JUSOT Florence

Abstract Background Significant differences in COVID-19 incidence by gender, class and race/ethnicity are recorded in many countries in the world. Lockdown measures, shown to be effective in reducing the number of new cases, may not have been effective in the same way for all, failing to protect the most vulnerable populations. This survey aims to assess social inequalities in the trends in COVID-19 infections following lockdown. Methods A cross-sectional survey conducted among the general population in France in April 2020, during COVID-19 lockdown. Ten thousand one hundred one participants aged 18–64, from a national cohort who lived in the three metropolitan French regions most affected by the first wave of COVID-19. The main outcome was occurrence of possible COVID-19 symptoms, defined as the occurrence of sudden onset of cough, fever, dyspnea, ageusia and/or anosmia, that lasted more than 3 days in the 15 days before the survey. We used multinomial regression models to identify social and health factors related to possible COVID-19 before and during the lockdown. Results In all, 1304 (13.0%. 95% CI: 12.0–14.0%) reported cases of possible COVID-19. The effect of lockdown on the occurrence of possible COVID-19 was different across social hierarchies. The most privileged class individuals saw a significant decline in possible COVID-19 infections between the period prior to lockdown and during the lockdown (from 8.8 to 4.3%, P = 0.0001) while the decline was less pronounced among working class individuals (6.9% before lockdown and 5.5% during lockdown, P = 0.03). This differential effect of lockdown remained significant after adjusting for other factors including history of chronic disease. The odds of being infected during lockdown as opposed to the prior period increased by 57% among working class individuals (OR = 1.57. 95% CI: 1.00–2.48). The same was true for those engaged in in-person professional activities during lockdown (OR = 1.53. 95% CI: 1.03–2.29). Conclusions Lockdown was associated with social inequalities in the decline in COVID-19 infections, calling for the adoption of preventive policies to account for living and working conditions. Such adoptions are critical to reduce social inequalities related to COVID-19, as working-class individuals also have the highest COVID-19 related mortality, due to higher prevalence of comorbidities.

Background Our main objectives were to estimate the incidence of illnesses presumably caused by SARS-CoV-2 infection during the lockdown period and to identify the associated risk factors. Methods Participants from 3 adult cohorts in the general population in France were invited to participate in a survey on COVID-19. The main outcome was COVID-19-Like Symptoms (CLS), defined as a sudden onset of cough, fever, dyspnea, ageusia and/or anosmia, that lasted more than 3 days and occurred during the 17 days before the survey. We used delayed-entry Cox models to identify associated factors. Results Between April 2, 2020 and May 12, 2020, 279,478 participants were invited, 116,903 validated the questionnaire and 106,848 were included in the analysis. Three thousand thirty-five cases of CLS were reported during 62,099 person-months of follow-up. The cumulative incidences of CLS were 6.2% (95% Confidence Interval (95%CI): 5.7%. 6.6%) on day 15 and 8.8% (95%CI 8.3%. 9.2%) on day 45 of lockdown. The risk of CLS was lower in older age groups and higher in French regions with a high prevalence of SARS-CoV-2 infection, in participants living in cities > 100,000 inhabitants (vs rural areas), when at least one child or adolescent was living in the same household, in overweight or obese people, and in people with chronic respiratory diseases, anxiety or depression or chronic diseases other than diabetes, cancer, hypertension or cardiovascular diseases. Conclusion The incidence of CLS in the general population remained high during the first 2 weeks of lockdown, and decreased significantly thereafter. Modifiable and non-modifiable risk factors were identified.

