The paradox of the Ile-de-France (IDF) region: a concerning medical desert in the most populated urban area of Europe

By Thibaut Mbangwe Biaya, LLM student International Human Rights law, thibautmb gmail.com

In the region surrounding Paris, France, the geographical distribution of medical practitioners is well below national and European averages. Yet, it is the largest urban area in Europe and the richest economy in France. How can health policies ensure the availability and accessibility of health professionals for 12 million people? In the present context, there is surprisingly no contradiction between urbanisation and deserts. Emmanuel Macron, the French president, acknowledged that medical deserts are not only found in rural areas, but very often in the outskirts of big cities and in the most disadvantaged areas.[1]

Yet, France has the second highest healthcare expenditure relative to GDP (11.9%) amongst EU countries.[2] Funding the health system alone is not sufficient. Financial and human resources have to be well distributed to secure healthcare for all. The World Health Organization (WHO) recently confirmed that health workers are “the cornerstone” of health systems, and that they must therefore be “available in the right quantity in the right places”.[3]

Ile-de-France: a medical desert

There is no consensual definition of medical deserts, although academics have tried to provide one. A group of six scholars suggested that a medical desert exists when there is improper access or quality of healthcare services in a particular area, including insufficient human resources.[4] In France, researchers in health economics also noted this spatial factor and found other factors such as waiting times, socio-cultural barriers and local medical needs to be of importance as well.[5]

The national policy of numerus clausus was repealed in 2020 after having severely limited the number of applications in medical studies for almost 50 years.[6] As a consequence, the present generation of doctors is substantially aging while there are not enough young practitioners to replace them.[7] The 2024 report on medical demographics from the French Medical Association revealed that in the IDF region, 36.2% of the generalist and specialist practitioners were above 60 years old while only 22.7% were below 40.[8] Therefore, more than one third of the current practitioners will retire in the next years in a context of low generational renewal. Additionally, medical doctors have the freedom to choose where they want to establish their office, thus often favouring nice and wealthy areas over disadvantaged suburbs.[9]

How alarming is the situation in the Ile-de-France region?

The density of doctors per 10,000 inhabitants is the indicator used by the WHO to compare the geographical distribution of generalist and specialist practitioners altogether.[10] According to the latest statistics, the European average is 37.6 doctors per 10,000 inhabitants.[11] It is relatively lower in France (33.4), and even more in the IDF region (27.5, excluding the city of Paris).[12] Neighbouring countries are doing much better, especially Belgium (63.9), Germany (45.2) and Spain (44.8).[13]

In my hometown of Conflans-Sainte-Honorine, located 20km from Paris, there are currently 33 practitioners for about 35,000 inhabitants, including 17 generalists, 2 gynaecologists, 1 paediatrician and a few other specialists.[14] Despite being part of the largest urban area in Europe, this average of 9.4 practitioners per 10,000 inhabitants is worryingly low. Moreover, a significant part of the local population is above 60 years old (21.4%), thus expected to be in need of increased medical care.[15] Therefore, the IDF region and my hometown in particular are true medical deserts where the availability of health workers is well below national and European averages.

How do human rights address French medical deserts?

Under international law, States have the obligation to guarantee the right to health, that is to say to ensure that healthcare is available, accessible, acceptable and of adequate quality (AAAQ).[16] More specifically, the UN Committee on Economic, Social and Cultural Rights (CESCR) asserted that health facilities, goods and services must be “available in sufficient quantity” and “accessible to everyone”, pointing out the importance of health professionals.[17]

In recent concluding observations on France’s 4^th and 5^th periodic reports, the CESCR expressed its concerns about the “limited nature of access to health services in priority urban zones (…) where medical personnel are in short supply” and deplored the “uneven distribution of health professionals”.[18] The CESCR eventually recommended that France allocate more resources – both human and financial – in the said areas. Medical deserts are indeed a human rights priority as they adversely affect the availability and accessibility of healthcare for millions of people. The observations made by the CESCR acknowledged that France is not complying with its obligations under international human rights law, meaning that it must adopt measures to address the issue of medical deserts.

Concluding remarks: national policies

A number of measures have already been adopted since the 2000s by the State and the local authorities. They primarily consist of financial incentives for future practitioners, such as scholarships and tax exemptions.[19] Some experts have considered these to be irrelevant and rather recommended targeting the main underlying factor of medical deserts, namely the overall working environment.[20]

Others argued that increasing reliance on nurses, pharmacists and other health workers may rapidly improve access to healthcare, especially for frequent medical treatments.[21] Since 2023, a number of health professionals have been granted extensive competence. For instance, pharmacists are now authorised to administer vaccines and renew expired prescriptions.[22]

Finally, telemedicine has become an emerging alternative since the COVID-19 pandemic. Between 2021 and 2022, 7.8% of the medical consultations in the IDF region were conducted online.[23]  However, this solution may not be suitable for all as some may be unfamiliar with digital devices and others may require physical examinations.

Despite the actions adopted, the IDF region remains a medical desert. As the availability and accessibility of health workers are essential to secure the right to health of 12 million people living in the IDF region, the authorities are urged to adopt further effective measures to this effect.

