Abstract

France was the first European country to confirm cases of COVID-19, being one of the most affected by the pandemic in the first wave. This case study analyzed the measures adopted by the country in the fight against COVID-19 in 2020 and 2021, correlating it to the characteristics of its health and surveillance system. As a welfare state, it relied on compensatory policies and protection of the economy, as well as increased investments in health. There were weaknesses in the preparation and delay in the implementation of the coping plan. The response was coordinated by the national executive power, adopting strict lockdowns in the first two waves, mitigating restrictive measures in the other waves, after the increase in vaccination coverage and in the face of population resistance. The country faced problems with testing, case and contact surveillance and patient care, especially in the first wave. It was necessary to modify the health insurance rules to expand coverage, access and better articulation of surveillance actions. It indicates lessons learned about the limits of its social security system, but also the potential of a government with a strong response capacity in the financing of public policies and regulation of other sectors to face the crisis.

Key words:
COVID-19; Health system; France; Public policy; Health policy

Introduction

The study of France allows us to understand different aspects of the response to the COVID-19 pandemic. The country is characterized by a consolidated social welfare system, strong public administration¹1 Steffen M. Social health insurance systems: what makes the difference? The Bismarckian case in France and Germany. J Comparative Policy Anal Res Pract 2010; 12(1-2):141-161.^,22 Or Z, Gandré C, Durand Zaleski I, Steffen M. France's response to the COVID-19 pandemic: between a rock and a hard place. Health Econ Policy Law; 17(1):14-26. and a health insurance system that is among the most accessible ones in Europe¹1 Steffen M. Social health insurance systems: what makes the difference? The Bismarckian case in France and Germany. J Comparative Policy Anal Res Pract 2010; 12(1-2):141-161.^,33 Nanda M, Aashima, Sharma R. Review of COVID-19 epidemiology and public health response in Europe in 2020. Clin Epidemiol Glob Heal 2021; 12:100882.. At the outbreak of the pandemic, France experienced a political context with strong popular mobilization against government measures, strikes in hospitals and the call for municipal elections scheduled for March 2020⁴4 Yan B, Zhang X, Wu L, Zhu H, Chen B. Why do countries respond differently to COVID-19? A comparative study of Sweden, China, France, and Japan. Am Rev Public Adm 2020; 50(6):762-769..

It was the first country with confirmed cases of COVID-19 in Europe⁵5 Stoecklin SB, Rolland P, Silue Y, Mailles A, Campese C, Simondon A, Mechain M, Meurice L, Nguyen M, Bassi C, Yamani E, Behillil S, Ismael S, Nguyen D, Malvy D, Lescure FX, Georges S, Lazarus C, Tabai A, Stempfelet M, Enouf V, Coignard B, Levy-Bruhl D. First cases of coronavirus disease 2019 (COVID-19) in France: surveillance, investigations and control measures, January 2020. Eurosurveillance 2020; 25(6):2000094.; however, it was the third to enforce a national containment policy⁶6 Ghanchi A. Adaptation of the National Plan for the Prevention and Fight Against Pandemic Influenza to the 2020 COVID-19 Epidemic in France. Disaster Med Public Health Prep 2020; 14(6):805-807.. It was among the five nations most affected by the epidemic, with high mortality rates from the disease in the first wave⁷7 Duguet A-M, Rial-Sebbag E. The fight against the COVID 19 epidemic in France: Health organisation and legislative adaptation. Med Law 2020; 39(2):173-188.^,88 Organisation for Economic Co-operation and Development (OECD), European Observatory on Health Systems and Policies. France: country health profile 2021 [Internet]. Paris: OECD; 2021. [cited 2022 jun 8]. Available from: https://www.oecd-ilibrary.org/social-issues-migration-health/france-country-health-profile-2021_7d668926-en, and also started having problems with the resurgence of cases after the economic reopening⁹9 Desson Z, Weller E, McMeekin P, Ammi M. An analysis of the policy responses to the COVID-19 pandemic in France, Belgium, and Canada. Heal Policy Technol 2020; 9(4):430-446..

Some authors have highlighted the delay in adopting official preventive measures and the government’s unpreparedness²2 Or Z, Gandré C, Durand Zaleski I, Steffen M. France's response to the COVID-19 pandemic: between a rock and a hard place. Health Econ Policy Law; 17(1):14-26.^,1010 Arminjon M, Marion-Veyron R. Coronavirus biopolitics: the paradox of France's Foucauldian heritage. Hist Philos Life Sci 2021; 43(1)5., in addition to the contradictory communication in the country⁶6 Ghanchi A. Adaptation of the National Plan for the Prevention and Fight Against Pandemic Influenza to the 2020 COVID-19 Epidemic in France. Disaster Med Public Health Prep 2020; 14(6):805-807., at the beginning of the pandemic. Compared to other countries, France showed a unified response, due to the centralized institutional arrangement, with a certain degree of more coercive measures⁴4 Yan B, Zhang X, Wu L, Zhu H, Chen B. Why do countries respond differently to COVID-19? A comparative study of Sweden, China, France, and Japan. Am Rev Public Adm 2020; 50(6):762-769.. A comparison between francophone countries showed that the centralized decision-making process contributed to a more effective coordination of health resources and information across the country, in addition to having caused some changes to the health system that tend to remain as a legacy for the post-pandemic period⁹9 Desson Z, Weller E, McMeekin P, Ammi M. An analysis of the policy responses to the COVID-19 pandemic in France, Belgium, and Canada. Heal Policy Technol 2020; 9(4):430-446..

The literature has addressed many peculiarities of France in the pandemic context, both regarding the relationship between a supposed potential for responsiveness and failure to fight the first wave¹¹11 Barrera-Algarín E, Estepa-Maestre F, Sarasola-Sánchez-Serrano JL, Vallejo-Andrada A. COVID-19, neoliberalism and health systems in 30 european countries: relationship to deceases. Rev Esp Salud Publica 2020; 94:e202010140., as well as the controversies related to the government’s discourse¹²12 Hassenteufel P. Handling the COVID-19 crisis in France: paradoxes of a centralized state-led health system. Eur Policy Anal 2020; 6(2):170-179.^,1313 Dada S, Ashworth HC, Bewa MJ, Dhatt R. Words matter: political and gender analysis of speeches made by heads of government during the COVID-19 pandemic. BMJ Glob Heal 2021; 6(1):e003910. and even the contradictions related to the restrictive measures in the country, a symbol of individual freedoms and criticism of biopower¹⁰10 Arminjon M, Marion-Veyron R. Coronavirus biopolitics: the paradox of France's Foucauldian heritage. Hist Philos Life Sci 2021; 43(1)5.. Some aspects of the health system were addressed, albeit dispersed in several publications and showing no relationship with the health insurance model and the adopted surveillance system.

This study sought to analyze the French response in the fight against COVID-19, the characteristics of its health and surveillance system, aiming to identify reasons for the observed performance and draw lessons for other nations or other health emergencies.

Research strategy

The present is a case study supported by a literature review, documental analysis and secondary data collection.

A search for scientific publications corresponding to the period from January 2020 to December 2021 was carried out in the Pubmed Central, Web of Science, Scopus and Science Direct databases, using a combination of the descriptors “France” and “COVID-19” with “health system”, “surveillance”, “national response” and “welfare state”, with the Boolean operator “AND”. Of 222 identified documents, 60 were selected, using the following inclusion criteria: articles that analyzed measures to cope with the COVID-19 pandemic in France or that addressed characteristics of the surveillance model or the French health system. Articles that addressed only specificities of French overseas regions or territories were excluded, as well as those that were not available in English, French, Spanish or Portuguese.

For a better understanding of the institutions, organizational arrangements of the health system and the surveillance model and analysis of general indicators in the country, the publications of the European Observatory on Health Systems and Policies were consulted (https://health.ec.europa.eu/), as well as the Organization for Economic Cooperation and Development (OECD) platform (https://www.oecd.org/). Additionally, in a complementary way, manual searches were carried out and the references cited in the selected articles, which addressed the components and dynamics of the French health system, were identified.

Regarding data on the pandemic evolution and specific measures adopted by the government, the ‘Our World in Data’ database (https://ourworldindata.org/) and French government websites (www.data.gouv.fr) were consulted.

Data extraction took place according to the analysis matrix, which included the following dimensions: 1) identification of the country and demographic indicators; 2) characteristics of the state/government; 3) characterization of the health and surveillance system; 4) responses to the COVID-19 epidemic; 5) evolution of the epidemic in the country.