Background We aimed to estimate the seropositivity to anti-SARS-CoV-2 antibodies in May–June 2020 after the first lockdown period in adults living in three regions in France and to identify the associated risk factors. Methods Between 4 May 2020 and 23 June 2020, 16 000 participants in a survey on COVID-19 from an existing consortium of three general adult population cohorts living in the Ile-de-France (IDF) or Grand Est (GE) (two regions with high rate of COVID-19) or in the Nouvelle-Aquitaine (NA) (with a low rate) were randomly selected to take a dried-blood spot for anti-SARS-CoV-2 antibodies assessment with three different serological methods (ClinicalTrial Identifier #NCT04392388). The primary outcome was a positive anti-SARS-CoV-2 ELISA IgG result against the spike protein of the virus (ELISA-S). Estimates were adjusted using sampling weights and post-stratification methods. Multiple imputation was used to infer the cumulative incidence of SARS-CoV-2 infection with adjustments for imperfect tests accuracies. Results The analysis included 14 628 participants, 983 with a positive ELISA-S. The weighted estimates of seropositivity and cumulative incidence were 10.0% [95% confidence interval (CI): 9.1%, 10.9%] and 11.4% (95% CI: 10.1%, 12.8%) in IDF, 9.0% (95% CI: 7.7%, 10.2%) and 9.8% (95% CI: 8.1%, 11.8%) in GE and 3.1% (95% CI: 2.4%, 3.7%) and 2.9% (95% CI: 2.1%, 3.8%) in NA, respectively. Seropositivity was higher in younger participants [odds ratio (OR) = 1.84 (95% CI: 1.79, 6.09) in <.40 vs 50–60 years old and OR = 0.56 (95% CI: 0.42, 0.74) in ≥70 vs 50–60 years old)] and when at least one child or adolescent lived in the same household [OR = 1.30 (95% CI: 1.11, 1.53)] and was lower in smokers compared with non-smokers [OR = 0.71 (95% CI: 0.57, 0.89)]. Conclusions Seropositivity to anti-SARS-CoV-2 antibodies in the French adult population was ≤10% after the first wave. Modifiable and non-modifiable risk factors were identified.

In France, the beginning of a release from containment since May 11 has been accompanied by recommendations aimed at reducing contact for so-called "vulnerable" populations, i.e. those at increased risk of severe forms of Covid-19 due to their age or pathologies. Thus, the decree of May 5, 2020 defines "vulnerability" in the sense of Article 20 of the Law of April 25, 2020, i.e. as being able to give right to the partial activity device. According to our estimates, excluding age-related criteria, there are 12.6 million vulnerable people in metropolitan France, i.e. 24% of the population. Even if the prevalence of pathologies at risk is linked to age, it remains important at active ages and even if a significant number of vulnerable people are out of work, because of their age, but also because of the selection by health in the job, 4.8 million vulnerable people are employed, i.e. 17.5% of the employed people. If telework is theoretically possible for some of these workers, 3.5 million employed persons would meet the criteria of vulnerability without the possibility of working remotely, including 2.8 million employees. These are concentrated among craftsmen and tradesmen, blue collar workers and to a lesser extent white collar workers. Similarly, employees in agriculture, trade, construction and the food industry are more affected, both because of a higher prevalence of vulnerability and because of a lower propensity to telework than executives or intermediate professions. According to our estimates, under the hypothesis that all employees eligible for partial activity for vulnerability use it, and under the hypothesis that they are not already in partial activity because of a drop in their company's activity, the compensation of the 2.8 million employees concerned would cost the State and Unedic 2.8 billion euros per month and 400 million euros to companies. While the question of the use of protective devices, which we discuss in detail, is central to understanding the economic consequences of protecting vulnerable employees, our evaluation allows us to estimate the economic impact of targeted reconfinement measures that could be put in place in the event of an epidemic rebound and that would result in the systematic withdrawal of vulnerable people in employment who cannot telework. These targeted measures would help mitigate the economic shock of reconfinement.

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While the health of young adults is a recognised public health issue in France, less atten-tion is paid to their use of healthcare. This article examines the existence of unequal opportunities in the use of healthcare for young adults using data from the National Survey on the Resources of Young Adults (Enquête nationale sur les ressources des jeunes - 2014). Using the framework of the philosophy of responsibility, a distinction is made between “unfair” inequalities linked to circums-tances beyond the control of young people – or unequal opportunity, and “fair” inequalities linked to characteristics for which they are responsible. Linear probability models are used to estimate the associations between the probabilities of non-use (non-utilisation and foregone health care) and parental characteristics (complementary health insurance, main activity, income, marital and vital status) on the one hand and those of the young person (education, main activity, whether living in the parental home or not, financial resources, complementary health insurance) on the other, reflecting the existence of unfair and fair inequalities respectively. Variance decomposition makes it possible to quantify these inequalities and suggests that unfair inequalities outweigh fair inequalities.

