During the unprecedented health crisis caused by the coronavirus epidemic, France's health care system coped. Just.

With the help of a military hospital and a massive transfer of patients away from hot-spots the structure held, but it's what comes next that has those working on the inside of the system worried.

“There is a lethal risk to our health care system even before the pandemic is over,” said Daniel Camus, a professor at the Pasteur Institute in Lille, one of the France's top institutes researching the coronavirus and its impact.

France spends more than most countries on health, and its national health care service is vaunted as one of the most generous and best in the world, but the coronavirus has shed light on cracks that have been growing bigger over the years.

And with a major recession on the horizon, public spending is likely to be squeezed further.

“The coronavirus epidemic is revealing all the problems that we’ve tried to talk about for over a year,” said Hugo Huon, a nurse and representative of the social protest collective Inter Urgences, which had half of France's public hospital services on strike in the winter of 2019 and are mobilising again now.

READ ALSO How do nurses' salaries in France compare to Europe?

French President Emmanuel Macron has been criticised for ridding the country of over 4,100 hospital beds over the course of 2018 – reducing the total capacity by one percent – a little more than a year before the coronavirus would hit.

But decreasing France's long-term hospital care capacity was a project started long before Macron entered the Elysée Palace, and his socialist predecessor François Hollande saw more than 15,000 beds disappear during his mandate (2012-2017), according to numbers from the OECD.

Over the past two decades, 90,000 hospital beds have disappeared. 

The numbers reflect a longstanding international trend where France, along with other developed countries, has spent decades trying to optimise its healthcare system by rendering hospitals more dynamic and profitable.

Part of this strategy has involved reducing the number of hospital beds and replacing them with short-term care places, to incentivise hospitals to get patients in and out as quickly as they can. Surgical development such as key-hold surgery and laser surgery have also reduced the need for long-stay beds.

The graphic below, taken from a health ministry report, shows that while the numbers of hospital beds steadily decreases, the number of “places” (short-term beds) increases.

In total, France today has 395,693 hospital beds, 243,326 of which are in the public sector, according to the health ministry.

As showed in the graph below, this represents about 6 beds per 1,000 inhabitants, according to the OCDE. In 2000, the number was eight (which is the current level of Germany).

Despite this steady and gradual reduction of long-term care capacity, France finds itself among both the top spenders in Europe on health care – equal to Germany and only beaten by Switzerland when it comes to spending relative to GDP – and has more hospital beds per person than most European countries.

The reason is that the trend of rendering hospitals more efficient has been international, with most countries taking the same steps.

Looking at the relative number of intensive care beds illustrated in the graphic below, a heated issue during the coronavirus crisis because the virus had ICUs in hard-hit areas in France explode their capacities, the number has steadily decreased too over the years.

Photo: WHO

'The health sector is not an army'

After eight weeks of strict, nationwide lockdown, French hospitals are now bracing for a resurge in the number of coronavirus cases in the weeks to come as the country is taking its first small steps back to normality.

President Emmanuel Macron declared France “at war” with the virus, turning “health workers” into “frontline fighters” on a mission to save the nation.

But virologist Camus said France would not be able to maintain the teams indefinitely.

“The health sector is not an army. Eventually people will fall apart,” he said.

The French government has been subject to harsh criticism from hospital staff for having failed to ensure enough masks and other protective equipment during the first weeks of the coronavirus epidemic. Photo: AFP

'It’s not a war, it’s a virus’

“This is not a war, it’s a virus,” a 25-year-old nurse currently working in a private hospital in Pays de la Loire, west in France told The Local. 

“It’s exhausting. You want to care for people, but you can’t.”

“Saying 'war', 'warrior', 'soldier' is a way of justifying things that aren’t justifiable “

By “unjustifiable things” he meant not having enough masks, gloves and other protective equipment ready for the country's health personnel when the epidemic began.

Hugo Huon has been fighting for better work conditions for nurses since a woman was found dead in the waiting room at Labriboisière hospital in Paris, after queuing for 12 hours on a stretcher in December 2018. 

He was not himself working that night but he remembers the incident as a turning point that would eventually become the catalyst for the enduring social movement that had nearly half of France’s public hospital services taking industrial action in the winter of 2019.

“Talking to staff at other hospitals, we realised that in Paris, just during the month of March, there had been five similar incidents to that of the woman at Labriboisière,” he said.

Protesters are demanding more money to public hospitals and a salary raise for staff. Photo: AFP

The number of nurses in French hospitals has not decreased over the past years. In fact, the number increased by 2 percent between 2010 and 2017.

But this increase did not reflect the surge in demand, which jumped by over 14 percent over the course of the same period, sociologist and health politics specialist Frédéric Pierru told Le Monde in a video interview.

In the five years that follow graduating, one third of France’s nurses quit, according to the national union representing nurses.

A male protester is holding a sign saying “LBD rubber bullets and teargas straight in the face, but zero masks. Macron (and Interior Minister Christophe) Castaner, we won't forgive.”

'When a crisis is over, all good intentions disappear'

President Macron has promised a “massive” investment plan in the country’s hospitals and said hospital staff working during the pandemic will get a bonus between €500 to €1,500.

“We don’t want a bonus, we want a salary increase,” said Olivier Milleron, a doctor representative from the collective Inter-Urgences, which quickly re-mobilised after the worst peak of the coronavirus crisis had passed.

“We don’t want a medal. We did our job,” the doctor told France Info, referring to the honouring of the country’s nurses planned by the government on July 14th, France's national day, as a “provocation.”

The government has promised to enter talks with representatives from the sector this summer to discuss a revaluation of nurses' salaries, which is currently at one of the lowest levels in Europe.

“What the pandemic shows is that there are goods and services which must be protected from the laws of the market,” Macron said in one of his televised speeches to the nation.

But the big question is whether it will be feasible for the government to keep its promises in the long term, once the recession – predicted to be the worst since 1945 – starts to show its impact. 

“We have seen it before, when a crisis is over all good intentions disappear,” said Camus. 

The professor worried not about the government’s willingness, but the pressure from lenders to cut in public spending once the health crisis was at bay.

“I fear that financiers will say ‘wait a minute, that’s very expensive, we’re not going to dedicate enormous budgets to hypothetical scenarios’,” he said.