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A policy to be overhauled to reduce social
and regional health inequalities
Communication to the Social Affairs Committee of the
National Assembly
December 2021
Executive summary
A contrasting state of health, marked by social and regional inequalities
The state of health of children under the age of 12 in France seems to noticeably differ compared
with the countries of the European Union or the OECD, even if it is difficult to characterise with
precision, due to the lack of data regularly produced and its incomplete nature. Some indicators
such as mortality, overweight or dental health have improved. There is still room for improvement,
such as for perinatal health, for which France still ranks poorly, measles vaccination, or health
behaviours assessed on the basis of the consumption of sugary products, time spent in front of a
screen and a sedentary lifestyle.
In addition, this overall improvement masks very marked social inequalities in health from
an early age, and less pronounced regional disparities, except in the overseas territories. They
have been documented by means of an original study produced for the Court by the National
Institute for Demographic Studies (INED) based on data from the ELFE birth cohort study. Thus,
the impact of family socio-
economic factors such as household income or the mother’s level of
education is decisive in most child
ren’s health events. In particular, children’s weight, whether low
weight at birth, or high weight then overweight and obesity, depends on the vulnerability of
The follow-
up and monitoring system for children’s state of health suffers from shortcomings
and weaknesses that have long been identified. This deprives public authorities of the knowledge
essential for defining public health priorities and following up on actions implemented to remedy
social and regional health inequalities. In particular, monitoring based on mandatory health
certificates or examinations carried out in schools is impossible as they are not sufficiently
systematic and the quality of information provided is poor. Only surveys make it possible to
document this state of health, but they are not frequently updated, their regional granularity is
insufficient, and certain information on health behaviours is missing. This is why the Court
recommends improving the epidemiological tool, relying more on the use of enhanced medico-
administrative databases matched with social databases and strengthening coordination between
stakeholders, in particular for the production and use of surveys.
A policy of reducing inequalities with modest effect
A regularly stated priority, ensuring consistent strategies and actions that can still be
First of all, it appears that preventing social and regional health inequalities is a priority
regularly announced by the public authorities. The Law of 26 January 2016 on modernising our
health system was a major shift, which was reflected in the national health strategy. It is based
on a cross-cutting approach to reducing health inequalities, while paying particular attention to
However, it comes up against the wide range of institutional stakeholders involved
of Health, Ministry of National Education, the health insurance system, and departmental maternal
and child welfare services, etc. Depending on their priorities and their primary actions, each of
these stakeholders adopts objectives in terms of children’s health, which do not mak
e it possible
to define in the long term a real coherent policy for reducing social and regional inequalities.
Despite the creation of an inter-ministerial health committee and a body specific to children and
young people’s health, the CoSEJ, the announcem
ent of shared priorities is not embodied in
concrete, measurable and monitored actions. The Ministry of Health, in particular the Directorate-
General for Health (DGS), has neither the authorities nor the minimum monitoring instruments to
assess the implementation of the priorities of the national health strategy. This observation has
been made at regional level, reinforced by the gap between the regional level of action of the ARS
(regional health agencies) and that, at departmental level, of the health insurance system, national
education, and the maternal and child welfare service (PMI).
Expenditure on children’s health, which is not subject to any routine monitoring by the public
authorities, was estimated by the Court during this enquiry at approximately
€8.9 billion in 2019.
This estimate includes expenditure on care in doctors’ surgeries, health centres and in health
institutions, that on prevention, including that falling under national education and the PMI, and
that linked to social health cover.
Levers for action with results that can still be improved
In order to reduce social and regional health inequalities from an early age, several levers
are mobilised by the public authorities. Some, that are older, are specific to children, such as so-
called compulsory examinations and vaccination, and rely on general practitioners or
paediatricians and specific health professionals (school health services, the PMI). Others are also
rolled out for the entire population in order to prevent financial barriers when accessing
healthcare. Despite the implementation of these actions, children’s care pathways are
nevertheless characterised by differences in the use of professionals and health structures
depending on the social gradient of families and where they live.
