Original article
Waiting for common-law solutions for the most vulnerable populations’ healthcare accessL’accès aux soins de santé des populations les plus vulnérables en attente de solutions de droit commun

https://doi.org/10.1016/j.respe.2018.12.063Get rights and content

Abstract

Background

The state of populations’ health is linked to their access to quality healthcare. Best achieving this primary condition – a health, social and humanitarian condition – is an ongoing public policy objective. Although significant effort goes into this, do public policies sufficiently take into account the state of health of the most vulnerable populations? In France, reducing the non-take-up (NTU) of healthcare is a priority in current national health insurance policy. Under the local plans to tackle non-take-up, lack of understanding and exit from the system (PLANIR), national health insurance is currently rolling out a regional and partnership-based intervention framework in order to prevent NTU of healthcare by welfare clients. This social investment is unprecedented, yet the impact of the framework on the most vulnerable populations still seems to be limited.

Method

The study of this example is based on monitoring of the framework's general implementation. This task was entrusted to the research team co-founded by the author, ODENORE (Observatory for the Non-take-up of Social Rights and Public Services). It is organized in four parts: quantitative monitoring of the detection and addressing of non-take-up situations (n = 160,000 questionnaires); analysis of the results through qualitative interviews with beneficiaries and individuals who rejected the framework (n = 365 interviews); analysis of the framework's implementation, using qualitative interviews and participant observations at the services in charge of the framework's implementation (n = 18 collective interviews across three sites), and an analysis of the partnership through collective interviews with all the actors in the areas involved in the framework (three sites).

Results

The analysis shows that the integration of the most vulnerable populations’ state of health into a common-law framework for intervention is hindered by three limitations: the framework's neutrality regarding public decisions and non-decisions that exacerbate social and regional health inequalities; its organizational design, which does not take into account the need for long-term medical-psycho-social care; and the absence of regulation capable of bringing together and coordinating the actors working towards healthcare access locally but with different populations.

Conclusion

The difficulties of integrating the most vulnerable populations into a common-law framework such as the one proposed by the national health insurance do not seem insurmountable–provided, that is, that the regulatory authority (the regional health agencies) are willing and able to make it a strategic organizational objective at local level.

Résumé

Position du problème

L’état de santé des populations est lié à leur accès à des soins de santé de qualité. Réaliser au mieux cette condition principale – sanitaire, sociale et humanitaire – est un objectif permanent de politique publique. Beaucoup d’efforts sont réalisés. Mais intègrent-ils autant qu’il le faudrait l’état de santé des populations les plus vulnérables ? En France, la réduction du phénomène du renoncement à des soins est un axe prioritaire de la politique actuelle de l’Assurance maladie. Dans le cadre des plans locaux d’accompagnement du non-recours, des incompréhensions et des ruptures (PLANIR), cette institution est en train de généraliser un dispositif d’intervention territorial et partenarial dans le but d’éviter que les assurés sociaux renoncent à des soins. Cet investissement social est sans précédent. Pour autant, l’impact du dispositif sur les populations les plus vulnérables paraît limité pour le moment.

Méthode

L’examen de cet exemple repose sur le suivi de la généralisation du dispositif en question. Ce suivi a été confié à l’équipe de recherche cofondée par l’auteur (l’Observatoire des non-recours aux droits et services). Il comprend quatre volets : suivi quantitatif de la détection et du traitement des situations de non-recours (n = 160 000 questionnaires), analyse des résultats par entretiens qualitatifs auprès de bénéficiaires et de personnes ayant refusé le dispositif (n = 365 entretiens), analyse de la mise en œuvre par entretiens qualitatifs et observations participantes auprès des services chargés de la mise en œuvre (n = 18 entretiens collectifs sur trois sites), analyse du partenariat par entretiens collectifs avec l’ensemble des acteurs des territoires engagés dans le dispositif (trois sites).

Résultats

L’analyse montre que l’intégration de l’état de santé des plus vulnérables dans un dispositif d’intervention de droit commun dépend de trois limites : la neutralité du dispositif face aux décisions et non décisions publiques qui creusent les inégalités sociales et territoriales de santé ; son design organisationnel qui n’intègre pas la nécessité d’une intervention médico-psycho-sociale du temps long ; l’absence d’une régulation capable de rapprocher et de coordonner les acteurs qui agissent au local pour l’accès aux soins de santé mais pour des populations différentes.

