked by individuals (for instance to contest a norm which is inconsistent with the objectives of the report).

The new organisation at the regional level has also been criticised. The Act creates a new body: the "Groupement regional de santé publique", as a joint venture between the State administration, the Regional Hospitalisation Agency and the Regional union of health insurance funds, which is clearly put under the State responsibility. Some stakeholders would have preferred a merging of all institutions in a single one, the Regional Health Agency (Agence régionale de santé, ARS), which has been debated in the last years.

Adoption and implementation

The Act passed on August 9, 2004, only four days before the adoption of the Health Insurance Reform Act of August 13, 2004.

Although both laws have been enacted by the Parliament at the same time,  the Public Health Law has been initiatied by the previous Minister of Health.

Monitoring and evaluation

ImplementationThe Public Health Act holds that its implementation has to be assessed annually and that the government has to report every five years on the impact of its policy on population heath status. In March 2005, the Parliamentary office for health policy assessment, in charge of assessing the implementation of health policies and programs, reported on the implementation of the Public health act, six months after its adoption.

This report observes that if 68 out of the 158 sections of the Act were immediately applicable, the other sections needed the publication of other texts to be enforced (decrees, ministerial orders, administrative circulars). According to the government, 132 texts should be issued, of which only 7 have been published. This  shows that the implementation has been particularly slow until now. 

The report puts forward several explanations for the delay: first, the drafting of these texts suppose the consultation and cooperation of numerous actors. Second, the Public health department of the Ministry  has been strongly mobilised for the preparation and the implementation of the Health Insurance Act of August 13, 2004, which has been clearly a priority of the Minister. According to the Court of Accounts, drafting of all the necessary texts for the implementation of the two Acts represents four years of work for this department of the Ministry, which clearly compromises the achievement of five-year objectives.

Objectives which are included in National Health Plans already in force are more likely to be achieved.

Expected outcome

Impact of this policy

Quality of Health Care Services marginal neutral fundamental
Level of Equity system less equitable four system more equitable
Cost Efficiency very low neutral very high

References

Sources of Information

Assemblée nationale, Dossier législatif: www.assembleenationale.fr/12/dossiers/sante_publique.asp

Projet de loi relatif à la politique de santé publique, présenté à l'assemblé par le Ministère de la santé, de la famille et des personnes handicapées déposé le 21 mai 2003: www.assembleenationale.fr/12/projets/pl0877.asp

Loi n°2004-806 du 9 août 2004 relative à la politique de santé publique : www.legifrance.gouv.fr/WAspad/UnTexteDeJorf?numjo=SANX0300055L

Assemblée nationale, Rapport de la Commission des affaires culturelles, familiales et sociales sur la mise en application de la loi n°2004-608 du 9 août 2004 relative à la politique de santé publique, N° 2207, 45 pages www.assembleenationale.fr/12/rap-info/i2207.asp

Cour des comptes, "L'évolution du rôle de la Direction générale de la santé", in Rapport public annuel 2004, p. 141-170. www.lesechos.fr/info/medias/200052615.pdf

Reform formerly reported in

Reform of the public health law
Process Stages: Legislation

Author/s and/or contributors to this survey

Valérie PARIS

Suggested citation for this online article

Valérie PARIS. "Public Health Act passing and implementation". Health Policy Monitor, 18/05/2005. Available at http://www.hpm.org/survey/fr/a5/1