Policy responses for France - HSRM


Policy responses for France

5. Governance

5.1 Governance

The GOVERNANCE of the health system with regard to COVID-19 relates to pandemic response plans and the steering of the health system to ensure its continued functioning. It includes emergency response mechanisms, as well as how information is being communicated, and the regulation of health service provision to patients affected by the virus.

The transition measures presented by the Prime Minister on April 28, were voted at the National Assembly. They were accepted by 368 deputies against 100 who voted against and 103 who did not vote. This plan will be also discussed with local elected authorities and social partners. A senior high ranking official (Jean Castex) was designated to operationalize this plan. He became prime minister on July 3. The second phase of the easing of the lock-down measures was implemented in June 2, with further easing of the measures starting on June 15 and June 22.

The main elements are summarised below:

Schools (e.g. primary, higher education, etc.)
Starting on May 11, re-opening of child care and primary schools on a voluntary scheme proposed by the Minister of Education. Also possibility to re-open continuous training centres and vocational training centres.
May 18: re-opening of middle schools in areas classified as low risk (green) and on June 2 on the whole territory. But in more affected regions (orange) ,high schools will not be opened before September, with the exception of  vocational high schools, and in middle schools, the priority will be given to the youngest pupils (first two years).
June 22: re-opening of all nursery, primary and middle schools, with a compulsory attendance for all pupils, in the same conditions as before the epidemic.
All schools opened normally in early September 2020.

Workers (e.g. essential workers, childcare workers, etc.)
Essential workers have continued working during the whole lock-down period. Workers who can work remotely are strongly encouraged to pursue working from home after May 11.

Businesses (SMEs, restaurants, etc.)
On May 11, most businesses will be re-opened, except, hotels, restaurants, bars, cinemas, theatres and large museums for which a decision was taken by the end of May.
Restaurants & bars re-opened on June 2 with strict social distancing rules, and only on outdoor terraces in the most affected areas (but this restriction was lifted on June 15 in the whole mainland France). Theatres and sport venues re-opened on June 2 in the less affected areas, while large museums opened progressively between June and July. Cinemas and casinos can open again, starting on June 22.

These venues were all closed again during the second national lock-down.

Travel (local, cross-border, etc.)
Between May 1 and June 2, travelling was allowed only in the limit of 100km from the place of residence, except in case of important business or family reasons. This restriction has been lifted since June 2. Borders with EU countries were opened again since June 15, while it is possible to travel outside of the EU (in countries where the epidemic is under control) starting on July 1.
While borders with EU countries remain open during the second national lock-down, travels are strongly discouraged.

Gatherings (events, informal gatherings, religious services, etc.)
Gatherings of more than 10 people remain prohibited after June 2, while gatherings of more than 5,000 individuals are prohibited until October 30. The French state council ruled on June 13 that demonstrations could no longer be prohibited. Religious services are allowed since May 23 and weddings since June 2. New restrictions apply during the second lock-down (in particular for weddings which are limited to very few participants).

Meanwhile, the state-of-health emergency is first extended until July 10 following the vote in the parliament (instead of July 24 initially proposed by the government), to enable the application of such measures. Now, based on the evolution of the epidemic, the implementation of exceptional measures to control the pandemics will be prolonged at least until November 10. Following a new massive wave of infections, the state-of-health emergency was established again starting on October 17 (until at least February 2020), and enabled the implementation of a night curfew, and then a second national lock-down.

The Ministry of Health has started on May 25 a national consultation with all healthcare providers for improving care organization in France (‘Ségur de la santé’). Negotiations with the unions of hospital professionals to increase salaries, especially for hospital nurses, and the organization of working times, are an important part of this process.

A national senatorial investigation committee was created on June 30, in order to assess the appropriateness of public policies implemented during the Covid-19 epidemics. The first investigation aims to evaluate the national level of preparedness to the epidemics and the management of the situation by the government during the early stages of the epidemics. The committee started its work by auditioning former ministers of health. This will be complemented by a similar investigation led by the National Assembly which started two weeks earlier. In March 2021, the National court of auditors released its annual report which focused on the management of the pandemic and pointed to the unpreparedness of public services (in particular, health and education services) for the crisis.