In France, the Missions locales (ML) welcome young people in socio-professional integration - who are neither in employment, nor in training, nor in studies - aged 16 to 25, i.e. 10 to 15% of young people in this age group. The objective of the MLs is to enable these young people to overcome the difficulties that hinder their integration in their transition from school to working life - the issues of training, employment, housing and health being interdependent. In France, studies on the health of young people in integration were still exceptional before the Presaje project conducted in five MLs in 2011. The data from this work showed that, despite a certain heterogeneity in the pathways, this large and vulnerable group accumulates risk factors with regard to health: with few or no diplomas, socially isolated, with insufficient social security coverage, and with low self-confidence and low confidence in the institutions. Young people in integration are in poorer health than other young people of the same age. They are more likely to have a chronic illness, psychological malaise, obesity or overweight. Despite their significant health needs, they seek care less often than other young people in the general population. This thesis also highlighted the importance of "health points" within the MLs. The systematic proposal of a social and preventive medicine consultation to this public - in addition to improving certain health behaviors and knowledge - makes it possible to increase their number of entries into measures (participation in a training course or workshop) and, we hope, ultimately their employment rate.

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Objective: We assess the existence of unfair inequalities in health and death using the normative framework of inequality of opportunities, from birth to middle age in Great Britain. Methods: We use data from the 1958 National Child Development Study, which provides a unique opportunity to observe individual health from birth to the age of 54, including the occurrence of mortality. We measure health status combining self-assessed health and mortality. We compare and statistically test the differences between the cumulative distribution functions of health status at each age according to one childhood circumstance beyond people's control: the father's occupation. Results: At all ages, individuals born to a 'professional', 'senior manager or technician' father report a better health status and have a lower mortality rate than individuals born to 'skilled', 'partly skilled' or 'unskilled' manual workers and individuals without a father at birth. The gap in the probability to report good health between individuals born into high social backgrounds compared with low, increases from 12 percentage points at age 23 to 26 at age 54. Health gaps are even more marked in health states at the bottom of the health distribution when mortality is combined with self-assessed health. Conclusions: There is increasing inequality of opportunities in health over the lifespan in Great Britain. The tag of social background intensifies as individuals get older. Finally, there is added analytical value to combining mortality with self-assessed health when measuring health inequalities.

This thesis contributes to the understanding of human capital investment decisions of young adults in France. Young adults are in a decisive period in terms of their development and expression of preferences. Particular attention is paid to preferences, as well as to the resulting inequalities. The first chapter focuses on the roles of anticipatory treatment and multivariate preferences in the health insurance decision. Predictions from a theoretical model are tested on data collected in an experimental laboratory. Results show that higher health preference leads to more intensive treatment demand and that being correlation averse leads to more than full coverage. In the second chapter, using survey data, it is shown that differences in the use of care are primarily associated with need, followed by circumstances, reflecting inequalities of opportunity, and effort, reflecting fair inequalities. The third chapter focuses on the effect of students' psychological fragilities on their control beliefs. The instrumental variable strategy shows that more psychological frailties lead to increased control beliefs, which is consistent with the psychological literature that depressed and anxious individuals blame themselves more.

Demographic aging raises questions about the sustainability of the pension system and support for the elderly. These issues have led to pension reforms and several developments in policies to support the elderly. This thesis aims to improve knowledge of the implications of these policies. The first part focuses on the impact of retirement on health. Chapter 1 summarizes the results of previous studies regarding the impact of retirement on health. Chapters 2 and 3 focus on the impact of delayed retirement on mortality and on health expenditures, respectively. They show that retiring later as a result of the 1993 reform in France has no impact on mortality and decreases health care expenditures for men. The second part of this thesis focuses on support policies for the elderly in France. Chapter 4 uses a microsimulation model to project the future needs for assistance to the elderly. The number of dependent elderly is estimated at 3.63 million people in 2060, with an expansion of morbidity. Chapter 5 looks at the impact of a change in formal assistance on the use of informal assistance. It shows that an increase in the amount of formal assistance decreases the probability of reporting receiving informal assistance.

