Means and governance of environmental health policy

The mission letter, signed by the cabinet directors of six ministerial departments, asked the general inspectorates:

• to establish an inventory of the resources devoted from 2015 to 2021 to the policy of environmental health (EH) by the State, the territorial authorities and the European Union,
• and to formulate, based on the guidance of several parliamentary reports, proposals to improve the governance of this policy.

The mission is in response to a report of the General Inspectorates tasked in 2020 with providing situational analysis and recommendations on risk assessment and scientific expertise in environmental health as well as on the missions and organization of agencies and competent public bodies, and whose recommendations on governance it largely shares.
Environmental health was defined by the European office of the World Health Organization (WHO) in 1994 during the Helsinki conference: “environmental health comprises those aspects of human health, including quality of life, that are determined by physical, chemical, biological, social, and psychosocial factors in the environment. It also refers to the theory and practice of assessing, correcting, controlling, and preventing those factors in the environment that can potentially affect adversely the health of present and future generations”.

The French National Environmental Health Plan 2021-2025 (PNSE 4) integrates a “one health” approach, as the Ministers of Health and Ecology underline in their introduction: “The coronavirus pandemic has reminded us of the close links between our health, animal health and the health of ecosystems and, consequently, of the imperative need to integrate all of these aspects according to the “one health” principle. In keeping with this development, the mission recommends integrating the concept of environmental health into the “one health” principle by adopting a multisectoral and multidisciplinary approach to health.
In order to define the scope of its investigations, the mission drafted a list of environmental factors that affect human health to be taken into consideration, and prioritized them:

• by prioritizing in an “inner circle”, the factors with the most direct impact on human health (those with a less direct impact being placed in an “outer circle”). Figure 1 of the report illustrates these factors;
• by selecting the risks that can only be managed collectively (and by excluding factors based on individual behavior);
• by taking into account costs for governance, research, prevention, communication, training, monitoring and the fight against the effects of the environment on health (and not factoring in the consequences of environmental factors on health expenditure – on care or insurance).

The complex defining exercise undertaken by the mission should, in its opinion, be continued in order to define in the field of “one health”, the scope of environmental factors that must be taken into account in public policies for the preservation and improvement of the health of populations.

1/ With regard to the taking stock of environmental health expenditures from 2015 to 2021, the mission firstly highlights that environmental health is an emerging subject, and therefore little or poorly identified in the State’s budgetary nomenclature, as well as in the financial reporting frameworks of territorial authorities. In addition, the monitoring of European Union expenditures in France is lacking.

• At State level, we performed detailed analysis on the budgets of 39 programs within 13 missions, 28 of which include identifiable environmental health expenditures;
• The expenditures on the general budget, excluding titre 2 costs, as identified by the mission, would represent about €5 billion over 7 years (2015-2021), varying from 582 to €780 million each year without any clear trend. Between one third and one half of this expenditure stems from operators, mainly the French National Centre for Scientific Research (CNRS), the French National Agency for Food, Environmental and Occupational Health & Safety (ANSES) and the French National Public Health Agency (SPF).

It has only been possible to identify titre 2 costs – with some uncertainty – for four ministries, for approximately €370 million per year.
In total, albeit in a reduced form, the budget share allocated to environmental health would represent around 0.3% of general budget expenditure.
In 2019 and 2020, expenditure on the special appropriations account (contribution to the financing of aid for acquiring energy-efficient vehicles and withdrawing polluting vehicles from service) was significantly higher than expenditure on the general budget. These costs represent just over €4.2 billion over seven years and are rising over this period.

Thanks to an ad hoc database established by the mission, it has been possible to perform analyses based on budgetary descriptors (missions, programs, type of appropriations, etc.), objectives and intervention methods, and lastly environmental factors and the risks involved. Subject to the partial nature of these analyses, it appears that the Agriculture, Research and Ecology missions make up more than 80% of the funding that can be linked to environmental health (excluding titre 2), with the balance being split between numerous ministries. In addition, research (38%) and prevention and treatment interventions (47%) make use of most of the funding. Lastly, the application points of the environmental health policy vary, without any real perceptible priority: the first five domains in budgetary terms are animals, food, crops, air and water, each accounting for around 10% of expenditure.