The French government and compensatory policies in the face of the pandemic

France is a unitary, republican State, with a semi-presidential regime⁹9 Desson Z, Weller E, McMeekin P, Ammi M. An analysis of the policy responses to the COVID-19 pandemic in France, Belgium, and Canada. Heal Policy Technol 2020; 9(4):430-446., a typical social-democratic capitalist country¹⁴14 Esping-Andersen G. As três economias políticas do welfare state. Lua Nov Rev Cult e Política 1991; 24:85-116.. It has a centralized public administration, in which the main public tasks are carried out by the national government⁴4 Yan B, Zhang X, Wu L, Zhu H, Chen B. Why do countries respond differently to COVID-19? A comparative study of Sweden, China, France, and Japan. Am Rev Public Adm 2020; 50(6):762-769.. However, it has some level of decentralization, through the municipalities, departments and regions, with relative autonomy in areas that are clearly defined as having their competence¹⁵15 Chevreul K, Berg Brigham K, Durand-Zaleski I, Hernandez-Quevedo C. France: Health System Review. Health Syst Transit 2015; 17(3):1-218.

From a geographical point of view, it is the largest country in the European Union (EU) in area and the second most populous in this region, being largely urbanized and showing high population density¹⁶16 Organisation for Economic Co-operation and Development (OECD) [Internet]. 2022. [cited 2022 mar 14]. Available from: https://www.oecd.org/
https://www.oecd.org... . It has the tenth highest Gross Domestic Product (GDP) in the EU, the seventeenth Gini index among OECD countries and high life expectancy at birth, considering both sexes¹⁶16 Organisation for Economic Co-operation and Development (OECD) [Internet]. 2022. [cited 2022 mar 14]. Available from: https://www.oecd.org/
https://www.oecd.org... . Overall, it has above-average indicators in relation to its European neighbors.

The country is known for its social welfare system, with strong public funding of health and social assistance⁹9 Desson Z, Weller E, McMeekin P, Ammi M. An analysis of the policy responses to the COVID-19 pandemic in France, Belgium, and Canada. Heal Policy Technol 2020; 9(4):430-446.^,1515 Chevreul K, Berg Brigham K, Durand-Zaleski I, Hernandez-Quevedo C. France: Health System Review. Health Syst Transit 2015; 17(3):1-218. Vulnerable, low-income families are entitled to a fixed social assistance benefit of €150 and an additional €100 per child¹⁷17 Seemann A, Becker U, He L, Maria Hohnerlein E, Wilman N. Protecting livelihoods in the COVID-19 crisis: a comparative analysis of European labour market and social policies. Glob Soc Policy 2021; 21(3):550-568..

In the pandemic, the country was the first whose Minister of the Economy and Finance declared the need and urgency of economic measures to contain the pandemic effects¹⁸18 Androniceanu A. Major structural changes in the eu policies due to the problems and risks caused by COVID-19. Adm Si Manag Public 2020; 34:137-149.. Similarly, the French president also stood out regarding how promptly he made declarations of support to companies in the country, aimed at preventing unemployment and bankruptcies¹³13 Dada S, Ashworth HC, Bewa MJ, Dhatt R. Words matter: political and gender analysis of speeches made by heads of government during the COVID-19 pandemic. BMJ Glob Heal 2021; 6(1):e003910.. It was one of the countries to implement unprecedented financial support measures, with a 5% increase of the GDP in the national budget, in April 2020⁹9 Desson Z, Weller E, McMeekin P, Ammi M. An analysis of the policy responses to the COVID-19 pandemic in France, Belgium, and Canada. Heal Policy Technol 2020; 9(4):430-446..

During the pandemic, social security actions were expanded, both to increase health care and to help companies and mitigate the social consequences of the shutdown of the economy⁷7 Duguet A-M, Rial-Sebbag E. The fight against the COVID 19 epidemic in France: Health organisation and legislative adaptation. Med Law 2020; 39(2):173-188.. Unemployment insurance was extended from 6 to 12 months, a solidarity fund was created to support small businesses, and monetary subsidies were implemented for self-employed workers, in addition to several types of cash transfers to be paid to people who already received the benefit of minimum income transfer¹⁷17 Seemann A, Becker U, He L, Maria Hohnerlein E, Wilman N. Protecting livelihoods in the COVID-19 crisis: a comparative analysis of European labour market and social policies. Glob Soc Policy 2021; 21(3):550-568..

The country also had at its disposal the EU initiatives to help workers maintain their income and support companies to remain active. These initiatives included government assistance to companies that reduced the workday of employees or that completely interrupted their activities, income replacement for self-employed workers and support for fishermen and agricultural workers¹⁸18 Androniceanu A. Major structural changes in the eu policies due to the problems and risks caused by COVID-19. Adm Si Manag Public 2020; 34:137-149..

The French health system and its capacity to fight the pandemic

The country has a mandatory social health insurance system, financed by contributions from employers and employees, in addition to taxes on income and additional sources, such as taxation of tobacco, alcohol and pharmaceutical products¹⁵15 Chevreul K, Berg Brigham K, Durand-Zaleski I, Hernandez-Quevedo C. France: Health System Review. Health Syst Transit 2015; 17(3):1-218. Created in 1945, the French health system initially offered coverage based only on professional activity, but over the years it has sought universal coverage and greater uniformity of protection among different funds²2 Or Z, Gandré C, Durand Zaleski I, Steffen M. France's response to the COVID-19 pandemic: between a rock and a hard place. Health Econ Policy Law; 17(1):14-26.^,88 Organisation for Economic Co-operation and Development (OECD), European Observatory on Health Systems and Policies. France: country health profile 2021 [Internet]. Paris: OECD; 2021. [cited 2022 jun 8]. Available from: https://www.oecd-ilibrary.org/social-issues-migration-health/france-country-health-profile-2021_7d668926-en^,1919 Organisation for Economic Co-operation and Development (OECD), European Observatory on Health Systems and Policies. France: country health profile 2017 [Internet]. Paris: OECD; 2017. [cited 2022 jun 1]. Available from: https://www.oecd-ilibrary.org/social-issues-migration-health/france-country-health-profile-2017_9789264283374-en. Social Security covers legal residents in the country⁷7 Duguet A-M, Rial-Sebbag E. The fight against the COVID 19 epidemic in France: Health organisation and legislative adaptation. Med Law 2020; 39(2):173-188. and a scheme, fully funded by the Government, provides access to an essential care package for unauthorized migrants⁸8 Organisation for Economic Co-operation and Development (OECD), European Observatory on Health Systems and Policies. France: country health profile 2021 [Internet]. Paris: OECD; 2021. [cited 2022 jun 8]. Available from: https://www.oecd-ilibrary.org/social-issues-migration-health/france-country-health-profile-2021_7d668926-en.

After Germany, it has the highest percentage of the GDP spent on health in European countries and more than three quarters of health expenses correspond to public expenditures, of which approximately one-third are spent on hospital services⁸8 Organisation for Economic Co-operation and Development (OECD), European Observatory on Health Systems and Policies. France: country health profile 2021 [Internet]. Paris: OECD; 2021. [cited 2022 jun 8]. Available from: https://www.oecd-ilibrary.org/social-issues-migration-health/france-country-health-profile-2021_7d668926-en^,1919 Organisation for Economic Co-operation and Development (OECD), European Observatory on Health Systems and Policies. France: country health profile 2017 [Internet]. Paris: OECD; 2017. [cited 2022 jun 1]. Available from: https://www.oecd-ilibrary.org/social-issues-migration-health/france-country-health-profile-2017_9789264283374-en and only 2% are aimed at prevention⁸8 Organisation for Economic Co-operation and Development (OECD), European Observatory on Health Systems and Policies. France: country health profile 2021 [Internet]. Paris: OECD; 2021. [cited 2022 jun 8]. Available from: https://www.oecd-ilibrary.org/social-issues-migration-health/france-country-health-profile-2021_7d668926-en. With a more centralized governance than other health insurance systems¹⁵15 Chevreul K, Berg Brigham K, Durand-Zaleski I, Hernandez-Quevedo C. France: Health System Review. Health Syst Transit 2015; 17(3):1-218, the provision of services is a responsibility of the national government, which regulates it and negotiates with providers and insurers, with a small part of the operations delegated to the Regional Health Agencies (RHAs)⁹9 Desson Z, Weller E, McMeekin P, Ammi M. An analysis of the policy responses to the COVID-19 pandemic in France, Belgium, and Canada. Heal Policy Technol 2020; 9(4):430-446..