This dissertation addresses social inequalities in health by attempting to identify their main determinants. The aim of this research is to examine the impact of health systems and their reforms on social inequality in health, focusing on a deeper understanding of the pathways and mechanisms by which socio-economic factors reduce or increase inequalities in health. Based on a review of the literature on the determinants of social inequalities in health, we propose a conceptual analysis of the links between health and socio-economic status, including the income of individuals and countries by studying the impact of the latter on the health status of a population. We propose to explore the relationship between income inequality, social inequality and disparities in health status in the context of the emergence of social inequalities in health (SII). According to the definitions of social determinants, health inequality must be considered from a systematic analysis perspective with particular reference to the most explicitly cited and proven socio-economic theories in the health economics literature. A conceptual framework on the methods of measuring social inequalities in health has been proposed to discuss the approaches to decompose inequalities in the consumption of health care, in particular with the concentration index as a hitherto little explored measure. This allowed to assess health inequalities, to make a judgment on the inequity of the distribution of health care, and to highlight the relevance of this measure in this field.Among the aspects of health inequality, several determinants support disparities in the demand for health services that are related to both economic situations and health systems. Many theoretical approaches assert that inequality in access to care is related to the characteristics and norms of health systems that lead to conditions of inequity in financial access to care and the use of the resources and services of these systems. This has been the motivation for successive and ongoing reforms of health financing and health insurance in several countries around the world. These reforms have also sought to improve the performance of health systems. Thus, in this thesis, we have tried to measure the levels of efficiency and equity in the Tunisian health system, by studying the causal factors of health inequalities in Tunisia and the reform of health insurance as well as the determinants of its development as a means of financing health care. We then presented an evaluation of the reform of the National Health Insurance Fund (CNAM) in 2007, examining its impact on access to care. A conceptual framework is presented concerning the evaluation of health system performance to discuss the methods of measurement and estimation of the level of technical and economic efficiency using in particular the DEA method.

In France, the principle of horizontal equity in access to care is at the heart of the 1945 pact, according to the maxim "From each according to his means, to each according to his needs". However, since its creation, the health insurance system has left part of the cost of care to be paid by patients, in order to make them more responsible. However, these instruments constitute financial barriers to access to care, which are all sources of social inequalities in the use of care. In order to improve equity in financial access to care, various policies have been implemented over the last decades. This article proposes to draw lessons from them and to review the knowledge on inequalities in the use of health care in France. Most of these policies have consisted in introducing free access to certain types of care or in reducing the cost of supplementary health insurance for the poorest households. The available evaluations demonstrate the effectiveness of free care, whether it applies to care or to insurance, even if it can lead to a lower perceived quality or to discrimination when it is accompanied by capped tariffs. The literature also converges on the inefficiency of insurance subsidies. The most recent reforms, which have not yet been evaluated, aim to moderate the prices of care poorly covered by health insurance. Despite these measures, inequalities in the use of health care remain, given a given need for care, and are particularly significant for specialist care, dental and optical care, and preventive care. Reducing financial barriers is therefore a necessary but not sufficient condition for achieving health equity.

What role do caregivers play in accompanying and supporting people with disabilities?

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A number of issues arise from the context of demographic ageing in Europe, the prevalence and generalisation of which on the European continent make it unprecedented. Thus, the increase in the number of elderly people, and more particularly, the number of elderly people in a situation of dependence, democratizes the question of their care and the role of each of the stakeholders. This thesis proposes to study the issues related to aging and the provision of informal care. The first chapter studies the relationship between mortality and income. The second chapter examines the motivations of children to become informal caregivers for their parents. The third and fourth chapters analyze, respectively, the impact of informal care on the health of the caregiver and that of his or her partner.

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The starting point of this thesis is the observation that in post-soviet health systems, informal payments to health professionals persist well beyond the post-socialist transition, despite successive waves of health system reform. At the same time, since the independence of the Republic of Tajikistan, a profound mistrust of certain health professionals has developed and the renunciation of care has increased, affecting vulnerable populations in particular. What role do the various informal remuneration practices play then? Are they a source of mistrust or a means of restoring trust? Are informal payments adjusted to the standard of living of patients or do they create inequalities between patients? According to the equity indicators mobilized, and contrary to popular belief, informal payments do not make it possible to make the system progressive and to guarantee access for all. In the face of these barriers to access to care, households implement different strategies: informal solidarity, debt, recourse to traditional medicine, mobilization of social capital, etc. We then study, more precisely, the extent to which migration, a massive phenomenon in Tajikistan, is part of these strategies and the extent to which remittances enable beneficiary households to improve their access to care.

This chapter opens with a thorough review of the literature on the health effects of social capital in a large collection of countries, especially in developing countries such as Indonesia. The study includes many innovations and new findings. For example, it finds that inequalities in health opportunities account for 10 per cent of inequalities in health.

While the arduousness of work contributes to a deterioration in health, studies also show that employment preserves health by promoting access to healthcare. The relationship between the state of health of individuals and the labour market has been the subject of much debate and legislation. The current provisions, based on a logic of compensation and reparation, do not take sufficient account of the complexity of these interactions, which are further increased by the ageing of the population and the lengthening and precariousness of professional trajectories. Faced with health risks, there is a need for more prevention and more secure career paths.