• For several years now, the social security system has been financing certain establishments (particularly SPF), but also the regional intervention fund (FIR) of the regional health agencies (ARS). The expenditure for preventing occupational diseases developed as a result of the work environment (physical, chemical, biological, but also psychosocial factors) has also been identified. In total, the annual social welfare contribution amounts to nearly €200M.
• As for local authorities, the mission worked on the basis of the environmental protection accounts kept by the Statistical Data and Studies Department (SDES) of the Ministry of Ecological Transition and Ministry of Territorial Cohesion, and secondarily on extractions from the operational nomenclature provided by the DGFiP (General Directorate for Public Finance). In terms of the compulsory responsibilities of local authorities, excluding the regions (water purification and waste treatment, areas belonging to the “outer circle” of environmental factors assessed by the mission), it appears that expenditure exceeds €4 billion each year. In total, the proportion of environmental health expenditure in relation to the total expenditure of local authorities (excluding the regions) would be around 2%.
• The regions spend approximately €130M each year (water, waste, air). In relation to their total expenditure, this effort would be similar to that of the State (0.35%). At national level, the annual expenditure on environmental health of the various stakeholders would thus be a little more than €6 billion, of which more than two thirds are covered by the local authorities, a little less than 30% by the State and about 3% financed by social security.
• Lastly, with regard to the European Union, the mission noted that, in addition to the uncertainty about the scope of the “environmental health” field, there are gaps in the recording of European expenditure benefiting France. These funds can be paid directly to a large number of public (research organizations, universities, etc.) and private organizations. EU institution databases listing projects financed in the fields of health, research and the environment have allowed us to gain some insight into the situation.

2/ “One health” policy governance should be strengthened.
The mission recommends that France adopt a “one health” strategy, as already recommended by several parliamentary reports and General Inspectorates. The difficulty of mapping out the resources used confirms that this strategy would be useful, which would set multi-year, interdisciplinary and prioritized objectives and would establish a link with European policies and regulations. Lastly, it would facilitate interministerial coordination of the various related policies (health, agriculture, ecology, research, consumer affairs and fraud control, industry, territorial development, even development aid, etc.), as well as their own strategies (national health strategies, research strategies, etc.).
The strategy could be adopted and implemented with a four-year timeline, based on:

• a concerted effort to implement the strategy,
• its presentation to Parliament,
• interministerial steering of its implementation,
• and its evaluation at set intervals.

This interministerial steering could be established rapidly to the benefit of the new governmental organization. In this context, it could be integrated into the missions of the General Secretariat for Ecological Planning (SGPE).
It should be supported by both:

• the expertise of the Interministerial Committee for Health (CIS) for decision-making, with expansion of the select standing committee to include the main ministries concerned and an involvement or comprehensive information from other ministries investing significantly in “one health”. If the responsibility of interministerial steering was entrusted to the SGPE, the CIS meetings would be held under its supervision for matters related to environmental health;
• the creation of a national “one health” council, replacing the environmental health group, a body for strategic guidance and consultation representing the stakeholders, with a legal status and operating resources;
• the drafting of a “one health” national plan (replacing the PNSE) as an instrument for the implementation of the future “one health” national strategy and for the federation of sectoral plans governing the different fields of environmental health. Currently, the PNSE 4 has difficulty, due to insufficient authority, positioning itself as a simple addition to the thirty-odd existing sector plans and creating synergy among them;
• the possibility of trialing, between the State and the regions, alternative ways to manage environmental health in the territories.

Lastly, with regard to mapping out the financing of this policy, which would seem desirable, a government information report could be shared with Parliament when this consolidated governance is put in place. This report could then be released periodically, or even constitute a cross-disciplinary policy document appended to the annual draft budget plan, particularly if the choice were made to appoint an interministerial steering committee. For it to be reliable and so it does not involve a disproportionate workload, this inventory work requires the harmonization of expenditure nomenclatures in order to allow simpler identification costs and classify them by risk category. While this work is being conducted, monitoring the funding of the PNSE and sector plans seems to be a realistic improvement.

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