Following the end of the lock-down period, the governance of the measures to limit the spread of the virus has very much shifted from the government to local authorities and in particular prefects. However, with the onset of the second wave of the epidemic at the end of September, the government has started to once again impose measures to local levels, such as temporary closures of bars and restaurants in the region of Marseille, with have been contested by local mayors. The policy response to the Covid-19 pandemic in the first trimester of 2021 was therefore piloted at the national level but driven by and adapted to the local epidemiological situations.

On February, 9, 2021, the state-of-health emergency was once again extended until June 1, 2021.

The management of the epidemic is integrated in a prevention and management plan with four stages. The first stage consists of stopping the introduction of the virus on the national territory; the second stage consists of limiting the spread of the virus on the national territory; the third stage consists of reducing the effects of the epidemic and the fourth stage aims to going back to the baseline situation before the start of the epidemic. The third stage was reached on March 14 in mainland France, while as of March 29, some overseas territories were still in stages 1 to 2.

The national response to Covid-19 is led by the French government, with the support of an expert scientific committee set up specifically for this purpose on March 12. The committee consists of 12 scientists, mainly medical with two sociologists and anthropologists and had an important role on the decisions made by the government. On March 24, the president announced that a second scientific committee, the Care Committee (Committee for analysis and research expertise), grouping 12 doctors and researchers, was set up to look more closely at therapeutic options for Covid-19, providing rapid guidance on technologies that could be implemented and ensuring that clinical trials on tests and drugs follow valid methodologies. Furthermore, on March 30 the government asked all researchers working on Covid-19 to give free public access to all their data and findings.

An emergency legislation was adopted to deal with the Covid-19 epidemic. It introduces officially the state of health emergency, and the official role of the scientific committee, which advises the government on the public health measures that should be adopted during the epidemic. The legislation further lay down both health-system related aspects (in particular, the stronger role given to community pharmacists and the reorganization of hospital activities) and other economic measures (see Section 6. Measures in other sectors). Following the random restrictions and decisions of some mayors to make compulsory the use of protective masks in their municipalities, the French State Council ruled on April 17 that municipalities were not allowed to take additional decisions different from the national emergency legislation.

Another major institution managing the situation is the National Public Health Agency (Santé publique France), which is the body coordinating epidemiological surveillance and information for health professionals and general public. Regional health authorities and local authorities (prefects) are allowed to apply some specific decisions at the "département" or municipal level based on regional specificities.

Fast-track procedures were introduced for clinical trials focusing on the development of treatment and vaccines for the Covid-19 virus, which are evaluated in priority by the French National Agency for Medicines and Health Products Safety (ANSM). The government has also allowed the prescription of hydrochloroquine for severe hospitalized cases despite criticisms of the first trial carried out to assess its efficacy. On April 13, the president announced that France was the European country involved in the most clinical trials on Covid-19 treatment and that an investment plan for research and health will be planned after the crisis.

The position of the government regarding the use of masks in the general population and the widespread use of tests has varied over time, linked to the availability of the resources and the difficulties to obtain them in the world market. The recommendations on the use of tests in nursing homes have also changed in early April, following a rapid increase in cases in nursing homes in the past month.
On April 2, the national consultative commission on human rights announced the creation of an Observatory of measures taken to deal with the epidemic during the state of health emergency (‘Observatoire des mesures de l’état d’urgence sanitaire et du confinement’) to ensure that they respect human rights.

The government’s management of the Covid-19 crisis has attracted criticism in France: by mid-May, more than 100 complaints from citizens had been filed against the members of the government denouncing the management of the Covid-19 crisis. They target in particular the Prime Minister, Edouard Philippe, and the Ministers of Health, the Interior, Labor and Justice. Some complaints also target Marisol Touraine, Minister of Social Affairs and Health from 2012 to 2017, for her responsibility in managing the stock of PPE. Families of the older population who died from the virus in long-term care homes have claimed that there has been a lack of transparency during the health crisis and are filing complaints against nursing homes and local authorities.

On July 24, a national defence council on the sanitary crisis was organized by the French President in order to start planning the response to the new surge in the number of Covid-19 cases as well as measures for the end of the summer break.