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HEALTH

Can France’s hospitals survive both the coronavirus and the looming economic crisis?

France prides itself as having one of the best healthcare systems in the world. But how will it cope with a coming economic crisis and a possible second wave of coronavirus cases?

Can France’s hospitals survive both the coronavirus and the looming economic crisis?
Photo: AFP

During the unprecedented health crisis caused by the coronavirus epidemic, France's health care system coped. Just.

With the help of a military hospital and a massive transfer of patients away from hot-spots the structure held, but it's what comes next that has those working on the inside of the system worried.

“There is a lethal risk to our health care system even before the pandemic is over,” said Daniel Camus, a professor at the Pasteur Institute in Lille, one of the France's top institutes researching the coronavirus and its impact.

France spends more than most countries on health, and its national health care service is vaunted as one of the most generous and best in the world, but the coronavirus has shed light on cracks that have been growing bigger over the years.

And with a major recession on the horizon, public spending is likely to be squeezed further.

“The coronavirus epidemic is revealing all the problems that we’ve tried to talk about for over a year,” said Hugo Huon, a nurse and representative of the social protest collective Inter Urgences, which had half of France's public hospital services on strike in the winter of 2019 and are mobilising again now.

READ ALSO How do nurses' salaries in France compare to Europe?

French President Emmanuel Macron has been criticised for ridding the country of over 4,100 hospital beds over the course of 2018 – reducing the total capacity by one percent – a little more than a year before the coronavirus would hit.

But decreasing France's long-term hospital care capacity was a project started long before Macron entered the Elysée Palace, and his socialist predecessor François Hollande saw more than 15,000 beds disappear during his mandate (2012-2017), according to numbers from the OECD.

Over the past two decades, 90,000 hospital beds have disappeared

The numbers reflect a longstanding international trend where France, along with other developed countries, has spent decades trying to optimise its healthcare system by rendering hospitals more dynamic and profitable.

Part of this strategy has involved reducing the number of hospital beds and replacing them with short-term care places, to incentivise hospitals to get patients in and out as quickly as they can. Surgical development such as key-hold surgery and laser surgery have also reduced the need for long-stay beds.

The graphic below, taken from a health ministry report, shows that while the numbers of hospital beds steadily decreases, the number of “places” (short-term beds) increases.

Photo: French Health Ministry

In total, France today has 395,693 hospital beds, 243,326 of which are in the public sector, according to the health ministry.

As showed in the graph below, this represents about 6 beds per 1,000 inhabitants, according to the OCDE. In 2000, the number was eight (which is the current level of Germany).

Photo: OCDE

Despite this steady and gradual reduction of long-term care capacity, France finds itself among both the top spenders in Europe on health care – equal to Germany and only beaten by Switzerland when it comes to spending relative to GDP – and has more hospital beds per person than most European countries.

The reason is that the trend of rendering hospitals more efficient has been international, with most countries taking the same steps.

Looking at the relative number of intensive care beds illustrated in the graphic below, a heated issue during the coronavirus crisis because the virus had ICUs in hard-hit areas in France explode their capacities, the number has steadily decreased too over the years.

Photo: WHO

'The health sector is not an army'

After eight weeks of strict, nationwide lockdown, French hospitals are now bracing for a resurge in the number of coronavirus cases in the weeks to come as the country is taking its first small steps back to normality.

President Emmanuel Macron declared France “at war” with the virus, turning “health workers” into “frontline fighters” on a mission to save the nation.

But virologist Camus said France would not be able to maintain the teams indefinitely.

“The health sector is not an army. Eventually people will fall apart,” he said.

The French government has been subject to harsh criticism from hospital staff for having failed to ensure enough masks and other protective equipment during the first weeks of the coronavirus epidemic. Photo: AFP

'It’s not a war, it’s a virus’

“This is not a war, it’s a virus,” a 25-year-old nurse currently working in a private hospital in Pays de la Loire, west in France told The Local. 

“It’s exhausting. You want to care for people, but you can’t.”

“Saying 'war', 'warrior', 'soldier' is a way of justifying things that aren’t justifiable “

By “unjustifiable things” he meant not having enough masks, gloves and other protective equipment ready for the country's health personnel when the epidemic began.

Hugo Huon has been fighting for better work conditions for nurses since a woman was found dead in the waiting room at Labriboisière hospital in Paris, after queuing for 12 hours on a stretcher in December 2018. 

He was not himself working that night but he remembers the incident as a turning point that would eventually become the catalyst for the enduring social movement that had nearly half of France’s public hospital services taking industrial action in the winter of 2019.