Children’s health is monitored essentially on the basis of twenty
medical examinations and
five oral examinations, defined by the French Public Health Code. These are carried out at key
ages by var
ious professionals working in doctor’s surgeries and health centres, the PMI or in
school, and upon vaccination. These actions aim, through their obligatory and universal nature,
to reduce social and regional health inequalities by detecting and screening for the main health
problems or developmental delays early on and by enabling the delivery of tailored prevention
and health promotion messages. However, their results only have a limited scope and are very
difficult to monitor. Therefore, in 2019, only 60,000 medical examinations in the 9th and 24th
month were counted per month on average compared with the 125,000 expected given the
numbers of children of these ages. Furthermore, less than one in five children benefited from an
scheduled examination by a school doctor during their sixth year, in 2018.
This is why the Court recommends strengthening the management of the policy to reduce
social and regional health inequalities in childhood both at national level by relying on a CoSEJ
[committee for children and young people’s health], whose actions and operation have been
renewed, and at regional level. In this respect, defining a single contractual framework between
the regional health agency, the health insurance system, the departmental PMI service and
national education would make it possible to ensure the coherence of actions and financing while
strengthening the coordination skills of the ARS at departmental level.
Restructuring child health policy
The two networks of historic stakeholders, the PMI and school health services, are
experiencing significant difficulties that are regularly noted. These compromise their ability to fulfil
their missions in terms of children’s health and preventing social and regional health inequalities.
On the one hand, the PMI, the only area of health decentralised to the departments, has seen its
programme considerably extended, including outside of healthcare, without substantial changes
to its means of financing, while its workforce, in particular medical staff, has tended to decrease.
On the other hand, school health services, to which the Court devoted a report in April 2020, no
longer manages to fulfil its mission of monitoring children individually but remains a suitable place
for preventive and health promotion actions aimed at children and parents, the scope of which is
poorly evaluated. This situation can be explained in particular by the shortage of school doctors
and organisational problems. These difficulties encountered by the PMI and school health
services are more broadly part of a movement involving the gradual disappearance and dispersal
of spec
ialised medical and paramedical skills for children, particularly in doctor’s surgeries and
health centres. The provision of care for children now relies mainly on general practitioners, with
paediatricians providing only 33% of consultations for children under 12 years of age in 2019 and
concentrating their activity on children under two years of age, living in large urban areas and
socially-advantaged environments. While the coexistence of several health professions dedicated
to children’s health, whether
prevention or care, could have alleviated the difficulties of accessing
the health system, they tend to accumulate in certain areas.
Consequently, strengthening the health policy for children in order to prevent social and
regional health inequalities req
uires redefining children’s care pathways around prevention and
the treating physician. This needs to be done by placing it within a framework of regional action
adapted to the region’s needs and resources, and by relying on digital transformation. It invo
more effectively allocating, around clearer and better managed priorities, resources that are
currently dispersed, and clarifying stakeholders’ actions by encouraging their complementarity
within a framework of coordinated exercises. This reallocation of resources within a controlled
financial framework should be a priority in order to reduce health inequalities among children,
improve their current and future state of health, and thus limit avoidable expenditure.
Putting prevention at the heart of the child health policy means improving the information
and support given to parents, by providing easily accessible and reliable information, and to
children so that they participate in their health by developing their psychosocial skills. This effort
involves in particular the continual support of the PMIs by consolidating their funding through the
recognition of certain childcare actions and by extending the scope of procedures and products
covered by the health insurance system.
Given the demographic context of the professionals involved, such a reorganisation of child
healthcare cannot be envisaged without changing organisational methods in doctors’ surgeries
and health centres, based in particular on enhancing the role of the child’s treating physici
an and
their preventive action, and on clearer inclusion in a regional multi-professional approach. In order
to guarantee that compulsory examinations and screenings are carried out, they should be
entrusted to the child’s treating physician and based on t
he complementarity of independent
healthcare professionals, and therefore on the delegation of actions or the recognition of
independent childcare nurses, consequently refocusing the intervention of school health
personnel on supporting children with special needs and educational teams.
