FRENCH PUBLIC HEALTH
AGENCY
Extended missions,
a strategy to be better defined
Communication to the Senate Social Affairs Committee
December 2022
2
Executive summary
The National Public Health Agency, also known as Santé Publique France (SPF)
1
, is a
public administrative institution under the supervision of the Minister for Health. Its missions
are epidemiological observation and monitoring of the health status of populations,
surveillance of health risks threatening populations, health promotion and risk mitigation in
health, health education, preparation and response to health threats, alerts and crises, as well
as launching health alerts.
A first merger of national health agencies into coherent clusters, corresponding to their
major missions, was announced by the Council for the modernisation of public policies on 4
April 2008. These agencies were to be brought together to simplify the conditions for their
management by the State, to strengthen their internal expertise, to reduce the risks of
redundancy between them and to make the whole system more coherent.
Unlike other agencies
2
, however, the Institut de veille sanitaire (Institute for Health
Monitoring), the Institut national de prévention et
d’éducation
pour la santé (National Institute
for Prevention and Health Education) and the Établissement de préparation et de réponse aux
urgences sanitaires (Health Emergency Preparedness and Response Facility) were not
affected by the initial mergers. These organisations and the public interest grouping
“
Addictions drugs alcohol info service
”
finally merged as of 1 May 2016 within SPF, in
application of an order issued on the basis of the law on the modernisation of our health system
of 26 January 2016.
According to the terms of the law and a prefiguration report, the creation of the new
agency was intended to improve the coherence and continuity of the missions entrusted to the
pre-existing bodies in the service of the national health strategy, as well as the efficiency of
public policies.
A consolidated
continuum
of missions
Between 2016 and 2019, SPF had started to strengthen the links between the missions
inherited from the pre-existing organisations. However, given the scale of the challenges
associated with the merger (construction of the new headquarters, decompartmentalisation of
previous professional practices, numerous administrative reorganisations), the expected
synergies had not yet borne full fruit at the beginning of 2020.
1
Article 166 of Law no. 2016-41 of 26 January 2016 on the modernisation of our health system.
2
Such as the National Agency for Food, Environmental and Occupational Health Safety (Anses), created on 1 July
2010 by the merger of the French Food Safety Agency (Afssa) and the French Agency for Environmental and
Occupational Health Safety (Afsset).
3
The Covid-19 health crisis was a major challenge for the agency, which played an
important role during this period, in particular by contributing to the establishment and
management of strategic healthcare stockpiles and to vaccination campaigns. This
mobilisation has resulted in substantial changes for SPF, particularly in terms of creating posts
and carrying out its legal missions.
The agency was able to show responsiveness and flexibility in its organisation to meet
the urgent needs related to the management of the epidemic crisis, as shown by the rapid
reorganisation of its services, the provision of the Géodes mapping observatory, the creation
of new partnerships with research players and the modification of its scheduling. While the
crisis has slowed down the implementation of some actions, it has also strengthened some of
the links between the missions entrusted to SPF.
The health reserve, composed in particular of volunteer health professionals, which
contributes to the reinforcement of the health system to respond to exceptional health
situations, has grown in strength during the first years of the
agency’s
existence. However, this
tool was overtaken by the scale of the Covid-19 pandemic. Its intrinsic characteristics partly
explain its difficulties in fulfilling its mission and the rapid development of alternative solutions
to support the care system from March 2020. However, the lack of management tools adapted
to the issues at stake, and the absence of a proposal and adoption of a new framework for the
use of the health reserve, despite the fact that it has been requested by the supervisory
authority since 2016, testify to the insufficiency of the expected synergies. A new employment
framework must now be adopted and integrate a more interministerial vision of the human
reinforcements to be provided in the event of a major health crisis.
Since 2020, SPF has made progress in crisis management and the value of its
competence in this field does not seem to be called into question, subject, on the one hand, to
modifying the aforementioned employment framework and, on the other hand, to reinforcing
the doctrine for the constitution and management of strategic stocks. In this respect, the
legislation should be amended to extend the
agency’s
competence over strategic healthcare
stocks to include the power of self-referral, which enables it to make recommendations, a
power that the agency has been granted for the exercise of its other missions.
In terms of epidemiological observation, monitoring of the state of health of the
population and monitoring of health risks, the agency has placed its action in a context of
extension of sometimes obsolete monitoring and monitoring systems. It now seeks to identify
early and weak signals in order to consolidate this mission. In conjunction with the Directorate
General for Health (DGS), work should now be relaunched to analyse the relevance of these
systems and to quantify
SPF’s
future needs to trigger health alerts.