Do remittances sent by migrants have an impact on their families' consumption of health care at home? By relaxing the budget constraint, remittances should improve access to care, especially in systems with low public health spending. However, one may suspect that remittances are endogenous, as the need for care may induce migrants to send more money. This paper examines the issue in the case of Tajikistan, where there is both high direct health spending and a high dependence on migration. It uses data from the Tajikistan Living Standards Survey (2007). The results show that transfers have a positive but heterogeneous impact depending on the level of health care consumption.

Since January 1, 2016, private sector employers are obliged to offer and partially finance a complementary health insurance to all their employees. In this work, we simulate the welfare gains and losses to be expected from this reform on the whole population by mobilizing the expected utility theory. The results show that the reform increases collective welfare if and only if wages and premiums of the contracts remain unchanged. If we assume that individual contract premiums increase as a result of the ANI, the impact of the reform on collective welfare is almost zero. The gain in welfare of employees who benefit from the reform is then counterbalanced by the loss of welfare suffered by those covered on an individual basis or who are obliged by the reform to take out insurance. If we also consider that employers include the amount of their subsidy in their salaries, the ANI strongly reduces collective welfare.

The 4th cover page states: "Although the arduousness of work contributes to the deterioration of health, studies also show that employment preserves it by promoting access to healthcare. The relationship between the state of health of individuals and the labour market has been the subject of much debate and legislation. The current provisions, based on a logic of compensation and reparation, do not take sufficient account of the complexity of these interactions, which are further increased by the ageing of the population and the lengthening and precariousness of professional trajectories. Faced with health risks, we need more prevention and more secure career paths".

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The market for professional home help for dependent elderly people in France is regulated. The APA makes part of the demand for professional home help financially viable, while certain professional help structures are subject to fees and are obliged to respond to all the requests they receive. These regulation policies are decentralized at the level of the departmental councils and aim to reduce financial and geographical inequalities in access to professional help within each department. The goal of the thesis is to determine whether these policies of reducing intra-departmental inequalities lead to inter-departmental inequalities. The first chapter of the dissertation uses a survey of departmental councils to determine whether the decentralization of regulatory policies leads to significant policy heterogeneity across departments. The second chapter of the thesis analyzes the impact of the observed heterogeneity. This chapter proposes an estimation of the elasticity of the demand for home help of dependent elderly people, using a national survey. The third chapter of the thesis analyzes, within a department, the distribution of public financing according to income and its impact on consumption differentials. For this we use billing data from a home help service. Finally, the fourth chapter of the thesis proposes a theoretical model of a mixed market, studying the effects of the service obligation of a part of the market structures on the quality of the assistance offered.

This thesis focuses on the difficulties of access to dental care in the French semi-regulated market. The analysis focuses on the financial barrier to access to dental care and thus the role and mechanism of price setting. The first part allows us to contextualize the delivery of dental care in France and shows that the dental profession is particularly isolated in the French health field. The purpose of the second part is to identify the determinants of access to dental care. We show that the M'T'dents preventive program for children, which is entirely free of charge, was used only by the most affluent households and had little impact on the disadvantaged households that need it most. The importance of social support in access to care is also affirmed in our second empirical study. Primary access to adult dental care presents the main barrier to access. Once this difficulty is overcome, patients most often engage in the next necessary treatments, with expenditure levels that can be significant even for the less affluent. Following these results, we were specifically interested in the role of price. We showed that the higher the price of dental prostheses, the greater the renunciation of this care for financial reasons. According to our work, the intensity of competition has a negative impact on pricing, as opposed to the solvency of the demand. Prices between competitors are also strategic complements. These are all factors that could be regulated to combat the renunciation of dental care and the resulting social inequalities in health.

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This paper proposes a method to quantify the contribution of inequalities of opportunities and inequalities due to differences in effort to be in good health to overall health inequality. It examines three alternative specifications of legitimate and illegitimate inequalities drawing on Roemer, Barry and Swift‟s considerations of circumstances and effort. The issue at stake is how to treat the correlation between circumstances and effort. Using a representative French health survey undertaken in 2006 and partly designed for this purpose, and the natural decomposition of the variance, the contribution of circumstances to inequalities in self-assessed health only differs of a few percentage points according to the approach. The same applies for the contribution of effort which represents at most 8%, while circumstances can account for up to 46%. The remaining part is due to the impact of age and sex.