These developments are intended to be part of an approach broken down by region and by
population, based on a reinforced contractual framework between institutional stakeholders, and
between health professionals, based on an assessment of the needs and available resources.
The experimentation of a children’s health centre, a single place that would bring together the
various professionals regardless of their practice, would not only improve parents’ understanding
of the system, but also encourage coordinated and multi-professional practice and thus
compensate for the supply shortage in certain regions.
There is therefore room for manoeuvre to develop an ambitious prevention and health
promotion policy for children. This could be the starting point for social investment, the efficiency
of which would be measured in the long term by the improvement in adults’ state of health.
Improve governance and management
Improve epidemiological monitoring by making more use of medico-administrative data,
enhancing the indicators produced, facilitating matching with social databases, and carrying
out regular and targeted surveys on certain health problems
(Ministry of Health, Ministry of
National Education, Public Health France, CAM [National health insurance fund]).
Strengthen inter-
ministerial leadership for children’s health through the continuation of the
CoSEJ’s actions and operation
(Ministry of Health).
Standardise the contractual framework between the ARS, health insurance system, PMI and
national education to ensure the coherence of actions and financing relating to children’s
health in order to strengthen the ARS’ coordination skills at departmental level
[General Secretariat of Ministries of Social Affairs], CAM).
Entrust the ARS with the steering and increased monitoring of health promotion actions
carried out in schools by associations under the single contractual framework
DGESCO [General Directorate of School Education]).
Strengthen the care offering for children
Consolidate the PMI’s actions by extending the scope of procedures and products reimbursed
by the health insurance system to departmental councils in order to better provide for the
activity carried out
(DGS, DSS [Department of Social Security], CAM).
Strengthen the preventive role of the child’s treating physician by giving them the responsibility
of all compulsory examinations, upgrading them as complex consultations within the
framework of specific requirements and developing the delegation of procedures and assisted
Recognise childcare procedures in the general nomenclature of professional procedures
(NGAP) in order to develop the practice of childcare nurses on an outpatient basis alongside
the child’s treating physician
(DSS, CAM, HAS [French National Authority for Health]).
Focus the intervention of school doctors on their mission of supporting children with special
needs and the intervention of nurses on their primary mission, by entrusting examinations at
the ages of 6 and 12 to treating physicians
Prioritise the integration of the digital health record into the digital health space
Build a regional care pathway
Draw on a regional assessment of the child’s health needs and available resources to build a
care pathway (
Try out a children’s
health centre bringing together, from existing organisations, the health
professionals of a region based on a local assessment of children’s health needs, in order to
improve access to care and support for children and encourage coordinated multi-
professional practice (
Appendix 4: international comparisons
The international comparisons focus on three main areas: the organisation of primary care
for children, universal prevention and screening programmes, and the state of children’s health.
A specific analysis was carried out on the Danish, English, German and Quebec models of
prevention and care for children.
A - Primary care systems for children
Three primary care models for the care of children coexist in Europe, as shown on the map
below. Access to the health system is different, reception and care being provided either by
paediatricians, as in Spain or Germany, or by general practitioners as in the UK, the Netherlands
and Ireland, or by paediatricians or general practitioners as in France, Italy, Belgium and Portugal
among others.
According to the European Mocha study
(2015-2018) carried out in 30 European
, each model has different health outcomes. For example, measles vaccination
coverage is significantly higher in countries where the primary care system relies either on the
paediatrician or the general practitioner than in countries that have adopted a mixed model. For
autism spectrum disorders, a diagnosis is made on average at 56 months in countries relying
exclusively on the general practitioner while this period increases to 76 months in countries with
a primary care system for children which relies only on the paediatrician. It is not easy to
distinguish what pertains to the general pattern of care provision in the countries or specifically to
the effects of the paediatric primary care model in respect of these observations. Furthermore,
differences are not systematically highlighted: for asthma, for example, the primary care model
does not seem to have any effect on the time taken for treatment or its effectiveness.