[1] Déclaration de M. Emmanuel Macron, Président de la République, sur la transformation du système de santé, à Paris le 18 septembre 2018 (Vie publique, 18 September 2018) <https://www.vie-publique.fr/discours/206738-declaration-de-m-emmanuel-macron-president-de-la-republique-sur-la-tr> accessed 6 December 2024.

[2]‘Healthcare expenditure statistics’ (Eurostat, November 2024) <https://ec.europa.eu/eurostat/statistics-explained/index.php?title=Healthcare_expenditure_statistics_-_overview&oldid=625409> accessed 29 November 2024.

[3] WHO, World health statistics 2024: Monitoring health for the Sustainable Development Goals (Geneva WHO 2024), p 45.

[4] Brînzac MG and others, ‘Defining medical deserts – an international consensus-building exercise’ (2023) 33(5) European Journal of Public Health 785, 785-88 <https://academic.oup.com/eurpub/article/33/5/785/7221624> accessed 7 February 2025.

[5] Chevillard G and others, ‘‘Medical deserts’ in France: Current state of research and future trends’ (2018) 47(4) L’espace géographique 362, 363-64 <https://shs.cairn.info/journal-espace-geographique-2018-4-page-362?lang=en&tab=texte-integral> accessed 7 February 2025.

[6] Loi n°2019-774 du 24 juillet 2019 relative à l’organisation et à la transformation du système de santé (1), art 1.

[7] Roberto A, ‘La fin du numerus clausus n’aura pas d’effets avant 2035’ (Fondation IFRAP, 19 July 2022) <https://www.ifrap.org/emploi-et-politiques-sociales/la-fin-du-numerus-clausus-naura-pas-deffets-avant-2035> accessed 6 February 2025.

[8] ‘Atlas de la démographie médicale en France : Situation au 1er Janvier 2024’ (Conseil national de l’Ordre des médecins 2024), 34-36.

[9] ibid, 54-55: Among the 101 French départements, the ones with the highest density of generalist practitioners per 10,000 inhabitants are located on the coastline (Atlantic and Mediterranean) and on the borders with Spain and Italy. On the contrary, the départements with the lowest density are located in the centre of France, including the IDF region and its large suburbs.

[10] ‘Density of physicians (per 10 000 population)’ (WHO, May 2024) <https://data.who.int/indicators/i/CCCEBB2/217795A> accessed 6 February 2025.

[11] ibid.

[12] ibid.

[13] ibid.

[14] ‘Annuaire santé’ (Assurance maladie) <https://annuairesante.ameli.fr/> accessed 13 December 2024; ‘Populations légales 2021: Commune de Conflans-Sainte-Honorine’ (INSEE 2023) <https://www.insee.fr/fr/statistiques/7725600?geo=COM-78172> accessed 13 December 2024.

[15] ‘Dossier complet: Commune de Conflans-Sainte-Honorine’ (INSEE 2024) <https://www.insee.fr/fr/statistiques/2011101?geo=COM-78172> accessed 13 December 2024.

[16] International Covenant on Economic, Social and Cultural Rights (adopted 16 December 1966, entered into force 3 January 1976) 993 UNTS 3, art 12: “(…) the right of everyone to the enjoyment of the highest attainable standard of physical and mental health”.

[17] UN Committee on Economic, Social and Cultural Rights, General Comment No. 14: The Right to the Highest Attainable Standard of Health (Article 12) (11 August 2000) UN Doc E/C.12/2000/4, para 12.

[18] Committee on Economic, Social and Cultural Rights, Concluding observations on the fourth periodic report of France (13 July 2016) E/C.12/FRA/CO/4, paras 44-47; Committee on Economic, Social and Cultural Rights, Concluding observations on the fifth periodic report of France (30 October 2023) UN Doc E/C.12/FRA/CO/5, paras 48-49.

[19] ‘Zonage médecins 2022 : carte des zones concernées par les aides à l’installation et au maintien des médecins généralistes pour l’Ile-de-France’ (Agence Régionale de Santé – Ile-de-France, 21 August 2024) <https://www.iledefrance.ars.sante.fr/zonage-medecins-2022-carte-des-zones-concernees-par-les-aides-linstallation-et-au-maintien-des> accessed 14 December 2024.

[20] Chevillard and others (n 5), 364: “When choosing where to set up practice, doctors are currently more concerned with criteria linked to family life and to work conditions than with their revenue. This calls into question measures based on financial incentives.”

[21] Dumontet M and Grimaldi A, ‘Que faire contre les déserts médicaux ?’ (2024) 439(3) Cahiers français 87, 94-95 <https://shs.cairn.info/magazine-cahiers-francais-2024-3-page-87?lang=fr> accessed 7 February 2025.

[22] Loi n°2023-379 du 19 mai 2023 portant amélioration de l’accès aux soins par la confiance aux professionnels de santé, art 9.

[23] ‘Sept téléconsultations de médecine générale sur dix concernent en 2021 des patients des grands pôles urbains’ (DREES, 8 December 2022) <https://drees.solidarites-sante.gouv.fr/publications-communique-de-presse/etudes-et-resultats/sept-teleconsultations-de-medecine-generale> accessed 14 December 2024.