Part IV - The reform agenda for recovered sovereignty
5 - Health and sanitary sovereignty
Health is an essential lever of sovereignty. The health crisis of 2020 exposed three structural vulnerabilities that this project addresses simultaneously: dependence on foreign active ingredients and equipment, the disorganization of the decision-making chain, and insufficient hospital capacity in times of crisis.
Industrial sanitary sovereignty
France produces on its territory the equipment and molecules without which its health system is vulnerable to any international supply disruption. This is not optional: it is a condition of sovereignty in the same way as food or energy production.
Concerned are protective equipment - masks, gowns, gloves, coveralls - in sufficient quantities to cover a major crisis, essential molecules (aspirin, paracetamol, codeine, first-line antibiotics, anticoagulants, insulin, corticosteroids, active ingredients of strategic vaccines), and critical machines (ventilators, dialysis machines, basic imaging equipment) with sovereign maintenance that eliminates any foreign dependence for spare parts.
Strategic stocks are planned by the Planning Commission, regularly evaluated by the HCEP, with a rotation guaranteeing their freshness. The lesson of 2020 is simple: a sovereign state does not discover in the middle of a crisis that it depends on China for its masks.
Medication: national preference and sovereign negotiation
Medication policy rests on two distinct regimes according to the origin of production.
For medications produced in France - whether a brand-name drug or a national generic - the State exercises a direct presence in the capital of strategic laboratories via the CDC, with a golden share guaranteeing the maintenance of production on the territory. These companies are not negotiated downward: they are supported.
Pour les médicaments étrangers, la France applique le modèle néo-zélandais de négociation centralisée agressive : l'État achète en volume, impose ses prix, et conditionne l'accès au marché français. Le principe de préférence nationale s'impose à chaque maillon de la chaîne. Un pharmacien substitue systématiquement par un médicament français, qu'il soit princeps ou générique, lorsqu'une production nationale existe. En l'absence de production nationale, il substitue par le générique étranger le moins coûteux, sauf contre-indication médicale écrite et documentée. Le médecin ne peut pas écrire « non substituable » sans justification traçable. L'objectif est que chaque euro dépensé en médicament serve d'abord la filière pharmaceutique française.
Healthcare system: the 1946 mixed model preserved and reformed
Le système de santé mixte public-privé issu de 1946 a produit l’un des meilleurs systèmes de soins au monde. Il est conservé dans son principe et réformé sur quatre points structurants : la formation médicale, la répartition géographique, la gouvernance des hôpitaux et leur financement.
Social Security is backed by the sovereign Bank of France, without structurally imposed external debt.
Hospital governance
The public hospital is a sovereign service: it is not meant to be profitable, it is meant to heal. This obvious truth was lost through successive reforms that progressively entrusted the management of institutions to administrators whose priority was budgetary balance rather than quality of care.
Public hospitals are henceforth directed by physicians, and not by directors from administrative and financial sectors. Healthcare staff - doctors, nurses, nursing assistants, paramedical personnel - are the purpose of the hospital, not a budgetary adjustment variable. Healthcare staff are revalued at a floor of twice the SMIC: a nurse, a nursing assistant, an emergency physician cannot be paid less than what the nation owes those who heal. The cost of this revaluation is real - 1.5 to 1.8 billion euros annually - but its returns are equally so: reduction of hospital temping, filling of vacant posts, stabilization of teams, reduction of deficits in institutions that were recruiting contractors at a premium for lack of permanent staff. The net result is positive from the second year onward.
Administrative staff are reduced by 20% over five to seven years through non-replacement of departures. The savings thus generated do not leave the hospital: they are entirely redeployed toward the front line, in equipment and healthcare staff. This is not a budgetary saving, it is an internal reallocation in the service of care.
Hospital financing is revised in its principle: an institution receives the means corresponding to its real operating needs, evaluated by the Planning Commission in conjunction with local medical directorates, and not a constrained budget to which it must conform even at the cost of degrading the quality of care or patient reception. Activity-based pricing, which transformed medical acts into countable production units, is abolished. A hospital that heals well is not one that optimizes its profitability indicators: it is one whose patients leave cured.
Medical training and geographical distribution
The numerus clausus and its successor the numerus habitus are abolished for as long as medical deserts exist and waiting times for specialists are unacceptable. A six-month wait for an urgent specialist appointment is a national emergency: it requires additional staff, not a regulation of supply. Academic requirements are maintained in their entirety; the quantitative filter is abolished, not the qualitative filter. The objective is to train more equally good doctors, not to train less well-trained doctors.
The objective is the end of medical deserts within twenty years, monitored by the HCEP with precise indicators by territory and an annual public report. To achieve this, every newly qualified physician is subject to a service obligation of two to three years in an underserved area, with a preference for placement in the region of training to limit social uprooting, and a distance allowance for those who voluntarily accept a more distant area. If an overproduction of physicians were to be established in ten to fifteen years, a numerus adapted to the real situation could be reintroduced: a decision based on data, not on the corporatist pressure of the dissolved orders.
Abolition of Regional Health Agencies
The Regional Health Agencies are abolished. Created in 2010 to coordinate health policy at the regional level, they have produced exactly what any intermediate administrative layer produces: a costly bureaucracy, a dilution of responsibilities between the State and front-line institutions, and an additional management layer that consumes resources without treating a single patient.
Their legitimate missions are redistributed according to the territorial logic of the project. Coordination of health policy on the territory falls to the departmental prefect: a single, identified, responsible interlocutor. Monitoring of public health indicators and evaluation of the real needs of institutions fall to the Planning Commission in conjunction with local medical directorates. Oversight of quality of care and compliance with national standards falls to the HCEP.
What disappears with the ARS is their administrative mass, their regional directors, their steering committees, their calls for projects, their performance indicators disconnected from the front line, and their operating budgets. What remains is national health policy, applied by physicians in hospitals endowed with their real needs, under the supervision of a prefect who is directly responsible for it.
Work as a lever of health
A worker who damages their body every day in an arduous trade is not a social problem to be managed: it is a failure of work organization that the State has a duty to correct. Occupational medicine is massively strengthened: doubling of occupational physicians, systematic visits, arduousness statistics by trade produced and transmitted to the Planning Commission. This data directly feeds industrial policy: trades presenting the highest rates of musculoskeletal disorders and long-term sick leave are identified as automation priorities. Automation is financed by the CDC with stake-taking in beneficiary companies. Eliminated jobs are reoriented toward expanding sovereign industrial sectors. The sought result is not the elimination of jobs but their transformation: fewer damaged bodies, more value produced, an industry that moves upmarket.
Strengthened occupational medicine also ensures oversight of sick leave. An occupational physician who knows the real conditions of a post, the constraints of a sector, the reality of a company, is infinitely better placed than an external oversight body to evaluate the legitimacy of a sick leave. This is not a competing mission: it is the same logic applied at both ends of the chain: prevent what can be prevented, control what must be controlled. Savings on unjustified daily allowances partially finance the strengthening of the arrangement itself. Overseeing sick leave is not punishing the sick: it is guaranteeing that allowances serve those who genuinely need them.
Prevention as transversal coherence
Prevention is not an isolated budget line nor a separate chapter. It is the natural consequence of all the project's policies: from school canteens sourcing local products, occupational medicine that intervenes before illness, a national pharmaceutical industry that has an interest in producing effective medications, a tobacco policy that prohibits all industry lobbying and aims at the progressive eradication of commercial practices that sustain addiction, targeting the industry, not the consumers. A nation that heals well is first and foremost a nation that prevents.