Conclusion

Les difficultés pour intégrer les plus vulnérables dans un dispositif de droit commun comme celui proposé par l’Assurance maladie ne paraissent pas insurmontables. Mais à la condition que l’autorité de régulation (les agences régionales de santé) ait la volonté et la possibilité d’en faire un objectif stratégique organisationnel au plan local.

Introduction

There are many determinants of the state of populations’ health, and access to quality healthcare is one of the main factors. Best achieving this is an ongoing public policy objective. Although substantial effort goes into it, does public policy sufficiently take into account the state of health of the most vulnerable populations? In France, reducing non-take-up (NTU) of healthcare is a priority within the current national health insurance policy. As part of the local plans to tackle non-take-up, lack of understanding and exit from the system (PLANIR)1, the national health insurance is currently rolling out a local and partnership-based intervention framework. This social investment is unprecedented. For the time being, however, the solutions offered by the framework are not (or very poorly) geared towards the most vulnerable populations. The analysis of this example shows that integrating the most vulnerable populations’ state of health into a common-law intervention framework is hindered by three limitations: the framework's neutrality regarding public decisions and non-decisions that exacerbate social and regional health inequalities; its organizational design, which does not take into account the need for long-term medical-psycho-social care; and the absence of regulation capable of bringing together and coordinating the actors working towards healthcare access locally but with different populations. Ultimately, such difficulties raise questions about the transformation of the social welfare model.

Section snippets

Healthcare access: availability, accessibility, acceptability

The links between the most vulnerable populations’ state of health and healthcare access have long been of concern. Internationally, many research reports and expert reports have reiterated that strong health and health insurance systems improve the state of health of the entire population and especially of those with insufficient access to care [1], [2], [3]. In France, this is also an ongoing issue [4], [5].

These reports draw on ample evidence that the poor state of health of the most

A health insurance framework to improve healthcare access

This framework is known as a PFIDASS6, that is, a department-level intervention platform for access to healthcare. It was created specifically to address NTU of healthcare. The initiative, designed and spearheaded by a few CPAM directors, has become one of the national health insurance fund's institutional commitments. The general implementation of this framework is enshrined in the new objectives and management

A framework built on a cooperative partnership

From the outside, the national health insurance initiative has been hailed as innovative and important. It is unanimously accepted as a major and exemplary commitment in the fight against non-take-up and for access to rights and services. The report of the High Council for equality between women and men on “Health and access to care”, among others, presents the framework and its benefits at length [21], and the 2016 report of the Médecins du Monde observatory on access to healthcare “welcomes

Neutrality regarding the structural reasons for social and regional health inequalities

The reactions of major national non-profit networks to the presentation by the Minister of Solidarity and Health, on 13 October 2017, of the Plan to “Improve local and regional access to care”, are telling. These reactions clearly indicate the governmental decisions and non-decisions in the face of which action frameworks such as PFIDASSs are necessarily powerless. The national inter-federal union of health and social welfare charities and private non-profits, which represents 75% of non-profit

A framework that does not take into account the need for long-term intervention

Depending on the region, CPAMs’ local partners are more or less emphatic about the need to integrate populations facing high levels of precariousness or exclusion: migrant or refugee populations, in particular, and more generally other populations in highly precarious situations, who survive on social emergency measures. Expectations focus primarily on the idea of “outreach PFIDASSs” that would visit places such as day centres and centres for shelter and social reintegration (CHRS11

A need for regulation

The question of regulation seems all the more decisive in the eyes of all local PFIDASS actors, since the State – through the ARSs (regional health agencies) – does not generally contribute when it attends meetings to which it is invited by the CPAMs. As public State institutions, the ARSs, created by the “Hospital, patients, health, territory” law of July 2009, have a degree of autonomy to carry out their missions. As provided for in the law, they are supposed to be authorized to encourage the

Conclusion

Access to healthcare hinges strongly on the availability, accessibility and acceptability of health and health insurance systems. While action plans help to partially remove barriers, their success is contingent on institutional, organizational and political contexts. The example discussed here shows that wanting to combat the mass phenomenon of NTU of healthcare, however necessary it may be, is not enough to take into account those who do not have direct access to common-law frameworks. The

Disclosure of interest

The author declares that he has no competing interest.

Acknowledgements

Thank you to Héléna Revil, (Univ. Grenoble Alpes, PACTE laboratory, Cross Disciplinary Programme LIFE), Aurélie Bonche, Aurore Crouzet and Christian Fatoux (Assurance maladie) for proofreading this article.

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