It stands out among the best health systems in the world regarding coverage, accessibility³3 Nanda M, Aashima, Sharma R. Review of COVID-19 epidemiology and public health response in Europe in 2020. Clin Epidemiol Glob Heal 2021; 12:100882., quality and effectiveness¹⁹19 Organisation for Economic Co-operation and Development (OECD), European Observatory on Health Systems and Policies. France: country health profile 2017 [Internet]. Paris: OECD; 2017. [cited 2022 jun 1]. Available from: https://www.oecd-ilibrary.org/social-issues-migration-health/france-country-health-profile-2017_9789264283374-en. However, it is still faced with socioeconomic and geographic inequalities, both related to the risks for diseases and illnesses, as well as disparities in access to services¹⁵15 Chevreul K, Berg Brigham K, Durand-Zaleski I, Hernandez-Quevedo C. France: Health System Review. Health Syst Transit 2015; 17(3):1-218, in addition to the challenges related to prevention and continuing care actions¹⁹19 Organisation for Economic Co-operation and Development (OECD), European Observatory on Health Systems and Policies. France: country health profile 2017 [Internet]. Paris: OECD; 2017. [cited 2022 jun 1]. Available from: https://www.oecd-ilibrary.org/social-issues-migration-health/france-country-health-profile-2017_9789264283374-en. It is considered a complex system with poor coordination between the different levels of care²2 Or Z, Gandré C, Durand Zaleski I, Steffen M. France's response to the COVID-19 pandemic: between a rock and a hard place. Health Econ Policy Law; 17(1):14-26.. Moreover, as it is still a hospital-centered system, it is suffocated from the management and financial points of view, due to the high costs and complex operation²⁰20 Giraud-Gatineau A, Gautret P, Colson P, Chaudet H, Raoult D. Evaluation of strategies to fight COVID-19: the French paradigm. J Clin Med 2021; 10(13):2942..

Service provision is carried out by public and private institutions, with hospital and long-term care services being mostly public, whereas outpatient services are mostly private⁹9 Desson Z, Weller E, McMeekin P, Ammi M. An analysis of the policy responses to the COVID-19 pandemic in France, Belgium, and Canada. Heal Policy Technol 2020; 9(4):430-446.^,1515 Chevreul K, Berg Brigham K, Durand-Zaleski I, Hernandez-Quevedo C. France: Health System Review. Health Syst Transit 2015; 17(3):1-218. The use of health services is based on the co-payment system, in which the proportion of social security coverage is higher for hospital care and lower for other services and products¹⁹19 Organisation for Economic Co-operation and Development (OECD), European Observatory on Health Systems and Policies. France: country health profile 2017 [Internet]. Paris: OECD; 2017. [cited 2022 jun 1]. Available from: https://www.oecd-ilibrary.org/social-issues-migration-health/france-country-health-profile-2017_9789264283374-en. This co-payment reality and the search for better coverage for some types of specific services make 95% of the population contract supplementary health insurance⁸8 Organisation for Economic Co-operation and Development (OECD), European Observatory on Health Systems and Policies. France: country health profile 2021 [Internet]. Paris: OECD; 2021. [cited 2022 jun 8]. Available from: https://www.oecd-ilibrary.org/social-issues-migration-health/france-country-health-profile-2021_7d668926-en. This makes the direct expenditure for health services in France one of the lowest in Europe, but still corresponds to almost 50% of expenses on non-hospital services by those who do not have supplementary insurance¹⁹19 Organisation for Economic Co-operation and Development (OECD), European Observatory on Health Systems and Policies. France: country health profile 2017 [Internet]. Paris: OECD; 2017. [cited 2022 jun 1]. Available from: https://www.oecd-ilibrary.org/social-issues-migration-health/france-country-health-profile-2017_9789264283374-en.

Primary and secondary outpatient care is mainly provided by self-employed professionals and, to a lesser extent, by salaried staff working in health centers and hospitals¹⁹19 Organisation for Economic Co-operation and Development (OECD), European Observatory on Health Systems and Policies. France: country health profile 2017 [Internet]. Paris: OECD; 2017. [cited 2022 jun 1]. Available from: https://www.oecd-ilibrary.org/social-issues-migration-health/france-country-health-profile-2017_9789264283374-en. There is no organized service network at the primary care level, only the individual search for a general practitioner by the patient⁹9 Desson Z, Weller E, McMeekin P, Ammi M. An analysis of the policy responses to the COVID-19 pandemic in France, Belgium, and Canada. Heal Policy Technol 2020; 9(4):430-446.. To favor the coordination of care for chronic conditions, social insurance has offered advantages in the percentage of coverage for people who see a general practitioner before consulting a specialist¹⁹19 Organisation for Economic Co-operation and Development (OECD), European Observatory on Health Systems and Policies. France: country health profile 2017 [Internet]. Paris: OECD; 2017. [cited 2022 jun 1]. Available from: https://www.oecd-ilibrary.org/social-issues-migration-health/france-country-health-profile-2017_9789264283374-en.

The country has reduced the number of hospital beds in recent decades and has a number of doctors below the EU average⁸8 Organisation for Economic Co-operation and Development (OECD), European Observatory on Health Systems and Policies. France: country health profile 2021 [Internet]. Paris: OECD; 2021. [cited 2022 jun 8]. Available from: https://www.oecd-ilibrary.org/social-issues-migration-health/france-country-health-profile-2021_7d668926-en. As the distribution of these professionals is unequal throughout the country, the government has offered incentives to retain physicians in some regions with greater scarcity⁸8 Organisation for Economic Co-operation and Development (OECD), European Observatory on Health Systems and Policies. France: country health profile 2021 [Internet]. Paris: OECD; 2021. [cited 2022 jun 8]. Available from: https://www.oecd-ilibrary.org/social-issues-migration-health/france-country-health-profile-2021_7d668926-en. Additionally, efforts have been made to expand the scope of practice of other professionals, such as nurses and pharmacists⁸8 Organisation for Economic Co-operation and Development (OECD), European Observatory on Health Systems and Policies. France: country health profile 2021 [Internet]. Paris: OECD; 2021. [cited 2022 jun 8]. Available from: https://www.oecd-ilibrary.org/social-issues-migration-health/france-country-health-profile-2021_7d668926-en^,1919 Organisation for Economic Co-operation and Development (OECD), European Observatory on Health Systems and Policies. France: country health profile 2017 [Internet]. Paris: OECD; 2017. [cited 2022 jun 1]. Available from: https://www.oecd-ilibrary.org/social-issues-migration-health/france-country-health-profile-2017_9789264283374-en.

In addition to Social Health Insurance, the country has the French Public Health Agency (SpFrance), which defines national health strategies and guides the RHAs⁹9 Desson Z, Weller E, McMeekin P, Ammi M. An analysis of the policy responses to the COVID-19 pandemic in France, Belgium, and Canada. Heal Policy Technol 2020; 9(4):430-446.^,2121 Antonini M, Eid MA, Falkenbach M, Rosenbluth ST, Prieto PA, Brammli-Greenberg S, McMeekin P, Paolucci F. An analysis of the COVID-19 vaccination campaigns in France, Israel, Italy and Spain and their impact on health and economic outcomes. Heal Policy Technol 2021; 11(2):100594.. One of SpFrance roles is the attribution of coordinating epidemiological surveillance, in an articulation that involves physicians, RHAs and national health authorities⁵5 Stoecklin SB, Rolland P, Silue Y, Mailles A, Campese C, Simondon A, Mechain M, Meurice L, Nguyen M, Bassi C, Yamani E, Behillil S, Ismael S, Nguyen D, Malvy D, Lescure FX, Georges S, Lazarus C, Tabai A, Stempfelet M, Enouf V, Coignard B, Levy-Bruhl D. First cases of coronavirus disease 2019 (COVID-19) in France: surveillance, investigations and control measures, January 2020. Eurosurveillance 2020; 25(6):2000094.. It is considered an extremely time-consuming process that requires a considerable workforce⁵5 Stoecklin SB, Rolland P, Silue Y, Mailles A, Campese C, Simondon A, Mechain M, Meurice L, Nguyen M, Bassi C, Yamani E, Behillil S, Ismael S, Nguyen D, Malvy D, Lescure FX, Georges S, Lazarus C, Tabai A, Stempfelet M, Enouf V, Coignard B, Levy-Bruhl D. First cases of coronavirus disease 2019 (COVID-19) in France: surveillance, investigations and control measures, January 2020. Eurosurveillance 2020; 25(6):2000094.; additionally, many different information systems are used²²22 Piarroux R, Batteux F, Rebaudet S, Boëlle PY, Piarroux R, Batteux F. COVID-19 alert and surveillance indicators. Ann Fr Med D Urgence 2020; 10(4):333-339.^,2323 Pullano G, Di Domenico L, Sabbatini CE, Valdano E, Turbelin C, Debin M, Guerrisi C, Kengne-Kuetche C, Souty C, Hanslik T, Blanchon T, Boëlle PY, Figoni J, Vaux S, Campèse C, Bernard-Stoecklin S, Colizza V. Underdetection of cases of COVID-19 in France threatens epidemic control. Nature 2021; 590(7844):134-139..