The mission of prevention and health promotion has benefited more than the others from
the
continuum
of missions, thanks to its connection with the monitoring of the state of health
of populations and remote health assistance. Progress has been made, also thanks to a
significant increase in the budgets allocated to this mission. Public health marketing actions
provide added value that SPF is committed to measuring and have been diversified and
improved since 2016. However, the process is not yet complete as it requires further
refinement of the available data on health determinants and an approach based more on the
study of disease lethality and severity.
The agency has also fallen behind in providing prevention and health promotion
stakeholders with a repository of promising actions
3
or evidence. This appears incomplete: as
it stands, these actions, which are still few in number, are insufficiently described, shared,
evaluated and analysed. The reference framework expected by the Ministry of Health and the
3
A promising action is one
“
whose effectiveness has not been evaluated by research but for which a solid normative
evaluation leads to a presumption of relevant results
”
; Lacouture, EHESP, 2016.
4
stakeholders must be enriched and updated regularly in order to inform the choices of public
funders, in particular regional health agencies.
Management to be consolidated
The structural lack of a strategic vision of public health priorities may have led to a feeling
within the agency that it was not adequately funded and staffed to carry out its missions. In
practice, however, the budget has been consolidated and, compared to developments in other
health agencies, the number of staff has been broadly maintained since 2016.
SPF’s
budgetary trajectory did not present any particular difficulties before 2020,
although in a context marked by underinvestment in the
State’s
strategic stocks. The
substitution of health insurance funding for the State budget from 2020 onwards has made it
possible to provide the additional funding needed during the year, without it being conditional
on the prior adoption of an amending finance act. However, part of the exceptional funds paid
to SPF were used to top up the State budget to finance purchases related to the health crisis.
The Court recalls that these funds should be phased out in favour of financing by budgetary
appropriations.
The allocation of the exceptional budgets linked to the implementation of Covid-19
management measures resulted at the time of the
Court’s
investigation in outstanding
payments close to €2.9bn in 2022
-2023.
In addition, to ensure that Parliament is properly informed, appendix 8 to the Social
Security Financing Bill should present the same financial information on SPF as was
mentioned until 2019 in the general appendix to the Finance Bill on State operators and include
information on staff numbers and the real estate situation.
The real estate strategy consisted in bringing together the staff of the former structures
to a single site. In addition to being essential for the success of the
continuum
of missions and
the emergence of a common identity, it is also cost-effective. However, the agency has not
gone all the way in streamlining its real estate locations.
The management of human resources shows a relative control of the wage bill, made
possible in particular by a significant rotation of the workforce. However, the future evolution
of expenditure in this area remains to be monitored: factors of increase in the wage bill have
indeed accumulated since 2020 and must be further controlled in the context of a request for
additional staff formulated by the agency in 2022. The DGS must move towards a budgetary
management based more on the wage bill, and SPF must strive to implement job and career
management.
Insufficient prioritisation of projects and structural underinvestment in information
systems, despite shortcomings identified even before the agency was created, have penalised
the implementation of all the missions. In a context of increasing outsourcing of IT services
and risks of unavailability of its information systems, SPF must adopt an information systems
master plan and ensure its operational implementation by finely prioritising the associated
projects, defining the targets to be reached and developing operational monitoring procedures.
More generally, the adoption of a multi-annual investment plan to be voted on by the board of
directors would increase awareness of the strategic nature of this issue in relation to the
agency's missions.
5
A strategy that needs to be clarified, linked to the scheduling of works
and prioritised more
The first objectives and performance contract covering the period 2018-2022 was signed
in February 2018 by the Minister of Solidarity and Health and the Director General of SPF,
more than a year and a half after the creation of the agency, despite the prefiguration period.
Its objectives were not articulated with those of the annual performance project of programme
204
–
Prevention, health security and health care supply
, which concerned SPF at the time,
and are not part of a performance approach, given the virtual absence of quantified indicators.
In particular, the expectations regarding management and steering efficiency were not
accompanied by any numerical targets, although this was one of the reasons for the creation
of SPF. The next objectives and performance contract, which should be adopted in the first
half of 2023, will have to remedy this shortcoming.
The occurrence of the Covid-19 pandemic has contributed to putting into perspective the
importance of this contract in the steering of the agency. This document was therefore not
followed up by the governance of SPF in 2020-2021.
