🔍💡 Chronic diseases: how to shift from a hospital-centred system to local, preventive, and sustainable care, without spending more but doing it differently.🌍🩺 Health system and climate: 8% of greenhouse gas emissions, 59% of spending related to chronic diseases… this report outlines a roadmap for upstream action in local areas.
📌 This report provides a comprehensive framework to redirect healthcare organisations, ARS, local authorities, CPTS, and associations towards prevention and early detection of chronic diseases, with very concrete recommendations by area (population, governance, care, funding, HR, technologies, environment).
A health centre director, a CPTS coordinator, or a community prevention officer can find specific levers (local governance, indicators, funding, human resources, digital tools, environment) to adapt their action plans.
Voluntary association members find quantified arguments on social health inequalities, the role of patients, and environmental sustainability, useful for advocacy and co-construction of projects.
The key idea: prevention should no longer be a "side" programme, but a core function integrated into every contact, in every living space, and prioritised in the most vulnerable areas and populations.
In other words: for field actors, the issue is not to "do more prevention" but to transform the way care is provided, to organise services, and to make local decisions, systematically placing the reduction of inequalities and the prevention of chronic diseases at the centre of action, not on the periphery.
Source: 📒 Strategic roadmap for a sustainable and resilient health system: acting upstream against chronic diseases.
✍️ Zeynep Or and Alexander Parry, Institute for Research and Documentation in Health Economics (Irdes), collection "Irdes Reports", no. 603, April 2026.📜🔗LINK
Number of pages: 138
1. Analytical summary
Context and issues: a performing but not very preventive system.
France combines a high life expectancy with low avoidable mortality, while concentrating 59% of health insurance reimbursements on chronic diseases (cancers, cardiovascular, renal and metabolic diseases, respiratory diseases). The report shows that prevention spending accounts for only 2.3% of health expenditure, with screening rates lower than in Nordic countries or the Netherlands, and marked socio-economic and territorial inequalities: the poorest 10% are 1.4 times more likely to have a chronic disease and live up to 13 years less for certain groups. Determinants outside of healthcare (tobacco, alcohol, diet, sedentary lifestyle, pesticides, air pollution) are insufficiently integrated into public policies, despite a rich body of data (SNDS, surveys, partial registers). The system remains structured around hospitals, fee-for-service payment, and central governance, with prevention fragmented between the State, health insurance, and local authorities, and a professional culture still predominantly curative. Finally, the report situates these issues within the international PHSSR framework, emphasising financial and environmental sustainability, the need for data, local governance, and new care models.
Operational contributions: a roadmap in 7 areas
The document proposes a structured roadmap in seven areas: population health, governance, organisation of care, financing, human resources, medicines and technologies, environmental sustainability, each with a diagnosis, recommendations, and existing or new indicators. It puts forward concrete measures: strengthening targeted campaigns in disadvantaged areas, developing prevention integrated into primary care, SMART objectives for chronic diseases, data governance, reforming payment methods (bundles, value incentives), a national HR plan, and diversifying skills (paramedics, peer supporters, digital). The report emphasises controlled decentralisation (ARS, CPTS, local authorities) for prevention, transparency on diagnostic timelines and health outcomes, and the use of real-world data to evaluate innovations. On the environment, it explicitly links prevention, reduction of chronic morbidity, and carbon footprint, and proposes to integrate sustainability into training, pricing, and planning. The whole constitutes a strategic and methodological foundation that can be directly mobilised for local plans, CPTS projects, or contractual approaches with Health Insurance.
2. Key points of the document
Impact of chronic diseases and social inequalities (pp. 15-41, 29-38)
The report reminds us that chronic diseases account for 59% of reimbursed expenses and more than 80% of premature deaths, with a very marked socio-economic gradient on prevalence, life expectancy, and avoidable hospitalisations. It precisely documents the disparities between income quintiles, metropolitan and overseas departments, and highlights the role of behavioural and environmental risk factors.
Centralised governance, fragmented implementation, poorly defined SMART objectives (pp. 45-52, 49-53)
The national health strategy and thematic plans remain largely non-operational, with objectives rarely defined according to SMART criteria, a clear separation between expenditure management (Ondam) and public health, and weak coordination between the State, ARS, and departments. The report highlights the insufficient use of data (SNDS, registers) to monitor the quality, efficiency, and equity of care, and the absence of an integrated strategy for cardiovascular, renal, and respiratory diseases.
Care organisation focused on curative treatment and underutilisation of primary care (pp. 57-66, 18-22)
Primary care is poorly equipped and incentivised for prevention and early detection, with clinical recommendations focused on treatment, a predominant fee-for-service payment model, and institutional prevention organised outside of primary care. Cancer screening programmes suffer from low and highly unequal participation rates between departments, in the absence of systematic monitoring of diagnostic timelines or national thresholds.