M. Blair et al.,
Models of child health appraised, Issues and Opportunities in Primary Health Care for Children in
Europe: The final summarised results of the Models of Child Health Appraised (Mocha) Project,
November 2018
European Union (28 members), Norway and Iceland.
Models of primary care for children in Europe
Source: according to M. Blair et al., Models of child health appraised, Issues and Opportunities in Primary Health
Care for Children in Europe: The final summarised results of the Models of Child Health Appraised (MOCHA)
Project, November 2018 (Court of Accounts representation)
Note: for Denmark, a hybrid system is described involving general practitioners and specialist nurses for children.
Health examinations and screening programmes in Europe
Most countries in the European Union have screening programmes and regular health
checks in place for children. However, there are notable differences in terms of the frequency and
content of health checks offered by country. Most check-ups and examinations include monitoring
(measurement of the child’s height, weight, and head circumference). Specific additional
screening and preventive tests are also organised in some countries, such as screening for
mental and psychological disorders, sometimes an orthopaedic examination or even biological
tests to detect certain rare diseases such as phenylketonuria and hypothyroidism
European Commission,
Feasibility Study for a Child Guarantee
FSCG2), final report, 2021
All countries
organise screening programmes in the first years of a child’s life. The methods
of carrying out these examinations can vary between home visits or a consultation at a surgery
or establishment, which can be carried out by a nurse or doctor depending on the system. Their
frequency is however fairly even. On average, these visits take place once a month until the age
of 6 months, then the visits are slightly spaced out, approximately every 2 or 3 months and then
twice or once a year from 2-3 years.
The existence of dental screening programmes for children varies by country. While some
countries organise programmes for preventive dental consultations or oral screenings for all
school-aged children (e.g. in Denmark and France), others do not have programmes in place in
this field or only offer superficial screening (e.g. in Slovakia).
The dental voucher scheme in Portugal
The principle of the dental voucher was created in 2008 in Portugal, allowing children, pregnant
women and certain vulnerable groups to benefit from care from dentists participating in the programme
without upfront payment. This programme is broadly comparable to the French programme
M’T dents
The vouchers are available for children attending state schools, and now also private schools that have
agreements with central government. Schools identify eligible children aged 7, 10 and 13, enabling
vouchers to be issued by the Portuguese NHS. The vouchers are then given to the schools. Vouchers
can also be given by the treating physician for children aged 3 to 18 when the state of health or certain
situations justify this. The vouchers can be used in all establishments participating in the programme
(dental practices, private dental clinics or public institutions). Their use is not mandatory; however, if an
issued voucher is not used, participation in the rest of the programme is complicated due to the limited
number of vouchers issued per person. The voucher has a value of €35 and allows the treatment of two
cavities and the sealing of fissures
. The participation rate for children increased from 31% in 2009 to
57% in 2017 with similar noticeable improvement in the dental health of children in Portugal. However,
as the Portuguese Court of Accounts and various research studies have reported, this system does not
ensure complete universal access to dental care due to the voucher’s terms of use (particularly the
deadline) or the difficulty that some families have in finding a dentist participating in the programme
Finally, the number of procedures covered by the voucher is also one of the limits of the programme, as
the regulatory authority for the Portuguese healthcare system pointed out in 2014.
In most countries, there is regular medical monitoring of children of school age. This
monitoring may take place at school (e.g. in Denmark and Austria) or in a dedicated centre,
primary care centres or in a paediatric clinic generally in collaboration with schools such as in
Belgium and Spain.
In most countries, health examinations and periodic screening programmes are free and
intended for all children, which allows those exposed to particular vulnerability (high levels of
insecurity, migrants, etc.) to benefit from them. The advantage of school-based consultations is
that they can more easily reach all children, including children from low-income households or
those remote from the primary care system. The French specificity of the PMI, which is universal
and open to all families, especially those in the most precarious situations, is not found in this
form in any other country of the European Union.
