‍Prevention: a neglected issue in our health system?

A health model that is at odds with prevention?

La prevention, defined by the WHO as “all measures aimed at avoiding or reducing the number and severity of diseases, accidents and disabilities” has become a major challenge in our societies, especially with the aging of the population. However, the results in France remain inadequate despite investments comparable to those of our neighbours. So how do you explain this disparity in results?

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At the beginning of 2024, at the National Assembly, the new Minister of Health Frédéric Valletoux took up the crucial challenge of transforming prevention policies in France. Indeed, if we refer to the reports of the Court of Auditors, in particular that of November 2021, France is a poor performer, with fairly poor results. So what is this due to?

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The first thing to note is that the investment allocated to prevention is not in question, as it remains similar to that of our neighboring countries. However, the traceability of these investments in health prevention seems to be less well defined in France, in particular because of poorly adapted management tools. These investments are distributed between a plurality of actors at different levels (Regional Health Agencies, Departments, Municipalities, Health Insurance), which are not sufficiently coordinated with each other and operate without a global strategy.

The complexity of coordinating regional and local actors is particularly harmful for certain pathologies, especially those related to work. It is also important to take into account disparities between territories, as the impact of medical density on some of them greatly influences the actions of health prevention, including the fall prevention among the elderly.

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Enshrined in law in 2002, the policy of health prevention, which must “extend to all dimensions of the health status of the population, whether preventive or curative”, now requires revision to give it a clear guideline. It is crucial to define a precise distribution of actions to be carried out between the various actors.

The other major factor is of course the dominant healing culture in France, which has shaped our health system and, by definition, is taking precedence over prevention. The construction of our health system around curative care is a reflection of this.

At a more micro level, businesses and individuals are also not devoting enough resources to the actions of health prevention. Numerous studies have shown that regular physical activity provides numerous health benefits, limiting the onset and development of certain diseases or physical disabilities, which is the essence of health prevention. This involvement would benefit them, reducing the number of work stoppages.

Finally, at the individual level, it is crucial to develop an approach to prevention through involvement rather than through accountability or guilt, as is often the case today.

What is prevention?

We talked about prevention, but in reality, there are several types. The WHO distinguishes three:

• Primary prevention: reducing the incidence of diseases in a given population (for example, through vaccination).
• Secondary prevention: reducing the prevalence of diseases in a given population through curative and therapeutic measures.
• Tertiary prevention: reducing the prevalence of disabilities and sequelae in a given population, for example through functional rehabilitation.

So, for autonomous people, the prevention is mainly focused on the promotion of a healthy lifestyle, the prevention of certain chronic and progressive disorders, the adoption of safety measures and the security of the environment, as well as vaccination and screening actions.

For people with mild disorders or reduced autonomy, the objective of prevention is to slow the decline in physical pathologies. It is important to note that the loss of autonomy is inevitable with the aging of the population, which makes it essential to fall prevention and other actions that promote healthy aging. This includes maintaining regular physical activity for muscle building. That is why many health facilities organize gymnastics sessions or other soft mobility activities with professionals for EHPAD residents. La fall prevention involves specific actions, such as the adaptation of the living environment, in particular the development of inclusive habitats, as well as effective tools for monitoring health status and for prevention, such asAugmented ear for caregivers. It makes it possible to anticipate changes in the state of health and to avoid falls, and to intervene quickly to limit the time residents spend on the ground in the event of a fall.

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Finally, it is important to note the five priority areas of action defined by the 1986 Ottawa Charter for Prevention, established at the first International Conference on Health Promotion:

• Health policy development
• The reorientation of health services
• Creating enabling environments
• The acquisition of individual skills
• Strengthening community action

The Ottawa Charter also highlights three key strategies: empowering, mediating, and promoting the idea. Already at that time, the importance of environmental determinants, working conditions and social inequalities was recognized as essential.

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Best practices/actions observed

La prevention through education in good health practices and habits, provided by institutions but also by peers, while identifying and resolving risk factors, is essential.

It is crucial to adopt a conception of prevention throughout life, involving citizen participation and individual ownership.

With the evolution of our healthcare system, it is also important to test and adopt new approaches, such as telemedicine and neuroscience, as well as to anticipate new genetic and environmental risks.

Finally, it is essential for the State to better coordinate its actions and actors in the health and medico-social fields, by promoting the continuity of prevention and care. This mission will probably increasingly be entrusted to Regional Health Agencies.