Shortly before the pandemic onset, the health system was affected by months-long protests and strikes by hospital workers, demanding more resources²2 Or Z, Gandré C, Durand Zaleski I, Steffen M. France's response to the COVID-19 pandemic: between a rock and a hard place. Health Econ Policy Law; 17(1):14-26.. Faced with particularly severe financial constraints resulting from activity-based funding, the hospital system has for some time sought to optimize scarce resources and concentrate its efforts on certain medical specialties, which led to many difficulties with the emergence of the pandemic²⁴24 Paché G. Facing the COVID-19 pandemic in France: from managerialism to business logistics. Popul Health Manag 2021; 24(2):158-160..

During this period, even with the decrease in the GDP, public spending on health increased, with additional investments to expand hospitals⁸8 Organisation for Economic Co-operation and Development (OECD), European Observatory on Health Systems and Policies. France: country health profile 2021 [Internet]. Paris: OECD; 2021. [cited 2022 jun 8]. Available from: https://www.oecd-ilibrary.org/social-issues-migration-health/france-country-health-profile-2021_7d668926-en, finance equipment and increase the workforce⁹9 Desson Z, Weller E, McMeekin P, Ammi M. An analysis of the policy responses to the COVID-19 pandemic in France, Belgium, and Canada. Heal Policy Technol 2020; 9(4):430-446.. Social Security expanded the access and compensation of costs with the diagnosis and treatment of COVID-19⁷7 Duguet A-M, Rial-Sebbag E. The fight against the COVID 19 epidemic in France: Health organisation and legislative adaptation. Med Law 2020; 39(2):173-188.^,88 Organisation for Economic Co-operation and Development (OECD), European Observatory on Health Systems and Policies. France: country health profile 2021 [Internet]. Paris: OECD; 2021. [cited 2022 jun 8]. Available from: https://www.oecd-ilibrary.org/social-issues-migration-health/france-country-health-profile-2021_7d668926-en^,2525 Schmidt AE, Merkur S, Haindl A, Gerkens S, Gandré C, Or Z, Groenewegen P, Kroneman M, De Jong J, Albreht T, Vracko P, Mantwill S, Hernández-Quevedo C, Quentin W, Webb E, Winkelmann J. Tackling the COVID-19 pandemic: Initial responses in 2020 in selected social health insurance countries in Europe. Health Policy 2021; 126(5):476-484.. The government increased the contributions from supplementary health insurance companies to help the national insurance fund to finance the costs of the health crisis²⁵25 Schmidt AE, Merkur S, Haindl A, Gerkens S, Gandré C, Or Z, Groenewegen P, Kroneman M, De Jong J, Albreht T, Vracko P, Mantwill S, Hernández-Quevedo C, Quentin W, Webb E, Winkelmann J. Tackling the COVID-19 pandemic: Initial responses in 2020 in selected social health insurance countries in Europe. Health Policy 2021; 126(5):476-484..

Despite the adopted measures, the impact of pre-existing weaknesses in the health system, added to the epidemic severity, led to the worsening of health conditions, including the discontinuity of routine care, which has been related to some difficulties the country had in coping with the health crisis²2 Or Z, Gandré C, Durand Zaleski I, Steffen M. France's response to the COVID-19 pandemic: between a rock and a hard place. Health Econ Policy Law; 17(1):14-26.^,88 Organisation for Economic Co-operation and Development (OECD), European Observatory on Health Systems and Policies. France: country health profile 2021 [Internet]. Paris: OECD; 2021. [cited 2022 jun 8]. Available from: https://www.oecd-ilibrary.org/social-issues-migration-health/france-country-health-profile-2021_7d668926-en^,1111 Barrera-Algarín E, Estepa-Maestre F, Sarasola-Sánchez-Serrano JL, Vallejo-Andrada A. COVID-19, neoliberalism and health systems in 30 european countries: relationship to deceases. Rev Esp Salud Publica 2020; 94:e202010140.^,2525 Schmidt AE, Merkur S, Haindl A, Gerkens S, Gandré C, Or Z, Groenewegen P, Kroneman M, De Jong J, Albreht T, Vracko P, Mantwill S, Hernández-Quevedo C, Quentin W, Webb E, Winkelmann J. Tackling the COVID-19 pandemic: Initial responses in 2020 in selected social health insurance countries in Europe. Health Policy 2021; 126(5):476-484..

The national response and the epidemic evolution in France

As soon as China disclosed the existence of the new virus, France started investigating suspected cases and established hospital institutions and reference laboratories⁵5 Stoecklin SB, Rolland P, Silue Y, Mailles A, Campese C, Simondon A, Mechain M, Meurice L, Nguyen M, Bassi C, Yamani E, Behillil S, Ismael S, Nguyen D, Malvy D, Lescure FX, Georges S, Lazarus C, Tabai A, Stempfelet M, Enouf V, Coignard B, Levy-Bruhl D. First cases of coronavirus disease 2019 (COVID-19) in France: surveillance, investigations and control measures, January 2020. Eurosurveillance 2020; 25(6):2000094.. The first cases were confirmed on January 24, 2020 and the preparation of the ‘Coping Plan’ started, based on the prepared plan for pandemic influenza⁶6 Ghanchi A. Adaptation of the National Plan for the Prevention and Fight Against Pandemic Influenza to the 2020 COVID-19 Epidemic in France. Disaster Med Public Health Prep 2020; 14(6):805-807..

A notable characteristic in the health crisis management in France was the centralization of decision-making at the national level²⁵25 Schmidt AE, Merkur S, Haindl A, Gerkens S, Gandré C, Or Z, Groenewegen P, Kroneman M, De Jong J, Albreht T, Vracko P, Mantwill S, Hernández-Quevedo C, Quentin W, Webb E, Winkelmann J. Tackling the COVID-19 pandemic: Initial responses in 2020 in selected social health insurance countries in Europe. Health Policy 2021; 126(5):476-484.^,2626 France. Conseil d'État. Port d'un masque de protection, commune de de Sceaux [Internet]. 2020. [cited 2022 jun 6]. Available from: https://www.conseil-etat.fr/decisions-de-justice/dernieres-decisions/conseil-d-etat-17-avril-2020-port-d-un-masque-de-protection-commune-de-de-sceaux
https://www.conseil-etat.fr/decisions-de... , with emphasis on the role of the Executive Branch²⁷27 Rozenblum SD. France's multidimensional COVID-19 response: ad hoc committees and the sidelining of public health agencies. In: Greer SL, King EJ, Massard da Fonseca E, Peralta-Santos A, editors. Coronavirus politics: the comparative politics and policy of COVID-19. Ann Arbor: University of Michigan Press; 2021. p. 264-279.. The coordination of the response fell to the Defence and National Security Council, whose natural president is the President of the Republic, in addition to the participation of the Prime Minister and other ministers appointed by them⁸8 Organisation for Economic Co-operation and Development (OECD), European Observatory on Health Systems and Policies. France: country health profile 2021 [Internet]. Paris: OECD; 2021. [cited 2022 jun 8]. Available from: https://www.oecd-ilibrary.org/social-issues-migration-health/france-country-health-profile-2021_7d668926-en.

The Coping Plan was not immediately implemented and it took the government some time to adopt the first preventive measures²2 Or Z, Gandré C, Durand Zaleski I, Steffen M. France's response to the COVID-19 pandemic: between a rock and a hard place. Health Econ Policy Law; 17(1):14-26.. Even with the first outbreaks in some regions⁹9 Desson Z, Weller E, McMeekin P, Ammi M. An analysis of the policy responses to the COVID-19 pandemic in France, Belgium, and Canada. Heal Policy Technol 2020; 9(4):430-446., the adopted measures were not incisive ones³3 Nanda M, Aashima, Sharma R. Review of COVID-19 epidemiology and public health response in Europe in 2020. Clin Epidemiol Glob Heal 2021; 12:100882.^,44 Yan B, Zhang X, Wu L, Zhu H, Chen B. Why do countries respond differently to COVID-19? A comparative study of Sweden, China, France, and Japan. Am Rev Public Adm 2020; 50(6):762-769.^,66 Ghanchi A. Adaptation of the National Plan for the Prevention and Fight Against Pandemic Influenza to the 2020 COVID-19 Epidemic in France. Disaster Med Public Health Prep 2020; 14(6):805-807.. This attitude has been mainly related to the need to maintain the scheduled elections⁴4 Yan B, Zhang X, Wu L, Zhu H, Chen B. Why do countries respond differently to COVID-19? A comparative study of Sweden, China, France, and Japan. Am Rev Public Adm 2020; 50(6):762-769.^,66 Ghanchi A. Adaptation of the National Plan for the Prevention and Fight Against Pandemic Influenza to the 2020 COVID-19 Epidemic in France. Disaster Med Public Health Prep 2020; 14(6):805-807.^,1212 Hassenteufel P. Handling the COVID-19 crisis in France: paradoxes of a centralized state-led health system. Eur Policy Anal 2020; 6(2):170-179., but also to the fear that strict measures could intensify popular demonstrations that were already occurring before the pandemic²⁸28 Atlani-Duault L, Lina B, Malvy D, Yazdanpanah Y, Chauvin F, Delfraissy J-F. COVID-19: France grapples with the pragmatics of isolation. Lancet Public Health 2020; 5(11):e573-e574..

