From time to time, until the crisis has passed, the HEPL blog series authors will be given the opportunity to provide short updates on their country/region’s continuing response to this worldwide catastrophe and their further reflections on those responses. Each update will be labelled accordingly with the original response at the bottom of each post.

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HEPL blog series: Country Responses to the Covid19 Pandemic

France’s Response to the Coronavirus Pandemic – Update (May 2020)

 Zeynep Or, Isabelle Durand-Zaleski, Coralie Gandré, Monika Steffen

France has been in lock-down since March 15 in order to slow down the spread of the Covid-19 pandemic. All schools, restaurants and shops, except for food, are closed. About 11 million people, almost 40% of the workforce, are on partial unemployment benefits. While the gradual end of the lockdown period is announced for May 11, the “State of Health Emergency” voted on March 23, which allows the government to take exceptional measures without parliamentary procedure, has been prolonged for another two months up to July 24. The initial consensus on restrictive measures justified for “saving lives” is increasingly questioned as the social and economic impact, as well as negative health consequences, start to become clearer.

The government began detailing the exit strategy at the end of April. Most businesses will be allowed to open after May 11, except hotels, restaurants and bars for which the decision to re-open will depend on the epidemiologic situation at the end of May. Employers are requested to maintain teleworking from home, if possible, until at least June 2. Otherwise, the opening of businesses is subject to strict measures on social distancing (number of persons allowed in close spaces) with a compulsory use of masks where it is impossible to respect these measures, i.e. shops, public transport, etc.  Other compulsory measures include 4 m² personal space for each employee, disinfecting the working place every day, etc.

To allow parents to go back to work, nursery and primary schools will be opened on May 11, but this decision will be applied on a voluntary basis, with classes limited to 15 children. Parents who can keep their children at home are encouraged to do so.  While secondary schools can re-open after May 18, the decision concerning high schools is pushed to the end of May. The scientific committee advising the Covid-19 policy had initially suggested not to open schools and universities before September, but later stated that they understand the political, economic and social consequences of school closures and the decision to re-open some schools.

The restrictions on travel both in France and internationally are maintained.  After May 11, people can only travel within 100km of their place of residence, gatherings of more than 10 individuals remain prohibited and most public places will remain closed until June 2. The decision on opening borders to non-EU countries is pushed back for the moment to June.

Meanwhile, the severe lack of masks and tests marked the lock-down period and caused major controversy. The government appears to have difficulty in overcoming its initial shortages despite efforts for higher domestic production and importation of masks, tests, and accompanying medicines.

The exit Plan presented by the Prime Minister follows the triple leitmotif: “Protect, Test, Isolate”.  But a week before the end of lockdown, the capacity and the strategy of testing is still not clear. Many employers, including healthcare professionals, dentists, paramedics, etc. do not have all the needed protective materials and tests. The guidelines on who should be tested, where and under what conditions are still not very clear.

Overall, while it is too early to make any sound assessment, the initial reactivity of the health system to protect front-line health workers (including in hospitals) and to organize its full capacity appears to be weak. In March, while hospitals were over-working and emergency rooms were flooded with new cases, consultations with primary and specialist care providers dropped by between 30% and 60%, despite increased use of teleconsultations, since patients were advised to avoid visits. Also, many self-employed health professionals including paramedics, dentists and physical therapists had to stop working because of the lack of protective material and adapted care protocols for them. The shortage of protective material in nursing homes may explain the very high death toll in residential care, which accounts for more than 40% of all Covid-19 related deaths. This is reflected in the ratio of about one staff member suspected of Covid-19 for every two residents infected in nursing homes.

Concerning the exit strategy, for the moment most of the attention has been on social distancing measures, with warnings from the government to renew the lock-down if the curve is not flattened. Meanwhile the strategy for strengthening the primary and social care capacity to fight the epidemic and assure needed care and testing for all is not yet well developed.

While the epidemic has sped up the reforms underway such as the use of telemedicine and task shifting, it also highlighted existing deficiencies in the system, in particular weak coordination between hospital and primary care and between healthcare and social care. To improve the system’s resilience, and avoid further restrictions of liberty, a first step would be to have a non-biased assessment of what worked and what didn’t.

France’s response to the coronavirus pandemic – Original post (April 2020)

Zeynep Or (or@irdes.fr) Institute of research and information in Health Economics (IRDES)
Isabelle Durand Zaleski, AP-HP Santé Publique Hôpital Henri Mondor
Coralie Gandré, Institute of research and information in Health Economics (IRDES)
Monika Steffen, PACTE, University Grenoble-Alps. 

France has strengths and weaknesses in containing and managing the epidemic. On the one hand, it benefits from universal health insurance, a centralized presidential regime and a strong public administration, which in theory means that rapid and country-wide decisions can be made. On the other hand, coordination between the different parts of the care system is weak, making it harder to take a joined-up response involving primary care providers and hospitals. Moreover, the public health system had been affected by recent months-long protests by the yellow-vests movement, including strikes by hospital personnel in protest about the lack of resources.

Prevention and testing

The first three cases, connected to Wuhan, were identified on January 24, but the first preventive measures were announced only in late February. This included official advice on hand hygiene and respiratory etiquette following the identification of the first transmission cluster in Eastern France (Mulhouse) after a religious gathering on 17-24 February. Communication on hygiene and, later on, self-isolation steadily intensified with the exponential increase in cases, but announcements about if and when to use masks were incoherent and created public confusion. Without really admitting a scarcity of masks, the government eventually declared that it was not useful for everyone to use a mask, and instead they must be reserved for health care and other professionals at high risk of contamination as well as for sick people.