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In France, access to health care greatly depends on having a complementary health insurance coverage (CHI). Thus, the generalisation of CHI became a core factor in the national health strategy created by the government in 2013. The first measure has been to compulsorily extend employer-sponsored CHI to all private sector employees on January 1st, 2016 and improve its portability coverage for unemployed former employees for up to 12 months. Based on data from the 2012 Health, Health Care and Insurance survey, this article provides a simulation of the likely effects of this mandate on CHI coverage and related inequalities in the general population by age, health status, socio-economic characteristics and time and risk preferences. We show that the non-coverage rate that was estimated to be 5% in 2012 will drop to 4% following the generalisation of employer-sponsored CHI and to 3.7% after accounting for portability coverage. The most vulnerable populations are expected to remain more often without CHI whereas non coverage will significantly decrease among the less risk averse and the more present oriented. With its focus on private sector employees, the policy is thus likely to do little for populations that would benefit most from additional insurance coverage while expanding coverage for other populations that appear to place little value on CHI.

Whereas health equity issues are undoubtedly more relevant in developing countries, research on healthinequalities and, more specifically, on inequality of opportunity in the health dimension, remains scarce in this context. This paper explores the degree of inequality of opportunity in health in a developing country, using the 2007 Indonesian Family Life Survey, a large-scale survey with extremely rich information about individualhealth outcomes (biomarkers and self-reports) and individual circumstances.We compute a continuous synthetic index of global health status based on a comprehensive set of healthindicators and subsequently implement non-parametric and parametric methods in order to quantify the level ofinequality of opportunity in the health dimension. Our results show large inequality of opportunities in health inIndonesia, compared to European countries. Concerning transmission mechanisms, parental (particularly maternal) vital status appears as the main channel. Compared to what has been observed in more developed countries, the effect of parental education on health is relatively smaller, and mainly indirect (passing through descendants’ socioeconomic, marital and migration statuses), while the existence of long-term differences in health related to religion, language spoken and particularly province of location suggest a relatively higher relevance of community belonging variables for health equity in the context of a developing country asIndonesia.

Malaria and pneumonia are still public health problems in low-income countries, including Madagascar. However, while malaria has received more attention and strengthened control programs since the creation of the Global Fund in 2002, pneumonia is often neglected. Recently, however, UNICEF, building on the encouraging results achieved at the community level in the fight against malaria, has been pushing for the integration of pneumonia screening and management at the community level. To support this advocacy, impact and cost-effectiveness studies are needed to verify that this strategy is effective and efficient. This is the purpose of Chapter 4 of this thesis, which examines the pilot experience conducted by Unicef in the Antalaha district. We show that this program has had a significant impact on the management of malaria and pneumonia. However, the quality of this management is still being questioned. This indicates that, before deciding to scale up, this program deserves to be revised to improve it. In addition to the loss of well-being, malaria and pneumonia have a financial cost first, and then an economic cost. One of the arguments for advocacy is therefore to show, if there are any, the economic effects of the two diseases. This is the subject of Chapters 2 and 3 with an application to Madagascar. Before that, the theoretical underpinning of the link between health and income or economic development is presented in the first chapter.

In 2005, France implemented a gatekeeping reform designed to improve care coordination and to reduce utilization of specialists’ services. Under this policy, patients designate a médecin traitant, typically a general practitioner, who will be their first point of contact during an episode of care and who will provide referrals to specialists. A key element of the policy is that patients who self-refer to a specialist face higher cost sharing than if they received a referral from their médecin traitant. We consider the effect of this policy on the utilization of physician services. Our analysis of administrative claims data spanning the years 2000–2008 indicates that visits to specialists, which were increasing in the years prior to the implementation of the reform, fell after the policy was in place. Additional evidence from the administrative claims as well as survey data suggest that this decline arose from a reduction in self-referrals, which is consistent with the objectives of the policy. Visits fell significantly both for specialties targeted by the policy and specialties for which self-referrals are still allowed for certain treatments. This apparent spillover effect may suggest that, at least initially, patients did not understand the subtleties of the policy.