“Talking to staff at other hospitals, we realised that in Paris, just during the month of March, there had been five similar incidents to that of the woman at Labriboisière,” he said.

Protesters are demanding more money to public hospitals and a salary raise for staff. Photo: AFP

The number of nurses in French hospitals has not decreased over the past years. In fact, the number increased by 2 percent between 2010 and 2017.

But this increase did not reflect the surge in demand, which jumped by over 14 percent over the course of the same period, sociologist and health politics specialist Frédéric Pierru told Le Monde in a video interview.

In the five years that follow graduating, one third of France’s nurses quit, according to the national union representing nurses.

A male protester is holding a sign saying “LBD rubber bullets and teargas straight in the face, but zero masks. Macron (and Interior Minister Christophe) Castaner, we won't forgive.”

'When a crisis is over, all good intentions disappear'

President Macron has promised a “massive” investment plan in the country’s hospitals and said hospital staff working during the pandemic will get a bonus between €500 to €1,500.

“We don’t want a bonus, we want a salary increase,” said Olivier Milleron, a doctor representative from the collective Inter-Urgences, which quickly re-mobilised after the worst peak of the coronavirus crisis had passed.

“We don’t want a medal. We did our job,” the doctor told France Info, referring to the honouring of the country’s nurses planned by the government on July 14th, France's national day, as a “provocation.”

The government has promised to enter talks with representatives from the sector this summer to discuss a revaluation of nurses' salaries, which is currently at one of the lowest levels in Europe.

“What the pandemic shows is that there are goods and services which must be protected from the laws of the market,” Macron said in one of his televised speeches to the nation.

But the big question is whether it will be feasible for the government to keep its promises in the long term, once the recession – predicted to be the worst since 1945 – starts to show its impact. 

“We have seen it before, when a crisis is over all good intentions disappear,” said Camus. 

The professor worried not about the government’s willingness, but the pressure from lenders to cut in public spending once the health crisis was at bay.

“I fear that financiers will say ‘wait a minute, that’s very expensive, we’re not going to dedicate enormous budgets to hypothetical scenarios’,” he said.

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MONEY

Revealed: What will you receive from France’s €65bn cost-of-living aid package?

The French parliament has finally passed a massive €65 billion package of measures aimed at helping French residents with the spiralling cost of living. Here's a rundown of the help on offer, who it's available to and when it comes into effect.

Revealed: What will you receive from France's €65bn cost-of-living aid package?

After three weeks of sometimes heated debate, France’s parliament has adopted its multi-part purchasing power package to help mitigate rising cost of living and inflation.

In total, parliament approved a budget of nearly €65 billion for the whole package. 

It includes a raft of measures including price shields, tax rebates and grants. Here’s what is included and who will benefit.

Electricity and gas The government has voted to extend the tariff shield on gas and electricity prices until the end of the year: this means that gas prices will continue to remain frozen and that price hikes for electricity prices will be capped at four percent. 

For who: This applies to everyone who has a gas or electricity account in France.

When: The price freeze is already in effect and will continue until at least December 31st.

Fuel subsidy – The government’s fuel rebate (on petrol/gasoline and diesel) will be increased from €0.18 per litre to €0.30 in September and October, and then in November and December it will fall to €0.10. 

For who: All drivers (including tourists) – this is applied automatically at all fuel stations in France

When: The €0.18 per litre rebate is already in place and remains until August 31st, and rises to €0.30 on September 1st.

Pensions – The index point for pensions will be raised by four percent.

Who: This covers anyone who receives a French pension – roughly 14 million people – it does not affect anyone who gets a pension from another country.

When: From September 9th. 

Abolishing the TV licence fee – The annual TV licence raised €3.7 billion a year for public broadcasting, with the majority having gone toward France Télévisions, but has now been scrapped. It was €138 per household. 

For who: Any household with a television. This equates to about 23 million households in France who will no longer have to pay this yearly tax.

When: The was due to be levied on November 15th, but this year no bills will be sent out.

Tripling the Macron bonus – The maximum annual bonus – which is exempt from income and social security taxes – will be tripled.

It is a one time, tax-free payout that can be given to workers by their employers – if they chose to. Companies will now be able to pay up to €3,000 to their employees (and up to €6,000 for those with a profit-sharing scheme).

Who: This pertains to salariés (employees) whose businesses choose to offer this bonus.

When: The bonus can be paid between August 1st and December 31st.

Rent cap – Rent increases will be limited to 3.5 percent per year for existing tenants. Some cities already have in place their own rent control schemes, but the 3.5 percent cap is nationwide.