Towards the end of February, people were advised to limit international travel and social activities, but travel restrictions initially concerned mainly China and countries where the virus was already very prevalent. Testing was first focused on people who came from these countries, and on symptomatic patients, but since mid-March symptomatic cases are no longer tested systematically.

The first national restrictions were the interdiction of large public meetings (March 8), and all visits to residential nursing homes (since March 11).

Containment measures

Covid-19 policy is defined by the government in consultation with a scientific committee set up specifically for this purpose on March 10. The committee consists of 12 multidisciplinary scientists (including epidemiologists, public health experts, and anthropologists) and plays an important role in justifying the measures introduced.

Partial containment measures were introduced from March 14, including closures of schools and universities and all other public places, except essential shops such as supermarkets. But, backed up by the scientific committee, the first round of the municipal elections on March 15 was maintained. Despite these measures, between March 13 and March 15, the declared incidence of Covid-19 has doubled, and the total number of confirmed cases reached 6,400. Consequently, the President announced a quite restrictive total lock-down (stay-at-home) policy from March 18 onwards. Anyone who goes out has to provide a written justification. People are only allowed to go out to get food, for medical reasons or short recreation activities of a maximum one hour and in the resident’s area. Those who do not respect the rules are fined up to €450 (minimum of €135) and after four fines they risk €3750 and 6 months in prison. The conditions of the confinement have become stricter over time with the closure of open food markets, parks, forests, beaches, and an intensification of police controls for making people respect the stay-at-home policy.

Health care capacity

In the context of the recent protests demanding additional resources for public hospitals, the health authorities initially focused on hospital capacity, in particular the number of intensive care and “resuscitation” beds.

In all hospitals, non-emergency medical procedures and surgery were de-scheduled in March to free up a maximum of beds and especially human resources. The government also authorized public and private hospitals to create intensive care beds across the country. In order the help the most affected regions, a medical transportation system has been organized, by TGV-trains, helicopters and airplanes, with effective help of the French army, for moving patients from overloaded hospitals to less affected regions, including to Luxembourg, Switzerland and Germany.

In order to reinforce the health workforce, volunteers from the medical care reserve (created in 2007 as part of a National Health Strategy) have been called to help. Around 7,000 volunteers, mostly retired health professionals or medical students and secretaries had signed up in the Parisian area by March 25.

Several issues surfaced very quickly in the early days of the epidemic, including an insufficient number of masks, hand-cleaning gel and diagnostic tests. Following the H1N1 epidemic crisis in 2009, when the government (and the WHO) were accused of overreacting in building up large stocks of masks and vaccines, the national reserve of masks was gradually reduced, and responsibility for managing these stocks was given to individual health facilities and healthcare providers. This subsequently resulted in a scarcity of masks, especially higher quality masks (FFP2) which are necessary for healthcare professionals at high risk, that is, those dealing with infected people.

Treatment of Covid-19

There are no designated hospitals to deal with Covid-19 patients. As the admittance of infected patients via emergency departments created tension regarding the risk of contamination, many hospitals set up tents outside for screening Covid-19 cases. As of March 1, the recommendations for patients with severe symptoms were to call mobile emergency services rather than to go directly to a hospital. For patients with milder symptoms, the recommendation was to “stay at home” and use teleconsultations, which are reimbursed since 2018. The Health Insurance Fund has decided, since March 18, to ease the conditions for benefiting from teleconsultations and to reimburse them 100% until the end of the epidemic. Their number has been increasing exponentially.

Reflection on the Covid-19 response in France

France was rather unprepared when the epidemic hit: there were not enough masks nor tests, and many hospitals were on strike. The policy response that was adapted as the situation unfolded has been to build a national consensus around strong measures.

On March 12, President Macron announced in a solemn speech that the Nation was “at war”, using a war terminology close to that of President Holland after the terrorist attacks in Paris in November 2015. Macron set two priorities: saving lives by protecting hospitals and the most vulnerable citizens (elderly, chronically ill); and saving the Nation’s economy. On the economy, the government proposed rather quickly an extensive plan to support families and employment, especially small-medium enterprises. Measures include full sickness allowances for parents who cannot work because of childcare; easy access to short-term unemployment allowance entirely supported by the State, compensation funds by sector to support enterprises and independent workers that have stopped activity, tax supports, etc.

Concerning the healthcare response, most of the attention has been on hospitals. Given the recent strikes in public hospitals, the Government promised a renewal of hospital policy, with substantially more resources, and reform of the highly criticized funding model. However, very little attention has been paid to the organization and resources of primary and social care in fighting the pandemic and ensuring care for others. There was no clear instruction for primary and social care providers to guide and help them deal with Covid-19 situation in February and March. Many providers including nursing homes announced that they are lacking resources, including masks for their personnel.

The shutdown policy is justified for “saving lives”, but it has many perverse effects on the health status of the population as well as on economy. The situation could become critical for those in difficult conditions (including those with mental health problems, in poor housing, in prison where visits are blocked), but also for the elderly who are supposed to be protected from Covid-19. For many older people who benefited from medico-social services at home, their usual care has been disrupted.

On the positive side, hospitals have been very reactive, mobilizing personnel, redirecting resources to intensive care units, and setting up telemonitoring of patients at home. There may be some long-term externalities in terms of prevention and more flexible, online, care provision. The crisis has also resulted in strengthened public health governance in France with new legal tools, and earmarked research funding.

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