Warin P
CNRS, Science Po Grenoble, School of Political Studies, Grenoble Alpes University, PACTE, 38000 Grenoble, France.
Rev Epidemiol Sante Publique. 2019 Feb;67 Suppl 1:S33-S40. doi: 10.1016/j.respe.2018.12.063. Epub 2019 Jan 11.
The state of populations' health is linked to their access to quality healthcare. Best achieving this primary condition - a health, social and humanitarian condition - is an ongoing public policy objective. Although significant effort goes into this, do public policies sufficiently take into account the state of health of the most vulnerable populations? In France, reducing the non-take-up (NTU) of healthcare is a priority in current national health insurance policy. Under the local plans to tackle non-take-up, lack of understanding and exit from the system (PLANIR), national health insurance is currently rolling out a regional and partnership-based intervention framework in order to prevent NTU of healthcare by welfare clients. This social investment is unprecedented, yet the impact of the framework on the most vulnerable populations still seems to be limited.
The study of this example is based on monitoring of the framework's general implementation. This task was entrusted to the research team co-founded by the author, ODENORE (Observatory for the Non-take-up of Social Rights and Public Services). It is organized in four parts: quantitative monitoring of the detection and addressing of non-take-up situations (n=160,000 questionnaires); analysis of the results through qualitative interviews with beneficiaries and individuals who rejected the framework (n=365 interviews); analysis of the framework's implementation, using qualitative interviews and participant observations at the services in charge of the framework's implementation (n=18 collective interviews across three sites), and an analysis of the partnership through collective interviews with all the actors in the areas involved in the framework (three sites).
The analysis shows that the integration of the most vulnerable populations' state of health into a common-law framework for intervention is hindered by three limitations: the framework's neutrality regarding public decisions and non-decisions that exacerbate social and regional health inequalities; its organizational design, which does not take into account the need for long-term medical-psycho-social care; and the absence of regulation capable of bringing together and coordinating the actors working towards healthcare access locally but with different populations.
The difficulties of integrating the most vulnerable populations into a common-law framework such as the one proposed by the national health insurance do not seem insurmountable-provided, that is, that the regulatory authority (the regional health agencies) are willing and able to make it a strategic organizational objective at local level.
民众的健康状况与其获得高质量医疗服务的机会相关。最好地实现这一基本条件——一种健康、社会和人道主义条件——是一项持续的公共政策目标。尽管为此付出了巨大努力，但公共政策是否充分考虑了最脆弱人群的健康状况呢？在法国，减少医疗服务未使用情况（NTU）是当前国家医疗保险政策的一项优先事项。在当地解决未使用、理解不足和退出系统的计划（PLANIR）下，国家医疗保险目前正在推出一个基于地区和伙伴关系的干预框架，以防止福利客户出现医疗服务未使用情况。这种社会投资是前所未有的，但该框架对最脆弱人群的影响似乎仍然有限。
对这个案例的研究基于对该框架总体实施情况的监测。这项任务委托给了由作者共同创立的研究团队ODENORE（社会权利和公共服务未使用情况观察站）。它分为四个部分：对未使用情况的检测和处理进行定量监测（n = 160,000份问卷）；通过对受益人和拒绝该框架的个人进行定性访谈来分析结果（n = 365次访谈）；利用对负责该框架实施的服务部门进行定性访谈和参与观察来分析该框架的实施情况（在三个地点进行n = 18次集体访谈），以及通过与该框架所涉地区的所有行为者进行集体访谈来分析伙伴关系（三个地点）。
分析表明，将最脆弱人群的健康状况纳入普通法干预框架受到三个限制：该框架在公共决策和不决策方面的中立性加剧了社会和地区健康不平等；其组织设计没有考虑到长期医疗 - 心理 - 社会护理的需求；以及缺乏能够汇集和协调致力于当地医疗服务获取但面向不同人群的行为者的监管。
将最脆弱人群纳入国家医疗保险所提议的普通法框架的困难似乎并非无法克服——前提是监管机构（地区卫生机构）愿意并能够将其作为地方层面的战略组织目标。