Funding without explicit priority for prevention, volume-oriented incentives (pp. 71-78, 20-23)
With 11.5% of GDP dedicated to health, France has high funding and good financial protection but allocates only 2.3% to prevention spending, which is fragmented among funders. The Ondam remains annual and downward, without consideration of needs or prevention, while the fee-for-service payment and the end of the Rosp have not yet been replaced by a robust quality and prevention remuneration system.
Environmental sustainability and chronic diseases: a still underexplored angle (pp. 103-107, 24-28)
The report reminds us that the healthcare system accounts for approximately 8% of national greenhouse gas emissions and that chronic diseases, through intensive care (dialysis, chemotherapy, repeated hospitalisations), contribute significantly to this. It highlights the first national environmental roadmap (2023) and the work of Cnam and the Shift Project, but notes the absence of a specific strategy to link prevention, low-carbon pathways, and the organisation of local care.
3. Action points for local stakeholders
Structuring targeted prevention in disadvantaged areas (pp. 17-19, 30-41)
Local authorities, CPTS, and associations can use available data (Insee, ARS, SNDS via regional observatories) to identify municipalities/areas with a high prevalence of risk factors (tobacco, obesity, inactivity) and deploy targeted actions there: health promotion workshops, interventions in schools, mobile screening campaigns, health mediation. The report emphasises the use of innovative communication channels and outreach, particularly for low-income households, young people, and overseas territories (options A-C of domain 1).
Anchoring prevention in primary care and CPTS (pp. 57-66, 83-88)
City professionals and CPTS can organise pathways that systematically integrate identification, risk assessment, and referral to "My Prevention Assessment", relying on advanced practice nurses, pharmacists, medical assistants, and social health actors. The report recommends developing multiprofessional prevention protocols, using delay and patient experience indicators to guide pathways, and promoting continuous training focused on prevention (domains 3 and 5).
Build a shared territorial governance ARS–local authorities–CPTS–associations (p. 45‑52, 52‑53)
The ARS, departmental councils, cities, and intercommunalities can formalise joint steering bodies for the prevention of chronic diseases, incorporating the participation of patient associations. The report suggests strengthening the role of CPTS in the design and implementation of actions tailored to the territory, disseminating best practices between regions, and moving away from a control-sanction logic in favour of learning and benchmarking.
Reorient local funding towards prevention and community care (p. 71‑78, 20‑23)
The ARS and local authorities can experiment with multi-year envelopes dedicated to prevention, directed towards local actors (CPTS, health centres, associations, schools, PMI), conditioning part of the funding on quality objectives (screening rates, timelines, reduction of avoidable hospitalisations). The report recommends creating a protected budget for health promotion and prevention, co-financed by the State–Health Insurance–local authorities, and transferring responsibilities and budgets to local actors for community health programmes.
Integrate environmental sustainability into territorial projects (p. 103‑107)
Establishments, CPTS and communities can include environmental objectives in their projects: reducing patient travel through telemedicine, developing outpatient care, therapeutic de-escalation programmes, streamlining low-value medications. The report recommends that care providers measure their carbon footprint, set reduction targets for the most emitting treatments, and develop training and educational materials on eco-responsible health behaviours.
4. Additional References
🔍➕ For more information, see the articles referenced by "Pratiques en Santé" on the theme of public policies ➡️🔗https://pratiquesensante.odoo.com/politiques-publiques
National Health Strategy – Priority for Prevention
The SNS sets a national direction by making prevention and the reduction of inequalities a cross-cutting priority, to be implemented in all plans and in regional health projects, which aligns with a structural rather than an additional approach to prevention.
URL :https://sante.gouv.fr/systeme-de-sante/strategie-nationale-de-sante/
Institut Montaigne – "Health Prevention, the New Imperatives" (2022)
This note advocates for a systematically structured prevention policy, through a multi-year programming law and clear governance, emphasising that prevention must be integrated at the heart of the health system (funding, organisation of care, management) and not treated separately from curative care.
URL (PDF) : https://www.institutmontaigne.org/ressources/pdfs/publications/note-enjeux-la-prevention-en-sante-les-nouveaux-imperatifs.pdf
5. Cross-Analysis – Values of Pratiques en Santé
Literacy: The report is not designed as a tool for public literacy, but offers recommendations on the use of digital educational resources and the adaptation of clinical guidelines to primary care, which opens up opportunities to produce tools suited to different levels of understanding.
Empowerment: Patient associations have been involved in the workshops and interviews, and the report recommends their co-involvement in the co-construction of clinical recommendations and pathways, but it does not describe concrete self-management tools for patients.
Participation: The document details the consultation mechanisms (association workshops, institutional interviews) and advocates for co-construction approaches at the local level (CPTS, ARS), but without a detailed methodological framework for citizen participation.