. Simoes et al.,
Ten years since the 2008 introduction of dental vouchers in the Portuguese NHS
, Health policy,
T. Takara et al.,
Use overview of
pediatrice “dental
voucher” in Portugal
, Clinical pediatrics and research, 2017
R. Filipe and P. Aguitar,
Oral health: factors of non-adherence to dental vouchers, a case control study
, Revista
Cientifica da ordem dos médicos, 2018
Different positions are adopted within the European Union on the issue of compulsory health
check-ups for children. While in some countries, screening is compulsory (as theoretically in
France but also in Finland and Austria
), in the majority of countries it is optional while being
recommended according to a specific timetable. Some countries have even made the payment
of child allowance conditional on participation in child screening programmes. In Austria,
examinations under the
mother child pass
are not in principle compulsory, but parents who do not
take part in these consultations see their childcare allowance reduced.
The table below from the second feasibility study for the “Child guarantee” summarises the
period during which periodic health examinations and check-ups are offered to children in
European Union countries, and the nature of the screenings offered and carried out.
The European Child Guarantee initiative
In March 2021, the European Commission adopted a recommendation to implement a European
guarantee for children: the “Child Guarantee”
. This system aims to ensure that all children in Europe in
situations of poverty, vulnerability or social exclusion have access to fundamental rights such as medical
care or education. This initiative is partly inspired by the Youth Guarantee existing since 2013. It should
be included in the EU budget (2021-2027), as part of the European Social Plan.
The “Child Guarantee” has been the subject of a preliminary study by the
European Commission
aimed at ensuring its feasibility and the arrangements for financing the system. This guarantee should
help Member States to implement the European Commission’s recommendations to ensure that every
child in Europe has access to free healthcare, free education, adequate food and decent housing.
To access financial assistance, Member States will need to have national strategic policy
frameworks in place for social inclusion and reducing poverty, with particular attention to preventing and
tackling child poverty. Countries with a child poverty rate above the European average are targeted as a
priority. According to the feasibility studies, France is mostly unaffected, and its authorities have therefore
had little involvement in the thought process since the services targeted are theoretically already
provided. In particular, the PMI was highlighted as a European specificity allowing universal access to
prevention for children, especially for the most vulnerable.
European Commission,
, final report, 2021
European Commission
. Proposal for a Council recommendation establishing a European Child Guarantee
. KE-02-
21-418-EN-N, 24 march 2021
Overview of regular screening programmes in the European Union
Source: according to the FSCG2 final report of the
European Commission, already cited
(translation Court of
: Organisation of screening programmes; X: specific screening programme not organised in the country; *: limited or
partial programmes
State of children’s health
The state of children’s health is documented through various sources. While the data
generally comes from research or epidemiological surveys, some is based on medico-
administrative data. In England, for example, health data collected by the NHS in the context of
patient care is extremely valuable and allows more epidemiological work on children than, for
instance, data from Sniiram and PMSI in France. However, comparisons of results obtained in
countries using different sources and methodologies are risky. The methodology for producing
perinatal or mortality indicators are relatively well standardised. In 2021, an important work of the
highlighted the complexity of having solid health data on children, in particular on health
behaviours, in the field of psychosocial and psycho-emotional determinants.
To compare health indicators of a pathological nature, when no international exists in a field,
the reference tool remains the international study
Global burden of disease
led by the University
of Washington (IHME). Each year, this study produces estimates on various health indicators by
country, with a breakdown by age group. The WHO quite frequently relies on these estimates for
its work. For instance, in the dental field, it is the only source of indicators on an international
scale. These are estimates made from statistical work based on existing data, or, as applicable,
assumptions. Without always producing very precise figures, this study has the merit of making it
possible to compare countries and observe temporal dynamics. Other data sources also make it
possible to specify certain international indicators, such as those of the UN Inter-agency Group
for Child Mortality Estimation (UN IGME) on mortality and perinatality, and those of WHO Europe
(European Health Information Gateway) on the prevalence of certain health events in childhood
(excess weight and obesity, vaccination).