When the Coping Plan was implemented, on February 23, the disease was already rapidly spreading across the country, with restrictions being established for some activities and social isolation being implemented in some regions²2 Or Z, Gandré C, Durand Zaleski I, Steffen M. France's response to the COVID-19 pandemic: between a rock and a hard place. Health Econ Policy Law; 17(1):14-26.^,44 Yan B, Zhang X, Wu L, Zhu H, Chen B. Why do countries respond differently to COVID-19? A comparative study of Sweden, China, France, and Japan. Am Rev Public Adm 2020; 50(6):762-769.^,66 Ghanchi A. Adaptation of the National Plan for the Prevention and Fight Against Pandemic Influenza to the 2020 COVID-19 Epidemic in France. Disaster Med Public Health Prep 2020; 14(6):805-807., which did not prevent the increase in cases and resulted in signs of panic among the population⁶6 Ghanchi A. Adaptation of the National Plan for the Prevention and Fight Against Pandemic Influenza to the 2020 COVID-19 Epidemic in France. Disaster Med Public Health Prep 2020; 14(6):805-807., whose reaction had not been triggered by the situation in other countries²⁹29 Hou Z, Du F, Zhou X, Jiang H, Martin S, Larson H, Lin L. Cross-country comparison of public awareness, rumors, and behavioral responses to the COVID-19 epidemic: infodemiology study. J Med Internet Res 2020; 22(8):e21143.. Nevertheless, it was only on March 16, after the municipal elections, that the government completely changed its conduct, by implementing the national lockdown and adopting the discourse of “war against COVID-19”²2 Or Z, Gandré C, Durand Zaleski I, Steffen M. France's response to the COVID-19 pandemic: between a rock and a hard place. Health Econ Policy Law; 17(1):14-26..

The pandemic evolution in the country, between February 2020 and June 2022, can be characterized by four periods of increase in the incidence rate of the disease, generically considered as “waves” (Figure 1).

The country’s response was adapted according to the pandemic dynamics³⁰30 Pageaud S, Pothier C, Rigotti C, Eyraud-Loisel A, Bertoglio J-P, Bienvenüe A, Leboisne N, Ponthus N, Gauchon R, Gueyffier F, Vanhems P, Iwaz J, Loisel S, Roy P, CovDyn Group (Covid Dynamics). Expected evolution of COVID-19 epidemic in france for several combinations of vaccination strategies and barrier measures. Vaccines 2021; 9(12):1462., with stricter measures at times when the government was pressured to do so, due to the increase in the number of cases²2 Or Z, Gandré C, Durand Zaleski I, Steffen M. France's response to the COVID-19 pandemic: between a rock and a hard place. Health Econ Policy Law; 17(1):14-26.. From one perspective, legal support was sought for exceptional coercive measures⁴4 Yan B, Zhang X, Wu L, Zhu H, Chen B. Why do countries respond differently to COVID-19? A comparative study of Sweden, China, France, and Japan. Am Rev Public Adm 2020; 50(6):762-769., with the approval of the State of Emergency Law³¹31 Simoes J, Magalhaes JPM, Biscaia A, Pereira AD, Augusto GF, Fronteira I. Organisation of the State, model of health system and COVID-19 health outcomes in six European countries, during the first months of the COVID-19 epidemic in 2020. Int J Health Plann Manage 2021; 36(5):1874-1886.. From another perspective, committees of experts were appointed seeking to provide scientific support for the decisions⁸8 Organisation for Economic Co-operation and Development (OECD), European Observatory on Health Systems and Policies. France: country health profile 2021 [Internet]. Paris: OECD; 2021. [cited 2022 jun 8]. Available from: https://www.oecd-ilibrary.org/social-issues-migration-health/france-country-health-profile-2021_7d668926-en. A first commission of physicians and epidemiologists had the task of indicating general measures to prevent the spread of the disease²2 Or Z, Gandré C, Durand Zaleski I, Steffen M. France's response to the COVID-19 pandemic: between a rock and a hard place. Health Econ Policy Law; 17(1):14-26.^,1212 Hassenteufel P. Handling the COVID-19 crisis in France: paradoxes of a centralized state-led health system. Eur Policy Anal 2020; 6(2):170-179.^,2828 Atlani-Duault L, Lina B, Malvy D, Yazdanpanah Y, Chauvin F, Delfraissy J-F. COVID-19: France grapples with the pragmatics of isolation. Lancet Public Health 2020; 5(11):e573-e574., whereas the second commission, which had members in common with the first and was chaired by a virologist (the recipient of a Nobel Prize in Medicine), was more focused on innovations in treatments, tests, screening and so forth¹²12 Hassenteufel P. Handling the COVID-19 crisis in France: paradoxes of a centralized state-led health system. Eur Policy Anal 2020; 6(2):170-179..

The appointment of these commissions has been, in part, criticized, since SpFrance already had government bodies with these attributions and accumulated experience¹²12 Hassenteufel P. Handling the COVID-19 crisis in France: paradoxes of a centralized state-led health system. Eur Policy Anal 2020; 6(2):170-179.^,2727 Rozenblum SD. France's multidimensional COVID-19 response: ad hoc committees and the sidelining of public health agencies. In: Greer SL, King EJ, Massard da Fonseca E, Peralta-Santos A, editors. Coronavirus politics: the comparative politics and policy of COVID-19. Ann Arbor: University of Michigan Press; 2021. p. 264-279.. The measures were monitored and supervised by the Parliament, with the participation of civil society, who monitored reports sent by the government⁷7 Duguet A-M, Rial-Sebbag E. The fight against the COVID 19 epidemic in France: Health organisation and legislative adaptation. Med Law 2020; 39(2):173-188., and sought to respond to the population’s demands¹²12 Hassenteufel P. Handling the COVID-19 crisis in France: paradoxes of a centralized state-led health system. Eur Policy Anal 2020; 6(2):170-179.. Between the two first waves, the mayors received authorization to adopt some necessary measures based on the local epidemiological situation, but this power was once again restricted in the course of the second wave²2 Or Z, Gandré C, Durand Zaleski I, Steffen M. France's response to the COVID-19 pandemic: between a rock and a hard place. Health Econ Policy Law; 17(1):14-26..

During the first national lockdown, between March and May 2020, there was great concern about the economic impact on the country²2 Or Z, Gandré C, Durand Zaleski I, Steffen M. France's response to the COVID-19 pandemic: between a rock and a hard place. Health Econ Policy Law; 17(1):14-26.^,99 Desson Z, Weller E, McMeekin P, Ammi M. An analysis of the policy responses to the COVID-19 pandemic in France, Belgium, and Canada. Heal Policy Technol 2020; 9(4):430-446.^,3232 Roche B, Garchitorena A, Roiz D. The impact of lockdown strategies targeting age groups on the burden of COVID-19 in France. Epidemics 2020; 33:100424.. To allow the lockdown suspension, efforts were made to expand testing capacity, with mobile facilities²⁰20 Giraud-Gatineau A, Gautret P, Colson P, Chaudet H, Raoult D. Evaluation of strategies to fight COVID-19: the French paradigm. J Clin Med 2021; 10(13):2942.^,2323 Pullano G, Di Domenico L, Sabbatini CE, Valdano E, Turbelin C, Debin M, Guerrisi C, Kengne-Kuetche C, Souty C, Hanslik T, Blanchon T, Boëlle PY, Figoni J, Vaux S, Campèse C, Bernard-Stoecklin S, Colizza V. Underdetection of cases of COVID-19 in France threatens epidemic control. Nature 2021; 590(7844):134-139. and the country’s reopening strategy was designed gradually, varying between regions according to the epidemiological situation³³33 Michelini E, Bortoletto N, Porrovecchio A. Outdoor Physical activity during the first wave of the COVID-19 pandemic. A comparative analysis of government restrictions in Italy, France, and Germany. Front Public Heal 2021; 9:615745.. This was accompanied by home monitoring of cases through an application²²22 Piarroux R, Batteux F, Rebaudet S, Boëlle PY, Piarroux R, Batteux F. COVID-19 alert and surveillance indicators. Ann Fr Med D Urgence 2020; 10(4):333-339. and, later, the mandatory use of face masks¹²12 Hassenteufel P. Handling the COVID-19 crisis in France: paradoxes of a centralized state-led health system. Eur Policy Anal 2020; 6(2):170-179. was adopted.