Community health: The community dimension is present through school programmes, PMI centres, outreach actions, and local care, but these systems are still described as under-resourced and insufficiently integrated into primary care.
Ethics: The report explicitly points out social, territorial, and access inequalities regarding innovations, but does not develop a thorough ethical analysis; it rather refers to the need for data, transparency, and SMART objectives to limit biases.
Human rights: The universality of the system and the reduction of inequalities are presented as goals, with particular attention to vulnerable populations (the poor, overseas), but without explicit mobilization of 'human rights' or anti-discrimination frameworks.
Intersectorality: The approach of 'Health in all policies' is strongly emphasised (education, employment, environment, urban planning), highlighting the need for intersectoral coordination supported by the national health strategy.
Partnership: Partnership models are described between the State, ARS, Health Insurance, local authorities, CPTS, and patient associations, notably through the PHSSR and national workshops, but without a standardised operational protocol.
Combating discrimination: The report documents de facto discrimination (social gradient, differentiated access to innovations, excess cancer mortality in disadvantaged areas), emphasises non-judgement and reducing disparities, but does not explicitly address discrimination related to gender, origin, or sexual orientation.
6. Assessment of the reliability of the resource
Scientific relevance
Methodology described and dated: review of grey and scientific literature (October 2024 – June 2025), interviews with patient associations and institutional experts, multi-pathology workshop (May 2025), followed by successive revisions based on feedback.
Numerous, recent, international sources (OECD, Eurostat, Global Burden of Disease, Insee, Drees, HAS, Cnam, etc.), with comparative tables and figures for France / neighbouring countries.
Anchoring in the PHSSR programme and consistency with other analyses on sustainability (Cnam, Shift Project, HCAAM), which strengthens the robustness of the diagnostics.
Operational relevance
Structured recommendations by area, with specific actions (governance, funding, organisation, data, HR, digital tools, environment) and existing and proposed indicators for monitoring.
Direct adaptability at national, regional, and local levels (ARS, CPTS, local authorities, establishments, associations), particularly for prevention, early detection, and reducing inequalities.
Limit: the report remains a macro strategic document; for local operationalisation, it requires complementary translations into guides or practical tools (checklists, territorial diagnostic grids, contract templates).
7. MCQ – 5 questions
Part 1 — Statements (without answers)
Question 1 (pp. 17-19, 29-31)
What proportion of health insurance reimbursements in 2022 is attributable to chronic diseases?
a) 29% b) 42% c) 59% d) 75%
Question 2 (pp. 20-23, 71-73)
What is the approximate share of total health expenditure dedicated to institutional prevention in France?
a) 0.8% b) 2.3% c) 5.0% d) 10.5%
Question 3 (pp. 45-52, 49-53)
What major structural barrier to prevention is highlighted regarding governance?
a) The abolition of ARS
b) The compartmentalisation between public health governance and expenditure management (Ondam)
c) The absence of patient associations at the national level
d) The complete regionalisation of health insurance
Question 4 (pp. 57-66, 83-88)
Among the following elements, which is presented as a positive development in the organisation of care?
a) The reduction of the role of pharmacists in prevention
b) The disappearance of nurses in advanced practice
c) The development of the "My Prevention Assessment" scheme
d) The decrease in outreach actions
Question 5 (p. 103‑107)
What proportion of national greenhouse gas emissions is attributed to the French healthcare system?
a) Approximately 2% b) Approximately 5% c) Approximately 8% d) Approximately 15%
Order of the chosen correct answers: c / b / b / c / c.
Part 2 — Commented correction
Question 1: share of reimbursements related to chronic diseases (p. 17‑19)
✅ Correct answer: c) 59%
📝 Explanation: The report indicates that chronic diseases account for 59% of the 190 billion euros reimbursed by Health Insurance in 2022, illustrating their financial weight and the importance of early intervention. Source: p. 17.
Question 2: share of prevention expenditures (p. 17‑18, 71‑73)
✅ Correct answer: b) 2.3%
📝 Explanation: Institutional prevention expenditures represent approximately 2.3% of health spending, a level lower than several neighbouring countries and deemed insufficient to support an ambitious prevention policy. Source: p. 17, 71‑73.
Question 3: governance barrier (p. 45‑52)
✅ Correct answer: b) The compartmentalisation between public health governance and expenditure management (Ondam)
📝 Explanation: The report highlights that the separation between the governance of public health policies (ministry, local authorities) and the management of spending via the Ondam hinders investments in prevention and the integration of policies. Source: p. 45‑47.
Question 4: positive evolution in the organisation of care (p. 57‑66)
✅ Correct answer: c) The development of the "My Prevention Assessment" scheme
📝 Explanation: The text mentions "My Prevention Assessment", launched in January 2024, as an important advancement that strengthens the population-based approach and risk assessment in primary care. Source: p. 21.
