Chance to Engage with France?

Chance to learn from FranceThere was an excellent series of articles, France: nation and world, published in The Lancet last year. The series looks at different aspects of the realization of the right to health for its citizens, and the role of France in the realm of global health. As the two founders of the IMAXI Cooperative, neither French by birth, are only alive today due to the excellence of the public health services of France, this Lancet series of papers rang a bell very close to home.

However, over the last 15 years we have witnessed the lack of participation of our comrades from Francophone communities in various global health governance bodies, including UN agencies and programmes. We have also rarely heard from the French government about how its excellent model of public health could be applied to other countries outside its ‘sphere of influence’ in its ex-colonies. Although IMAXI is a French registered NGO, our attempts to connect with the French delegates to discuss its role in global health have not been fruitful.

With the recent election of President Macron, and the anticipated success of his En Marche movement to win a majority in the French parliament next weekend, there is now a possibility that health activists can better engage with the new government in innovative and effective ways to advance our shared values, including realizing the right to health for everyone, everywhere.

Over the next few weeks, we will be re-posting some of the articles from the series in The Lancet. We hope they serve to both inform and to inspire others to join with us in a new ‘working’ group to explore ways in which we can turn this new political reality in France into more health justice for everyone. Contact us for more information.

We begin with the introduction to the series that provides both background and hope.
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France: a philosophy for health
by Richard Horton and Audrey Ceschia

The dominance of English as the language of science and, increasingly, global health too often closes the door on the history and experiences of others. In France’s case, careful study of the nation’s struggle to achieve universal health coverage, together with its distinctive approach to global health, has much to offer those who seek to understand the diversity of paths to achieve better health at home and abroad. The two Lancet Series papers (1, 2) on France’s contribution to health, along with four comments from French or Francophone leaders, (3, 4, 5, 6) aim to correct this imbalance in the English-language literature on health. They are also an invitation for France to reflect on its challenges and global role.

The modern story of France perhaps can be marked by The Declaration of the Rights of Man and the Citizen (1793). The statement of principles is one key to understanding France. The Declaration underlines the lessons to be learned from “the miseries of the world”. “The aim of society is the common welfare”, proclaims the Declaration. A person’s natural rights are equality, liberty, security, and property. Security means “the protection afforded by society to each of its members for the preservation of his person”, which today we might call human security. “The social guarantee consists in the action of all to secure to each the enjoyment and the maintenance of his rights.” Solidarity, equity, and globalism—all underscored in a single declaration. A social contract that still has power to stir the heart as well as the mind today.

Translating those principles into tangible benefits for society is less easy. But over two centuries France has been able to deliver universal health coverage for its people, as Olivier Nay and colleagues (1) show in the first Series paper, with consummate success. Those achievements, while perhaps not threatened, are certainly under pressure. The tensions between public and private provision, central and decentralised governance, and urban and rural demands are straining the contract between the people and State. Nay and colleagues1 raise important questions about the degree to which France’s redistributive system can meet the spirit of its founding principles, whether it can change to absorb the rapid demographic and epidemiological transitions engulfing all nations. They are not entirely optimistic in their outlook. The dangers of economic stagnation, rising disparities, increasing costs, and fragmentation of the public health-care system are pervasive. Values alone do not provide solutions. But the extraordinary adaptability of France’s social contract does provide the democratic space for reasoned public discussion based on a clear philosophy. That is more than can be said of many nations.

Despite fluctuations in the country’s financial support for international health, France has never stepped away from its global role. France’s colonial past differs from that of the UK. In the English-speaking world, the divide between vertical and horizontal approaches to overseas development assistance has tended to crowd out the debate about donor aid. As Laëtitia Atlani-Duault and colleagues (2) show, France has devised an alternative vision, not always without its own conflicts. The divide in France is less about vertical versus horizontal attitudes. Instead, the duality is one of humanitarianism versus egalitarianism. Whereas the Anglophone debate focuses on delivery, the Francophone preoccupation is again about values and principles. And in an era of sustainable development, this duality has much to commend it. At a moment when global health security is a serious concern, the notion of “preventive humanitarianism” has a special resonance. Instead of waiting for the next crisis to overtake us, France’s historic approach should spur us to act now to prevent further emergencies. And as countries seek their own path to universal health coverage, the notion of egalitarianism is a much more useful guiding principle than an argument about vertical or horizontal actions. The “new direction” called for by Atlani-Duault and colleagues (2) might at least partly be to more powerfully advocate for these two distinctive values—and to back them with unequivocal policies.

It can be easy to fall into the trap of over-idealising a country’s domestic and international motives and achievements. But France is indeed different in its approach at home and abroad compared with, for example, the USA and UK. These differences are important counterweights to the dominant Anglophone dialogue that drives thinking about health today. This Series also makes clear that France should consider playing a much more visible and decisive part in the global conversation about health. The lessons from France’s history have much to teach us. We should all listen.

We thank Jean-Paul Moatti for his commitment and inspiration in leading this Series and Jean-François Delfraissy, Olivier Nay, Laëtitia Atlani-Duault, Saran Branchi, and their colleagues for their contributions to this Series.

References
1.    Nay, O, Béjean, S, Benamouzig, D, Bergeron, H, Castel, P, and Ventelou, B. Achieving universal health coverage in France: policy reforms and the challenge of inequalities. (published online May 2.)Lancet. 2016;
http://dx.doi.org/10.1016/S0140-6736(16)00580-8

2.    Atlani-Duault, L, Dozon, J-P, Wilson, A, Delfraissy, J-F, and Moatti, J-P. State humanitarian verticalism versus universal health coverage: a century of French international health assistance revisited. (published online May 2.)Lancet. 2016; http://dx.doi.org/10.1016/S0140-6736(16)00379-2

3.    Sidibé, M. Democratising the global health agenda: why we need France. (published online May 2.)Lancet. 2016;
http://dx.doi.org/10.1016/S0140-6736(16)30060-5

4.    Baron, E. Liberté, égalité, fraternité…santé. (published online May 2.)Lancet. 2016; http://dx.doi.org/10.1016/S0140-6736(16)00656-5

5.    Bréchot, C. The Institut Pasteur International Network: a century-old global public health powerhouse. (published online May 2.)Lancet. 2016;
http://dx.doi.org/10.1016/S0140-6736(16)00744-3

6.    Delfraissy, J-F, Yazdanpanah, Y, and Levy, Y. REACTing: the French response to infectious disease crises. (published online May 2.)Lancet. 2016;
http://dx.doi.org/S0140-6736(16)30059-9