Who – This affects anyone who already has a tenancy agreement for a property in France (and also affects all landlords who are banned from making big rent hikes).

When – The 3.5 percent cap concerns annual rent increases that fall between July 2022 and June 2023.

Housing allowance – Those who benefit from personalised assistance for housing (APL) will see that increased by 3.5 percent.

Who: This pertains to those who qualify for governmental financial assistance with rent. Typically, this means low-income households. If you are already on APL – around 3.5 million people – the increase will be automatic, if you think you might qualify, apply through your local CAF.

When: The increase comes in your next payment, with the increased rate backdated to July 1st 2022.

Social benefits – The RSA top-up benefit will be increased by four percent (local authorities, who deal with RSA, will receive €600 million to help them finance and allocate this increase). Additionally, those who benefit from the ‘prime d’activité‘ (activity bonus) will see that value raised by four percent as well.

Who: Unemployed people below the age of 25 can qualify for RSA – this pertains to about 1.9 million people in France. The activity bonus is available to low-income workers – about 4.3 million people.

When: Catch-up payments will be in place from August 18th to September 5th. On September 5th, the updated payment will begin to be paid out.

Student grants – An increase of 4 percent for student grants (bourses) for higher education

Who: Students under the age of 28 who qualify for financial assistance in the form of grants. These students must qualify as ‘financially precarious’ for the school year of 2022-2023.

When: September 2022

Back-to-school grants – Families who meet certain income requirements are eligible for an allowance to help cover back-to-school costs – that grant will increase by four percent this year. There will also be an extra €100 subsidy for eligible families (with an additional €50 per child) paid “to those who need it most” according to Finance Minister Bruno Le Maire in an interview with RTL. 

Who: Low-income families with children. You can test your family’s eligibility on the website www.service-public.fr. This aid will impact 10.8 million households.

When: The one time payment will be paid at the start of the school-year in September.

The option to convert overtime days into extra cash – This is encompassed in two measures: increasing the ceiling of tax exempt overtime hours to €7,500 and opening the possibility for companies to buy back RTT days from their employees.

Eligible employees covered by the 35-hour week agreement accrue time in lieu if they work overtime, known as RTT days. Currently this time is taken as extra vacation days, but now employees will have the option to forgo the time off and instead be paid extra.

Who: For the buying back of RTT days, this applies to employees (salariés) who have an RTT agreement with their company.

For the increased cap on non-taxed overtime work, this applies to a range of employees, such as those who have 35-hour per week contracts and have their employer request that they work overtime or those who work beyond their part-time contract amount. You can learn more about whether you have the ability to declare overtime hours HERE

When: The RTT days buyout will run from between January 1st, 2022 to December 31st, 2025. For employees eligible for tax-free overtime compensation, the ceiling of €7,500 will only be in place for the year 2022.

READ MORE: EXPLAINED: Why is France’s 35-hour week such a sacred cow?

Pay rise for public sector workers – public sector pay will get a four percent rise in the index.

Who: Anyone employed in France as a fonctionnaire (eg civil servants, teachers, librarians).

When: This will be retroactive to July 1st

Assistance for some self-employed workers – A reduction in health and maternity insurance contributions will be introduced for low-earning self-employed workers. “Microentrepreneurs” will also benefit from a reduction in their flat-rate contributions.

Who: Self-employed workers whose monthly income does not exceed 1.6 times the minimum wage and who are registered as ‘microentrepeneurs’

When: TBC

The biometric carte vitale –  The Senate introduced this into the purchasing power package, but it is not a benefit. It will involve the implementation of a biometric carte vitale health card to “fight against social fraud” by adding an electronic chip with biometric data on it to health insurance cards. You can read more HERE.

Who: Everyone who is registered in the French health system and has a carte vitale (about 60 million people)

When: Lawmakers will begin plans to implement the plans in Autumn 2022, but it’s not clearly exactly what form the rollout will take.

How much will these measures impact inflation?

Some measures will likely be more effective than others. For instance, the extension of the tariff shield and increase of the fuel rebate in the early fall is largely to thank for France’s inflation level being two points lower than the European average, according to INSEE.

On the other hand, the tripling of the ceiling for the (optional) Macron bonus will likely not make a large difference. This is because it will likely not be widely taken advantage of, as last year only 4 million French people received the optional bonus, with the approximate average of the bonus having been only €500.

The pension changes will impact about 14.8 million people in France. However, according to economist Christopher Dembik, the revalorsation values are based on actual inflation and not on inflation expectations. “These revaluation measures will be too weak by the time they will be implemented,” Dembik said to French daily Le Parisien.

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