Question 5: share of GHG emissions from the health system (p. 103‑107)
✅ Correct answer: c) Approximately 8%
📝 Explanation: Domain 7 specifies that the health system is responsible for approximately 8% of national greenhouse gas emissions, which justifies the link between chronic disease prevention and environmental sustainability. Source: p. 103‑104.
8. Frequently Asked Questions (FAQ) – 7 Q/A
Why does this report focus on certain chronic diseases and not all? (p. 9‑11, 30‑37)
The report targets cardiovascular, renal and metabolic diseases, cancers, and chronic respiratory diseases as they account for over 80% of premature deaths related to non-communicable diseases and a significant financial burden. The proposed principles (prevention, early detection, integrated care) are, however, applicable to other chronic conditions, such as mental health or musculoskeletal disorders. Pages: 9‑11, 30‑37.
What is the main weakness of the French system in terms of prevention? (p. 17‑19, 37‑41)
The main weakness is the low structural investment in prevention (2.3% of health expenditure) and the lack of systematic integration of prevention into primary care, combined with strategies that are still largely generalist and poorly targeted at the most exposed populations. Pages: 17-19, 37-41.
How can primary care professionals concretely use this roadmap? (p. 57-66, 83-88)
They can rely on the recommendations to systematically integrate the identification of risk factors, referral for screening and monitoring of diagnostic timelines, develop multi-professional collaborations (IPA, pharmacists, medical assistants) and use the proposed indicators to guide their pathways. Pages: 57-66, 83-88.
What role is expected of the ARS and CPTS in the reorientation towards prevention? (p. 45-52, 71-78)
The ARS are expected to have more budgetary leeway and responsibility to direct resources towards prevention, while the CPTS must become central actors in the design and implementation of actions tailored to the territory, in connection with local authorities and associations. Pages: 45-52, 71-78.
Does the report propose concrete indicators that field actors can follow? (p. 41, 52, 66, 78, 87, 98, 106-107)
Yes, each area concludes with a list of existing indicators and new proposed indicators, for example, variations in accessibility to professionals, diagnostic timelines, screening rates, staff rotations, volumes of hospital waste, or the integration of environmental criteria in procurement. Pages: 41, 52, 66, 78, 87, 98, 106-107.
How does the document take into account social and territorial health inequalities? (pp. 17-19, 29-31, 34-38)
The report details the disparities in life expectancy between territories and income deciles, analyses the differences in participation in screening, and explicitly recommends targeting the poorest 10%, overseas territories, and disadvantaged areas by prioritising prevention investments. Pages: 17-19, 29-31, 34-38.
What framework is proposed between prevention, financial sustainability, and environmental sustainability? (pp. 20-23, 71-78, 103-107)
The roadmap shows that prevention and early intervention can reduce both morbidity, long-term costs, and the carbon footprint of care, particularly by decreasing reliance on intensive and hospital treatments. It calls for integrating these dimensions into budgets, remuneration models, and service planning. Pages: 20-23, 71-78, 103-107.
9. Rewriting in Easy-to-Read Language
Title
Roadmap for a more sustainable and resilient health system.
Summary in Easy-to-Read Language
1. Context and issues
In France, many people live long lives.
But many people have long-lasting illnesses.
These illnesses are very costly to the health system.
Poor people are more often ill.
They die earlier than rich people.
Polluted air, tobacco, alcohol, and poor diet increase the risk of illness.
2. What the document proposes
The document explains how to act earlier on illnesses.
He calls for more prevention in medical practices and health centres.
He suggests better use of data and figures for decision-making.
He wants hospitals, doctors, and communities to work together.
He proposes changing the way care is paid for to value prevention.
He also calls for consideration of the environment and climate in the organisation of care.
Key points FALC
Point 1 – Chronic diseases and inequalities
Chronic diseases account for more than half of health spending.
The poorest people have more illnesses and die younger.
Certain areas, especially overseas territories, are more affected.
Point 2 – Governance and objectives
The state decides a lot, but local actors have little leeway.
The objectives are not always clear or measurable.
There is a lot of data, but it is rarely used to improve prevention.
Point 3 – Organisation of care
Care is mainly focused on hospitals and curative treatment.
Prevention is often separated from community care.
Recent initiatives like 'My Prevention Assessment' are progress.
Point 4 – Funding
The health system is well funded, but prevention receives little money.
Fee-for-service payment encourages more procedures instead of more prevention.
The document proposes dedicated and more stable prevention budgets.
Point 5 – Environment
The healthcare system also pollutes, especially due to heavy treatments.
Acting earlier on diseases can reduce this pollution.
Healthcare providers must be trained to take the environment into account.