However, with the reopening, the population’s adherence to preventive measures was reduced, which made the scientific commission recommend to the government, as of September 2020, the reduction of the quarantine time to seven days and the offer of incentives and compensation for adherence to the regulations aimed at COVID-19 prevention²⁸28 Atlani-Duault L, Lina B, Malvy D, Yazdanpanah Y, Chauvin F, Delfraissy J-F. COVID-19: France grapples with the pragmatics of isolation. Lancet Public Health 2020; 5(11):e573-e574.. The government accepted a shorter quarantine but did not adopt the recommended incentives²⁸28 Atlani-Duault L, Lina B, Malvy D, Yazdanpanah Y, Chauvin F, Delfraissy J-F. COVID-19: France grapples with the pragmatics of isolation. Lancet Public Health 2020; 5(11):e573-e574.. And, despite the increase in testing and greater agility in case detection²³23 Pullano G, Di Domenico L, Sabbatini CE, Valdano E, Turbelin C, Debin M, Guerrisi C, Kengne-Kuetche C, Souty C, Hanslik T, Blanchon T, Boëlle PY, Figoni J, Vaux S, Campèse C, Bernard-Stoecklin S, Colizza V. Underdetection of cases of COVID-19 in France threatens epidemic control. Nature 2021; 590(7844):134-139., screening and isolation measures were not effective during the summer and autumn of 2020, which, associated with low adherence to restrictive measures¹²12 Hassenteufel P. Handling the COVID-19 crisis in France: paradoxes of a centralized state-led health system. Eur Policy Anal 2020; 6(2):170-179., contributed to the second wave of the epidemic in the country, leading to a new nationwide lockdown in October 2020²2 Or Z, Gandré C, Durand Zaleski I, Steffen M. France's response to the COVID-19 pandemic: between a rock and a hard place. Health Econ Policy Law; 17(1):14-26..

In this second wave, the resurgence of cases was not accompanied by the same levels of concern as in the first, probably due to the expansion of installed capacity for COVID-19 care⁹9 Desson Z, Weller E, McMeekin P, Ammi M. An analysis of the policy responses to the COVID-19 pandemic in France, Belgium, and Canada. Heal Policy Technol 2020; 9(4):430-446.. The period that corresponds to this prolonged wave had moments of greater intensification and some specific mitigation measures, until the gradual reopening started in May 2021, when the country already faced the challenge of non-acceptance, by the population, of long-lasting restrictions^30,34.35.

In the meantime, the vaccination plan was implemented in January 2021²¹21 Antonini M, Eid MA, Falkenbach M, Rosenbluth ST, Prieto PA, Brammli-Greenberg S, McMeekin P, Paolucci F. An analysis of the COVID-19 vaccination campaigns in France, Israel, Italy and Spain and their impact on health and economic outcomes. Heal Policy Technol 2021; 11(2):100594., with the initial objective of vaccinating the entire population within a period of six to nine months³⁰30 Pageaud S, Pothier C, Rigotti C, Eyraud-Loisel A, Bertoglio J-P, Bienvenüe A, Leboisne N, Ponthus N, Gauchon R, Gueyffier F, Vanhems P, Iwaz J, Loisel S, Roy P, CovDyn Group (Covid Dynamics). Expected evolution of COVID-19 epidemic in france for several combinations of vaccination strategies and barrier measures. Vaccines 2021; 9(12):1462.. Therefore, the reopening that followed coincided with the rise in the vaccination coverage curve and, even in the face of controversy and resistance from part of the population, on June 9, 2021, the Passe Sanitaire³⁶36 France. Info coronavirus COVID-19 - Les actions du Gouvernement [Internet]. [cited 2022 jul 8]. Available from: https://www.gouvernement.fr/info-coronavirus/les-actions-du-gouvernement
https://www.gouvernement.fr/info-coronav... was implemented, i.e., proof of vaccination that started being required for access to entertainment establishments and long-distance public transport²¹21 Antonini M, Eid MA, Falkenbach M, Rosenbluth ST, Prieto PA, Brammli-Greenberg S, McMeekin P, Paolucci F. An analysis of the COVID-19 vaccination campaigns in France, Israel, Italy and Spain and their impact on health and economic outcomes. Heal Policy Technol 2021; 11(2):100594..

At the end of August 2021, almost 60% of the population had a full vaccination schedule⁸8 Organisation for Economic Co-operation and Development (OECD), European Observatory on Health Systems and Policies. France: country health profile 2021 [Internet]. Paris: OECD; 2021. [cited 2022 jun 8]. Available from: https://www.oecd-ilibrary.org/social-issues-migration-health/france-country-health-profile-2021_7d668926-en, therefore, lower than expected³⁰30 Pageaud S, Pothier C, Rigotti C, Eyraud-Loisel A, Bertoglio J-P, Bienvenüe A, Leboisne N, Ponthus N, Gauchon R, Gueyffier F, Vanhems P, Iwaz J, Loisel S, Roy P, CovDyn Group (Covid Dynamics). Expected evolution of COVID-19 epidemic in france for several combinations of vaccination strategies and barrier measures. Vaccines 2021; 9(12):1462.. This delay in vaccination coverage, added to the prevalence of the Delta variant and the population mobility during summer, contributed to the third wave observed in the country³⁷37 Mazzoli M, Valdano E, Colizza V. Projecting the COVID-19 epidemic risk in France for the summer 2021. J Travel Med 2021; 28(7):taab129., a situation that became even more dramatic in this period due to the low adherence to protective measures, caused by the prolongation of the pandemic³⁰30 Pageaud S, Pothier C, Rigotti C, Eyraud-Loisel A, Bertoglio J-P, Bienvenüe A, Leboisne N, Ponthus N, Gauchon R, Gueyffier F, Vanhems P, Iwaz J, Loisel S, Roy P, CovDyn Group (Covid Dynamics). Expected evolution of COVID-19 epidemic in france for several combinations of vaccination strategies and barrier measures. Vaccines 2021; 9(12):1462..

The main strategy to fight the pandemic thus became vaccination and the maintenance of the health system’s strategies for the caring of COVID-19 cases, associated with preventive recommendations. Even with the emergence of the two other waves, resulting from the Delta and Omicron variants, France did not experience restrictive measures once again, as in the first and second waves.

Actions that comprise the response of the French health system

France based the implemented measures on experiences with previous epidemics, as well as on examples of successful measures in other countries to fight COVID-19⁶6 Ghanchi A. Adaptation of the National Plan for the Prevention and Fight Against Pandemic Influenza to the 2020 COVID-19 Epidemic in France. Disaster Med Public Health Prep 2020; 14(6):805-807.. Chart 1 summarizes the main actions related to the health and surveillance system, in some dimensions, which were implemented during the pandemic.

Performance and main problems when facing the crisis

Some analyses point to the failure of risk communication by the French authorities, at first, impairing public awareness and better behavioral responses⁶6 Ghanchi A. Adaptation of the National Plan for the Prevention and Fight Against Pandemic Influenza to the 2020 COVID-19 Epidemic in France. Disaster Med Public Health Prep 2020; 14(6):805-807.^,1313 Dada S, Ashworth HC, Bewa MJ, Dhatt R. Words matter: political and gender analysis of speeches made by heads of government during the COVID-19 pandemic. BMJ Glob Heal 2021; 6(1):e003910.^,2929 Hou Z, Du F, Zhou X, Jiang H, Martin S, Larson H, Lin L. Cross-country comparison of public awareness, rumors, and behavioral responses to the COVID-19 epidemic: infodemiology study. J Med Internet Res 2020; 22(8):e21143.. In Western Europe, the French people were those who trusted government measures the least, or even information from the scientific community⁷7 Duguet A-M, Rial-Sebbag E. The fight against the COVID 19 epidemic in France: Health organisation and legislative adaptation. Med Law 2020; 39(2):173-188..

The country’s inadequate preparedness led to a shortage of basic supplies ⁶6 Ghanchi A. Adaptation of the National Plan for the Prevention and Fight Against Pandemic Influenza to the 2020 COVID-19 Epidemic in France. Disaster Med Public Health Prep 2020; 14(6):805-807.^,1212 Hassenteufel P. Handling the COVID-19 crisis in France: paradoxes of a centralized state-led health system. Eur Policy Anal 2020; 6(2):170-179. and contributed to the spread of the epidemic, which required the government, within a seven-day period, to change its orientation from light restrictions to a complete lockdown, with intense monitoring and enforcement of fines⁹9 Desson Z, Weller E, McMeekin P, Ammi M. An analysis of the policy responses to the COVID-19 pandemic in France, Belgium, and Canada. Heal Policy Technol 2020; 9(4):430-446.. Criticisms were diverse, both from the press that accused the government of putting the population at risk¹⁰10 Arminjon M, Marion-Veyron R. Coronavirus biopolitics: the paradox of France's Foucauldian heritage. Hist Philos Life Sci 2021; 43(1)5., and from segments of society that warned about the compromising of individual rights caused by the adopted measures⁷7 Duguet A-M, Rial-Sebbag E. The fight against the COVID 19 epidemic in France: Health organisation and legislative adaptation. Med Law 2020; 39(2):173-188..