The following table presents various demographic, economic and health indicators for
France, Germany, Denmark, Quebec and England.
Main demographic, economic and health indicators for France, Germany, Denmark,
Canada and the United Kingdom (2019 or the most recent year available)
Demographic indicators
Total population
67,055,854 80,475,076
37.5 million
8.5 million
for Quebec)
in England)
Proportion of children
(% 0-14 years)
and 14.7
Life expectancy (years)
Economic indicators
GDP, dollars per capita
Total health expenditure, $PPP per capita
Public health expenditure as a % of total
health expenditure
Household out-of-pocket expenditure as a %
of total health expenditure
Health indicators
Birth rate
per 1,000
Infant mortality
per 1,000
Neonatal mortality
per 1,000
, Measuring what matters to child well-being and policies,
3 march 2021.
Likelihood of death between 5 and 9 years
Prevalence of asthma from 5 to 14 years (%)
(limit of the estimate)
Prevalence of excess weight and obesity at
11 years (%)
Prevalence of dental caries on primary teeth
(less than 5 years) (%)
Prevalence of dental caries on permanent
teeth (5-14 years) (%)
DTP vaccination coverage - 3 doses (%)
HiB vaccination coverage - 3 doses (%)
HBV vaccination coverage - 3 doses (%)
Measles vaccination coverage - 2 doses (%)
Sources: European health information gateway (WHO), HBSC surveys (WHO), Global burden of disease (IHME),
Cosi survey (Childhood Obesity Surveillance Initiative, WHO), WHO/UNICEF Estimates of National Immunization
Coverage, UN IGME
Note: N/D: data not available.
By taking all of the indicators considered, there is, overall, some similarity. Denmark stands
out with a series of rather favourable indicators and Canada with poor indicators, whether in terms
of obesity, dental health or asthma
. Regarding
vaccination coverage, the countries’ results
depend on the diseases covered (e.g., France has good DTP coverage and very insufficient MMR
Organisation of the primary care system for children in certain
The German healthcare system is based on two basic insurance schemes: a compulsory
one called
Gesetzliche Krankenversicherung
(GKV), and a private one called
(PKV). Each resident is required to be affiliated to one of these two
schemes. Affiliation to the private scheme is aimed at people whose monthly income is more than
€4,462 gross who can choose to upgrade their compulsory insurance to private insurance. 87%
of Germans are affiliated to the public health insurance scheme and 13% to private insurance for
their basic cover
The primary care structure is organised on a federal basis: the Federal Ministry of Health is
responsible for regulating and supervising care in the 16
[federal states]. The principle of
subsidiarity means that the 16 ministries of health of the
are responsible for the provision
of care in their respective states. This includes planning hospital services, prevention programmes
but also epidemiological surveys and the establishment of morbidity registers.
Health indicators for Quebec and England within Canada and the United Kingdom are generally not distinguished.
J. Ehrich et al.,
The child care system of Germany
, Journal of Pediatrics, 2016.
Early assistance networks: a model between the
Prado maternité
and the PMI
Since 2006, the “Early assistance” action programme has been implemented to offer support to
families in the form of home visits by nurses from pregnancy until the children are 3 years old
. This is
a system that particularly targets socially disadvantaged families. The goal of early intervention is to give
all children equal opportunities for healthy development and a non-violent upbringing, including by
developing parenting skills. Analysis of the data showed that children in families visited at home had
better birth outcomes and that children scored higher on cognitive development tests.
Parents are free to choose the practitioner for their children. Paediatricians are directly
accessible, as are general practitioners who can refer patients to specialists or hospital facilities.