In parallel to this contract, the agency has developed a multi-annual programme and
annual work programmes. Until 2020, these constituted an abundant framework, made up of
almost thirty programmes broken down into numerous projects, without management tools
(information systems) and formalised processes to ensure their proper implementation. These
documents also generally lacked quantitative indicators and did not specify the budgetary
resources and staff associated with the projects, despite requests to do so from the DGS and
the SPF scientific council. Furthermore, the guidelines adopted do not seem to be finely
supported with regard to the study of the lethality and severity of diseases, within the
framework of the so-called
“
global burden of disease
”
approach, which has only recently been
applied in France and remains to be refined at local level.
The vagueness of these documents did not facilitate the prioritisation of projects. For its
part, the DGS has formulated an increasing number of priorities each year, reaching almost
one hundred by 2022. In a context of decreasing employment authorisation ceilings, the lack
of real prioritisation of projects, for which responsibility thus appears to be shared, has not
made the task of an agency faced with the difficulties inherent in the merger of four
organisations any easier.
Since 2021, SPF has refocused its scheduling around six
“
issues
”
and started to clarify
its priorities for action. It must now accompany its projects with estimates of the resources
allocated to them and strengthen the link between the funding allocated and a detailed
consideration of the degree of severity and lethality of the diseases.
Expertise to be further mobilised
In addition to its scheduled activities, SPF receives numerous referrals, mainly from the
DGS and the regional health agencies (ARS), whose follow-up could be greatly improved. Prior
to these referrals, the consultation process with the DGS could be strengthened.
The dissemination of expertise in many organisations is the result of historical choices
and weakens SPF's own expertise which, unlike its foreign counterparts such as the
Centers
for Disease Control and Prevention
(CDC) in the United States, does not yet benefit from a
strong and cross-disciplinary legitimacy in the main fields of public health.
Since its creation, SPF's expertise has been underused by the Ministry of Health, which
often favours more collective bodies, in particular the High Council for Public Health.
Furthermore, the creation of several
ad hoc
structures during the Covid-19 pandemic
contributed to the agency's own expertise being overshadowed.
6
Although its constitutive texts in this field are less detailed than those of other health
agencies such as the Agence nationale de sécurité sanitaire de l'alimentation, de
l'environnement et du travail (National Agency for Food, Environmental and Occupational
Health Safety) or the Institut national du cancer (National Cancer Institute), SPF has
nonetheless been recognised as having an expertise that it can mobilise by taking up any issue
relating to most of its missions, a possibility it has made little use of.
The health crisis has allowed SPF to gain a higher profile through the production of
surveillance data and its participation in communication campaigns. As SPF does not have its
own legal competence in this field, it must consolidate its links with research stakeholders,
despite the structural weaknesses of public health research in France. In the latter respect, the
Covid-19 crisis has played a catalytic role that must be preserved, especially in the framework
of European projects in which SPF is now actively involved.
7
Recommendations
1.
Re-launch the analysis of the relevance of surveillance systems and quantify the future needs
of SPF to trigger health alerts and to produce the data necessary for the development and
conduct of health policy
(Ministry of Health and Prevention, SPF)
.
2.
Extend SPF's power of self-referral to issue recommendations to the management of strategic
stocks, as is provided for in the exercise of its other missions
(Ministry of Health and
Prevention)
.
3.
Regularly update the repository of promising and successful actions
(SPF
).
4.
Update the framework for the use of the health reserve with a more interministerial vision of
human reinforcements
(Ministry of Health and Prevention, SPF)
.
5.
Produce, in appendix 8 to the PLFSS, financial information on SPF identical to that which was
mentioned until 2019 in the general appendix to the PLF relating to State operators
(Ministry of
Health and Prevention)
.
6.
Terminate the assistance funds intended to finance purchases related to the health crisis and
finance these purchases through budgetary credits
(Ministry of Health and Prevention, Ministry
of the Economy, Finance and Industrial and Digital Sovereignty)
.
7.
Adopt an information systems master plan and ensure its operational implementation by
prioritising the associated projects in greater detail, defining the target to be achieved and
drawing up monitoring procedures
(SPF)
.
8.
Include quantified efficiency targets and indicators in the next objectives and performance
contract to be adopted in 2023
(Ministry of Health and Prevention, SPF)
.
9.
Provide annual work programmes with a costed estimate of human and budgetary resources
and proposals for prioritisation according to the degree of severity and lethality of the diseases
(SPF)
.