The French healthcare system can be characterized as a centralized health insurance system with a strong position of doctors, especially in ambulatory care where the principles of “la médecine libérale”, defined by the medical profession in 1927 during the parliamentary debate on the introduction of a health insurance system in France still prevail. The ambulatory sector is regulated by national negotiations between the sickness funds and the medical profession (represented by several competing organizations) focused on the payment mechanisms and not on the medical provision organisation, which is less regulated by the State than the hospital sector.

Since the creation of the health insurance system in 1928 (and even before) the public discourse in France on medical demography was dominated by the fear of a “medical plethora” put forward by physician’s representatives. With the establishing of a national Social security system in 1945 the number of doctors grew steadily, especially during the 1960’s. Claimed by doctor’s organization a limitation of the number of medical students (“numerus clausus”) was implemented in 1971 in order to regulate medical supply. This dominant discourse shifted in the early 2000’s with the pinpointing of two new trends by official reports: the beginning of the forecast of the decline of the number of doctors and the worsening of territorial disparities. A new expression was used to coin the latter evolution: the existence of “medical deserts” (déserts médicaux). At first used to point out the lack of doctors in some rural areas it was afterwards also used for disadvantaged suburbs of big cities (“banlieues”), especially in the Paris area.

A 6.5% decrease of the number of general practitioners between 2007 and 2014 has been observed (Atlas de la démographie médicale, 2014). Territorial differences are high between the South of France and the Paris region (having around 400 doctors for 100.000 inhabitants) and the North or the Center of France (having around 250 doctors for 100.000 inhabitants). According to the Health Ministry, around 2.5 million persons live in “medical deserts” and 20% of the French population lives in under-served territories. In his last regional reports (Atlas de la démographie médicale 2015) the medical Order identified 192 “medical deserts”, mainly in the Centre and the West of France.

The first measures aiming to tackle the issue of declining health demography and territorial inequalities were taken in 2004 by the sickness funds (CNAM). They created financial incentives (bonus, higher fees) for doctors settling down in underserved areas. Since 2004 the number of medical students is increased by improving the numerus clausus (from 5600 student places in 2005 to 7400 in 2009), and since 2012 the priority is given to the training of doctors in under-served territories.

In 2005 elected local authorities were allowed to give financial and material assistance to doctors in order to attract them.

In 2009 the Health, Patient and Territory Act gave an impulsion to the creation of new pluridisciplinary and collective healthcare structures (“maisons de santé pluridisciplinaires”-MSP). Their number grew from 174 in 2012 to around 800 at the end of 2015. The HPST law also obliged doctors in over-served territories to carry out a part of their activity in under-served territories (and to pay a penalty if they do not). This measure was strongly contested by the main physicians’ trade union and finally withdrawn by a new law in 2011.

At the end of 2012 a “Territory Health Pact” (Pacte santé territoire) was proposed to doctors by the new Health Minister (Marisol Touraine) to attract them in under-served areas. It is based on incentives: bonuses, higher fees, specific payments, financial engagement contracts for doctors in training (1200 € monthly if they settle down in underserved areas afterwards), guaranteed minimum income (3 640€ monthly during two years) for doctors adopting the status of territorial practitioner (“praticiens territoriaux de médecine générale) in underserved areas… At the end of 2015 1325 “public service engagement contracts” had been signed by doctors in-training (the Minister expects 1700 for 2017) and 480 young doctors had adopted the status of territorial practitioner (the Minister’s objective is 1000 for 2017). This Pact, reinforced in 2015 with the Health Modernisation Act, also promotes the development of distant treatment (“telemedicine”), better coordination between hospitals and ambulatory care, and changes in medical training (with the objective that all medical students make an internship in a generalist’s office in order to make young doctors more aware of working in rural areas) and the definition of new competencies for nurses and other health professionals.

DFG-ANR Project RegMedProv