Paediatricians mainly work with young children (under 12 years of age). Beyond that, it is mainly
the general practitioner who takes care of children and adolescents. 90% of children under 6 are
seen by a paediatrician and 10% by a general practitioner. From 7 to 11 years of age, 65% of
children are seen by a paediatrician and 35% are seen by a general practitioner, while from age
11, this ratio is 30% and 70%. Studies have shown that the most advantaged families tend more
towards paediatricians and that the least advantaged tend more towards general practitioners.
Medical and dental care, medicines as well as psychotherapy, speech therapy and
occupational therapy are free for all children and adolescents until the end of their studies and
are covered by health insurance.
An early detection system called “U1 to U9”
is in place in Germany for all children up to
the age of 6. The U1 to U9 are a series of ten
check-ups and screenings, taking place between
birth (U1) and the 60th-64th month (U9). These examinations make it possible to detect any
developmental disorders at an early stage and refer them for possible treatment. These medical
visits are free and carried out at
a general practitioner’ surgery or a paediatrician’s practice. In
addition, a compulsory health examination takes place before the child starts school. Following
the U1-U9 examinations, additional assessments are recommended for primary school children
(U10 for 7-8 year olds and U11 for 9-10 year olds) and adolescents (J1 for 12-14 year olds and
J2 for 16-17 year olds), but they may be chargeable in some cases. Participation in these
examinations has increased significantly over the past ten years. The fact that they are carried
out in medical practices is a means of ensuring the subsequent follow-up of the children if
disorders are detected. Participation rates for most visits exceeded 95% during the first six years
of life: however, children from low-income or immigrant families participate less frequently in this
The German vaccination schedule closely mirrors the French schedule. There are,
however, no compulsory vaccinations in Germany, except for measles since 2019. Parents
refusing to have t
heir child vaccinated are liable to a fine of up to €2,500.
The English health system is based on the British National Health Service (NHS). It allows
UK residents to access care without upfront costs, with the exception for adults of costs for
prescription drugs and optician and dental services. About 13% of the population has private
supplementary insurance to cover care provided by the private sector. However, most children
use public health services for all care.
General practitioners are almost the exclusive point of entry into the primary care system.
They are usually turned to first for children and are an essential step in accessing other specialists,
including paediatricians.
In England there is a policy similar to the French
Prado maternité
: the Family nurse
partnership programme. Pregnant women receive a home visit from a midwife who oversees their
European Commission,
op. cit.
European Commission,
op. cit.
The U7 and U7a examinations are separate
care during pregnancy and the immediate postnatal period. This programme is designed to further
support vulnerable young mothers, particularly during their first pregnancy, by focusing
intervention on support for parenthood.
The National Healthy Child Programme (HCP) focuses primarily on the first 100 days of life.
It includes strategies aimed at providing children and young people with a schedule of health
check-ups, screening tests, vaccinations, health promotion advice and personalised support for
children and families. This programme provides a framework to support collaborative working and
a more integrated service, with an emphasis on intervention in the early years.
The Early Intervention Foundation: a key partner for the implementation of health
intervention for children
The NHS is supported by the Early Intervention Foundation in its health policy for children. It is a
private non-profit organisation that works with public services to design prevention programmes targeting
a wide range of health, developmental or psychosocial problems that may arise during a child’s life. Its
scope covers areas broader than health, such as education or family policy.
Health check-ups are offered to all children from the neonatal period until they start school.
They take place just after birth, between the 1st and 2nd week, between the 6th and 8th week,
between 9 and 12 months, and between 2 and 2 and a half years. They include monitoring
The school period provides more time for health education and promotion. It is initiated by
teachers as part of the Personal, social, health and education programme (PSHE)
, which is
designed locally without national standards. This approach gives teachers the flexibility to deliver
an education programme tailored to their students’ needs.
Vaccination coverage for children has improved nationally for most childhood vaccinations,
although MMR coverage remains below the 95% threshold. Children are vaccinated either in
doctors’ surgeries and health centres or at school.
In 2016, the English NHS initiated the Digital Child Health Transformation programme: this
initiative aims to transform child health information systems by enabling better monitoring of each
child’s health and by giving all health professionals involved in the child’s care access to this
monitoring. Ultimately, this pl
an should lead to a digitisation of the “red book”, the health record
that all children in Great Britain have.