There were also criticisms regarding centralization, lack of transparency related to the decision-making process and low cooperation between actors at central and local levels⁴⁴44 Gay R, Steffen M. Une gestion étatique centralisée et désordonnée. Chron Int l'IRES 2020; 171(3):122-138., aimed to better equalize the availability of professionals and increase the installed capacity, according to the regional epidemiological situation²2 Or Z, Gandré C, Durand Zaleski I, Steffen M. France's response to the COVID-19 pandemic: between a rock and a hard place. Health Econ Policy Law; 17(1):14-26.. However, there are those who consider that centralization contributed to the effectiveness of the measures⁹9 Desson Z, Weller E, McMeekin P, Ammi M. An analysis of the policy responses to the COVID-19 pandemic in France, Belgium, and Canada. Heal Policy Technol 2020; 9(4):430-446., or even that the establishment of the Emergency Law, with parliamentary supervision and spaces for monitoring by civil society, balanced the guarantee of individual freedoms and the effective disease control⁶6 Ghanchi A. Adaptation of the National Plan for the Prevention and Fight Against Pandemic Influenza to the 2020 COVID-19 Epidemic in France. Disaster Med Public Health Prep 2020; 14(6):805-807.. With the first national lockdown, mobility was reduced by up to 60%²²22 Piarroux R, Batteux F, Rebaudet S, Boëlle PY, Piarroux R, Batteux F. COVID-19 alert and surveillance indicators. Ann Fr Med D Urgence 2020; 10(4):333-339. and that proved to be the right decision, according to a study of mathematical models, both in terms of reducing mortality and system overload³²32 Roche B, Garchitorena A, Roiz D. The impact of lockdown strategies targeting age groups on the burden of COVID-19 in France. Epidemics 2020; 33:100424..

Even if for some authors the system model is not enough to explain the response to the pandemic³¹31 Simoes J, Magalhaes JPM, Biscaia A, Pereira AD, Augusto GF, Fronteira I. Organisation of the State, model of health system and COVID-19 health outcomes in six European countries, during the first months of the COVID-19 epidemic in 2020. Int J Health Plann Manage 2021; 36(5):1874-1886., in countries with national insurance, in which the health system does not have a central role in decision-making, differences in installed capacity, governance and operational dynamics influenced the quality of the response²⁵25 Schmidt AE, Merkur S, Haindl A, Gerkens S, Gandré C, Or Z, Groenewegen P, Kroneman M, De Jong J, Albreht T, Vracko P, Mantwill S, Hernández-Quevedo C, Quentin W, Webb E, Winkelmann J. Tackling the COVID-19 pandemic: Initial responses in 2020 in selected social health insurance countries in Europe. Health Policy 2021; 126(5):476-484.. This can be observed in the French case.

The crisis revealed the health system weaknesses, indicating the need for structural reforms, both in governance and relations between central levels and local government bodies, as well as in the care model, organization of a care network, funding mechanisms, and ordering of the workforce²2 Or Z, Gandré C, Durand Zaleski I, Steffen M. France's response to the COVID-19 pandemic: between a rock and a hard place. Health Econ Policy Law; 17(1):14-26.^,88 Organisation for Economic Co-operation and Development (OECD), European Observatory on Health Systems and Policies. France: country health profile 2021 [Internet]. Paris: OECD; 2021. [cited 2022 jun 8]. Available from: https://www.oecd-ilibrary.org/social-issues-migration-health/france-country-health-profile-2021_7d668926-en, in addition to the installed low hospital network capacity²⁴24 Paché G. Facing the COVID-19 pandemic in France: from managerialism to business logistics. Popul Health Manag 2021; 24(2):158-160., weakened by several decades of austerity policies¹⁰10 Arminjon M, Marion-Veyron R. Coronavirus biopolitics: the paradox of France's Foucauldian heritage. Hist Philos Life Sci 2021; 43(1)5..

Having the hospital as the preferred place to provide health services may have favored the contamination of more people by the virus and generated more demands for the system¹²12 Hassenteufel P. Handling the COVID-19 crisis in France: paradoxes of a centralized state-led health system. Eur Policy Anal 2020; 6(2):170-179.^,2020 Giraud-Gatineau A, Gautret P, Colson P, Chaudet H, Raoult D. Evaluation of strategies to fight COVID-19: the French paradigm. J Clin Med 2021; 10(13):2942.. Moreover, the lack of coordination of care by an outpatient network compromised actions at the beginning of the pandemic, and the role of general practitioners was clearly defined only after the end of the first national lockdown²⁵25 Schmidt AE, Merkur S, Haindl A, Gerkens S, Gandré C, Or Z, Groenewegen P, Kroneman M, De Jong J, Albreht T, Vracko P, Mantwill S, Hernández-Quevedo C, Quentin W, Webb E, Winkelmann J. Tackling the COVID-19 pandemic: Initial responses in 2020 in selected social health insurance countries in Europe. Health Policy 2021; 126(5):476-484..

The system went into collapse in the most affected regions⁶6 Ghanchi A. Adaptation of the National Plan for the Prevention and Fight Against Pandemic Influenza to the 2020 COVID-19 Epidemic in France. Disaster Med Public Health Prep 2020; 14(6):805-807.^,1212 Hassenteufel P. Handling the COVID-19 crisis in France: paradoxes of a centralized state-led health system. Eur Policy Anal 2020; 6(2):170-179., and an excess mortality rate was high in the first wave of the pandemic¹¹11 Barrera-Algarín E, Estepa-Maestre F, Sarasola-Sánchez-Serrano JL, Vallejo-Andrada A. COVID-19, neoliberalism and health systems in 30 european countries: relationship to deceases. Rev Esp Salud Publica 2020; 94:e202010140., with emphasis on the deaths among the elderly⁹9 Desson Z, Weller E, McMeekin P, Ammi M. An analysis of the policy responses to the COVID-19 pandemic in France, Belgium, and Canada. Heal Policy Technol 2020; 9(4):430-446., which may have been influenced by the low coverage of the Influenza vaccine, which had already been occurring for some years¹⁹19 Organisation for Economic Co-operation and Development (OECD), European Observatory on Health Systems and Policies. France: country health profile 2017 [Internet]. Paris: OECD; 2017. [cited 2022 jun 1]. Available from: https://www.oecd-ilibrary.org/social-issues-migration-health/france-country-health-profile-2017_9789264283374-en, as well as the discontinuation of routine care⁸8 Organisation for Economic Co-operation and Development (OECD), European Observatory on Health Systems and Policies. France: country health profile 2021 [Internet]. Paris: OECD; 2021. [cited 2022 jun 8]. Available from: https://www.oecd-ilibrary.org/social-issues-migration-health/france-country-health-profile-2021_7d668926-en. The health system capacity remained insufficient, even with the low epidemic activity²³23 Pullano G, Di Domenico L, Sabbatini CE, Valdano E, Turbelin C, Debin M, Guerrisi C, Kengne-Kuetche C, Souty C, Hanslik T, Blanchon T, Boëlle PY, Figoni J, Vaux S, Campèse C, Bernard-Stoecklin S, Colizza V. Underdetection of cases of COVID-19 in France threatens epidemic control. Nature 2021; 590(7844):134-139. and, between March and November 2020, 75% of the patients died without having access to an ICU bed⁴⁵45 Lefrancq N, Paireau J, Hozé N, Courtejoie N, Yazdanpanah Y, Bouadma L, Boëlle P Y, Chereau F, Salje H, Cauchemez S. Evolution of outcomes for patients hospitalised during the first 9 months of the SARS-CoV-2 pandemic in France: a retrospective national surveillance data analysis. Lancet Reg Heal Eur 2021; 5:100087..

The fragmentation of the systems and mechanisms for collecting sociodemographic information and the difficulty in monitoring 100% of the national mortality by SpFrance prevented a more accurate analysis of the profile of COVID-19 cases and deaths⁵5 Stoecklin SB, Rolland P, Silue Y, Mailles A, Campese C, Simondon A, Mechain M, Meurice L, Nguyen M, Bassi C, Yamani E, Behillil S, Ismael S, Nguyen D, Malvy D, Lescure FX, Georges S, Lazarus C, Tabai A, Stempfelet M, Enouf V, Coignard B, Levy-Bruhl D. First cases of coronavirus disease 2019 (COVID-19) in France: surveillance, investigations and control measures, January 2020. Eurosurveillance 2020; 25(6):2000094.^,99 Desson Z, Weller E, McMeekin P, Ammi M. An analysis of the policy responses to the COVID-19 pandemic in France, Belgium, and Canada. Heal Policy Technol 2020; 9(4):430-446. and local and regional needs²⁴24 Paché G. Facing the COVID-19 pandemic in France: from managerialism to business logistics. Popul Health Manag 2021; 24(2):158-160.. Deaths that occurred at home were not monitored⁹9 Desson Z, Weller E, McMeekin P, Ammi M. An analysis of the policy responses to the COVID-19 pandemic in France, Belgium, and Canada. Heal Policy Technol 2020; 9(4):430-446. and analyses of the impact of socioeconomic, socio-professional and ethnic-racial factors on mortality could not be carried out¹⁰10 Arminjon M, Marion-Veyron R. Coronavirus biopolitics: the paradox of France's Foucauldian heritage. Hist Philos Life Sci 2021; 43(1)5..