Primary care is free in Denmark and is financed by taxes. Voluntary health insurance exists
but is very rarely taken out. All residents must have an identified general practitioner.
Children account for approximately 20% of consultations with general practitioners. In
addition to regular consultations, general practitioners carry out preventive health examinations
on children aged 5 weeks, 5 months and annually until the age of 5. More than 90% of children
attend the first 3 preventive health examinations
All parents are offered visits by public health nurses during the first week of their child’s life.
More than 90% of parents accept these visits, and more visits are offered during the first 12 to 18
months. Free visits to dentists are offered up to the age of 18.
In Denmark, screening takes place to a fairly large extent at school. For schoolchildren, the
school health nurse or school dental service may be the main contact and can in many cases
I. Wolfe I et al
Child health systems in the United Kingdom (England)
, Journal of pediatrics, 2016.
Department for Education
P. Mathiesen et al.,
the Child Health System in Denmark: Current Problems and Successes
, the Journal of Pediatrics,
resolve minor or benign problems. These professionals perform an important function in the early
identification of health and social problems.
More generally, nurses monitor children’s health at
school (measuring height and weight,
testing vision and hearing), involving municipal doctors in the first examination and the last
examination at age 9
. Finally, they play a key role in health promotion by organising health
workshops and health discussions in small groups.
In Canada, health policy is devolved to provincial health ministries which independently
direct healthcare policy. Two universal schemes enable the entire population to access hospital
and medical services paid for by central government. Health and social services are essentially
funded by general taxation.
In Quebec, the
Régie de l’assurance maladie du Québec
(RAMQ) is responsible for the
public health and prescription drug insurance plans and remunerates health professionals. It
issues Quebec citizens with a “sun card” which covers medical consultations and hospital stays
free of charge. This card makes it possible to cover almost all costs and in particular covers dental
costs for children up to their 10th birthday.
Quebec, in its National Public Health programme (2015-2025), considers the period of
childhood as “the most marked phase of human development
’”. ». The Canadian province has
therefore clearly targeted this period as a priority.
Children can be monitored in Canada both by family doctors (general practitioners
equivalent to general physicians with whom families must register) and by paediatricians. Across
Canada, it is estimated that 60 to 70% of children are usually monitored by a family doctor and
30 to 40% by a paediatrician. Nevertheless, in Quebec, the majority of young children up to 2
years of age consult a paediatrician for their general care
The preventive care for children is carried out through periodic examinations, the schedule
of which has no formal structure. Nevertheless, the recommendations of learned societies are
consistent on the fact that these visits should generally take place, for children in good health, at
the age of one week and two weeks, as well as at 1, 2, 4, 6, 9, 12 and 18 months, then at intervals
of one or two years. There is therefore no official timetable for preventive examinations
recommended for newborns, infants or children. These are mainly general recommendations
subject to the parents’ discretion.
Since May 2018, the electronic health record has been rolled out. It is a system similar to
the French
Dossier Médical Partagé
[shared medical record] which keeps records of the drugs
prescribed and imaging and biology results in particular. Children under 14 are currently attached
their parents’ record.
Regarding the vaccine strategy, despite ongoing debate and consideration of this topic for
several years, no vaccine is currently compulsory in Quebec, leaving parents some margin of
discretion. Other provinces in Canada have opted for other strategies such as Ontario, which
requires proof of various vaccinations for starting school. The Quebec immunisation programme
includes various vaccination programmes, which are free and voluntary depending on the
vaccination schedule. This programme stipulates that children receive certain vaccines at school.
These vaccines are free in the 4th year of primary school and in the 3rd year of secondary school.
The school nurse vaccinates children during vaccination sessions. A national vaccination register,
in which each vaccination must be recorded, makes it possible to monitor very precisely the
vaccination coverage of the population
European Commission, FSCG2, op. cit.
PNSP 2015-2025