Low testing rates at the beginning of the pandemic underestimated the incidence rates of cases and deaths²²22 Piarroux R, Batteux F, Rebaudet S, Boëlle PY, Piarroux R, Batteux F. COVID-19 alert and surveillance indicators. Ann Fr Med D Urgence 2020; 10(4):333-339., since the laboratory test was a necessary criterion for defining a case⁵5 Stoecklin SB, Rolland P, Silue Y, Mailles A, Campese C, Simondon A, Mechain M, Meurice L, Nguyen M, Bassi C, Yamani E, Behillil S, Ismael S, Nguyen D, Malvy D, Lescure FX, Georges S, Lazarus C, Tabai A, Stempfelet M, Enouf V, Coignard B, Levy-Bruhl D. First cases of coronavirus disease 2019 (COVID-19) in France: surveillance, investigations and control measures, January 2020. Eurosurveillance 2020; 25(6):2000094.. Since no mass screening was systematically performed on a national scale²⁰20 Giraud-Gatineau A, Gautret P, Colson P, Chaudet H, Raoult D. Evaluation of strategies to fight COVID-19: the French paradigm. J Clin Med 2021; 10(13):2942., case and contact tracing was hindered due to underdiagnosis³¹31 Simoes J, Magalhaes JPM, Biscaia A, Pereira AD, Augusto GF, Fronteira I. Organisation of the State, model of health system and COVID-19 health outcomes in six European countries, during the first months of the COVID-19 epidemic in 2020. Int J Health Plann Manage 2021; 36(5):1874-1886., leading to an overestimated case fatality rate.

At the beginning of the pandemic, there were not enough basic supplies or personnel for testing⁶6 Ghanchi A. Adaptation of the National Plan for the Prevention and Fight Against Pandemic Influenza to the 2020 COVID-19 Epidemic in France. Disaster Med Public Health Prep 2020; 14(6):805-807.^,1212 Hassenteufel P. Handling the COVID-19 crisis in France: paradoxes of a centralized state-led health system. Eur Policy Anal 2020; 6(2):170-179., in addition to the underutilization of public laboratories¹²12 Hassenteufel P. Handling the COVID-19 crisis in France: paradoxes of a centralized state-led health system. Eur Policy Anal 2020; 6(2):170-179.. Moreover, the hospital-centered care model restricted testing to the most critically-ill patients at the beginning of the pandemic²²22 Piarroux R, Batteux F, Rebaudet S, Boëlle PY, Piarroux R, Batteux F. COVID-19 alert and surveillance indicators. Ann Fr Med D Urgence 2020; 10(4):333-339.. Additionally, the requirement of a medical request to guarantee reimbursement (which at the beginning of the pandemic was 60% of the charge paid for the test)²2 Or Z, Gandré C, Durand Zaleski I, Steffen M. France's response to the COVID-19 pandemic: between a rock and a hard place. Health Econ Policy Law; 17(1):14-26., discouraged patients with milder cases from taking the test²³23 Pullano G, Di Domenico L, Sabbatini CE, Valdano E, Turbelin C, Debin M, Guerrisi C, Kengne-Kuetche C, Souty C, Hanslik T, Blanchon T, Boëlle PY, Figoni J, Vaux S, Campèse C, Bernard-Stoecklin S, Colizza V. Underdetection of cases of COVID-19 in France threatens epidemic control. Nature 2021; 590(7844):134-139.. Early attempts to increase testing capacity led to long queues and delays in delivering test results¹²12 Hassenteufel P. Handling the COVID-19 crisis in France: paradoxes of a centralized state-led health system. Eur Policy Anal 2020; 6(2):170-179..

As the course of the epidemic progressed, problems related to vaccination arose. With a history of the anti-vaccine movement, 25% of the French people, from the beginning, had already declared they would not be vaccinated⁷7 Duguet A-M, Rial-Sebbag E. The fight against the COVID 19 epidemic in France: Health organisation and legislative adaptation. Med Law 2020; 39(2):173-188.. There were public demonstrations against mass vaccination, with emphasis on the hesitation or reluctance of around 25% of health professionals, at the beginning of the vaccination campaign²¹21 Antonini M, Eid MA, Falkenbach M, Rosenbluth ST, Prieto PA, Brammli-Greenberg S, McMeekin P, Paolucci F. An analysis of the COVID-19 vaccination campaigns in France, Israel, Italy and Spain and their impact on health and economic outcomes. Heal Policy Technol 2021; 11(2):100594.. Additionally, there were moments of vaccine shortage, especially in March 2021, when the country had to suspend the use of the AstraZeneca vaccine due to adverse effects²¹21 Antonini M, Eid MA, Falkenbach M, Rosenbluth ST, Prieto PA, Brammli-Greenberg S, McMeekin P, Paolucci F. An analysis of the COVID-19 vaccination campaigns in France, Israel, Italy and Spain and their impact on health and economic outcomes. Heal Policy Technol 2021; 11(2):100594..

Therefore, although the vaccination coverage showed an upward curve, the country did not make progress towards achieving the coverage target intended by the plan that was initially prepared, which may have contributed to the maintenance of the mortality rates due to COVID-19 above the expected, mainly due to the low vaccination of the elderly³⁰30 Pageaud S, Pothier C, Rigotti C, Eyraud-Loisel A, Bertoglio J-P, Bienvenüe A, Leboisne N, Ponthus N, Gauchon R, Gueyffier F, Vanhems P, Iwaz J, Loisel S, Roy P, CovDyn Group (Covid Dynamics). Expected evolution of COVID-19 epidemic in france for several combinations of vaccination strategies and barrier measures. Vaccines 2021; 9(12):1462..

Final considerations

The response of France to the COVID-19 pandemic demonstrates the successful aspect of the national coordination of the response and the pre-existing government mechanisms of social protection; however, it discloses weaknesses related to the political decision-making process and characteristics of the health and surveillance system. The adopted measures varied according to the epidemiological situation, the increase in self-sufficiency of supplies, system’s capacity, the development of knowledge about the disease, the discovery of vaccines and the difficulty in maintaining restrictive measures for a prolonged time.

Although the institutional devices aimed at facing health crises identified the first suspected cases early on and the fact that the country had had experience in facing previous epidemics, France did not take the opportunity to prepare itself in a timely manner and prevent the spread of the disease and the health system collapse in some regions during the first wave. The political field interests around the elections overcame the needs arising from the epidemiological situation.

The fragmented epidemiological surveillance system, disconnected from service provision and, with limited information collection, hindered the analysis of the health situation to guide timely actions. On the other hand, the health insurance system, with its reimbursement and co-payment mechanism, hospital-centered and without coordination of the outpatient network, also constituted important obstacles for the initial fight against the pandemic.

The national lockdown as a strategy for moments of higher incidence of cases, before the expansion of vaccination coverage, was a strategy that showed to be effective in controlling the pandemic; however, the increase in public funding for health actions was crucial, as well as changes in health insurance rules to expand coverage and improve the outpatient network. The importance of initiatives to improve surveillance actions is also highlighted.

This analysis has limits, as it is supported by a literature review and secondary sources which, for instance, led to greater detailing of measures taken in the first year of the pandemic. However, it allowed the systematization of elements of the French response to the COVID-19 pandemic, related to its health and surveillance system, which can be used as an example for other countries, both regarding its potential and what can be learned from the limitations in the structure and dynamics of the health system operation and the performed changes, in addition to the set of articulated government’s actions to meet the specific reality of the country.

Therefore, the French response offers a lesson on the advantages of national coordination, with stronger lockdowns and measures at peak times prior to the expansion of vaccines, but which, after the expanded vaccine coverage, added to the difficulties of maintaining the restrictions, became more flexible, trying to ensure adequate care for cases and prevent the severe forms of the disease. It associated compensatory measures to protect the economy, changes in the health system and tried to balance the restrictive measures with the wishes and resistance of the population. Nevertheless, the strong role of the government must be highlighted, both concerning the financial investment and as a regulator, with regard to the rules of public and private insurance, organization of the productive sector and collection of taxes to face the crisis.

References

Publication Dates

History