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Objectives: (1) To explore and analyze individual perceptions of all-cause cancer risk and environmental factors. (2) To investigate the links between these perceptions and the adoption of health behaviors. (3) To identify and analyze the determinants of these perceptions. Methods: Reviews of the empirical and theoretical literature, qualitative study with people with and without a history of cancer, quantitative study with a representative sample of the French population. Results: (1) Cancer risks related to environmental factors are a matter of concern. A significant proportion of participants perceived themselves to be at risk of developing cancers related to air pollution, pesticides and stress. (2) Health behavior adoption is sometimes associated with risk perceptions but is more often associated with adherence to prevention beliefs and time and risk preferences. Taking endogeneity into account has a strong impact on the significance of associations between perceptions and behaviors. (3) Adherence to cancer-related beliefs and salience of environment-related cancer risks determine perceptions more strongly than affect and availability heuristics, knowledge, perceived control and perceived willingness to accept risk exposures, personal health history, and sociodemographic characteristics. Discussion: Our results, consistent with the literature, provide a better understanding of individual risk perceptions and can be used to support the development of targeted public health policies.

This paper aims to quantify and compare inequalities of opportunity in health across European countries considering two alternative normative ways of treating the correlation between effort, as measured by lifestyles, and circumstances, as measured by parental and childhood characteristics, championed by Brian Barry and John Roemer. This study relies on regression analysis and proposed several measures of inequality of opportunities. Data from the Retrospective Survey of SHARELIFE, which focuses on life histories of European people aged 50 and over, are used. In Europe at the whole, inequalities in opportunities stand for almost 50% of the health inequality due to circumstances and efforts in Barry scenario and 57.5% in Roemer scenario. The comparison of the magnitude of inequalities of opportunity in health across European countries shows considerable inequalities in Austria, France, Spain, Germany, whereas Sweden, Poland, Belgium, the Netherlands and Switzerland present the lowest inequalities of opportunities. The normative principle on the way to treat the correlation between circumstances and effort makes little difference in Spain, Austria, Greece, France, Czech Republic, Sweden and Switzerland whereas it would matter the most in Belgium, the Netherlands, Italy, Germany, Poland and Denmark. In most countries, inequalities of opportunity in health are mainly driven by social background affecting adult health directly, and so would require policies compensating for poorer initial conditions. On the other hand, our results suggest a strong social and family determinism of lifestyles in Belgium, the Netherlands, Italy, Germany, Poland and Denmark, which emphasises the importance of inequalities of opportunities in health within those countries and calls for targeted prevention policies.

This thesis is devoted to mixed health insurance systems where compulsory public coverage can be improved by a complementary health insurance. The questions addressed concern the inflationary effect of the complementary health insurance on the price of care and the impact of age-based pricing on solidarity between sick and healthy people and between income groups. The empirical analyses are based on French data. This original database includes the health care consumption of 99,878 MGEN members over the 2010-2012 period. Chapter 1 estimates the causal effect of better coverage on the consumption of excess fees and demonstrates the inflationary effect of complementary health insurance on the price of care. Chapter 2 considers the heterogeneity of the impact of better coverage on overcharges and its correlation with insurance demand. In fact, the inflationary effect of complementary insurance is accentuated by selection effects. Chapter 3 shows that age-based pricing maximizes transfers between the sick and the healthy at the expense of solidarity between high and low incomes.

INTRODUCTION: Maternal smoking during pregnancy is associated with adverse perinatal and postnatal health outcomes. The efficacy of nicotine replacement therapies in helping pregnant smokers to quit is not clearly demonstrated. therefore new interventions should be proposed and assessed. Financial incentives rewarding abstinence from tobacco smoking is one of the promising options. OBJECTIVE: To assess the efficacy of financial incentives on smoking abstinence among French pregnant smokers. METHODS AND ANALYSIS: PARTICIPANTS:pregnant smokers aged ≥18 years, smoking at least five manufactured or three roll-your-own cigarettes per day, and pregnant for <18 weeks of amenorrhoea (WA). SETTING: participants will be recruited, included and followed-up at monthly face-to-face visits in 16 maternity wards in France. INTERVENTIONS: participants will be randomised to a control or an intervention group. After a predefined quit date, participants in the control group will receive €20 vouchers at the completion of each visit but no financial incentive for smoking abstinence. Participants in the intervention group will be rewarded for their abstinence by vouchers on top of the €20 show-up fee. The amount of reward for abstinence will increase as a function of duration of abstinence to stimulate longer periods of abstinence. MAIN OUTCOME MEASURE: complete abstinence from quit date to the last predelivery visit. SECONDARY OUTCOME MEASURES: point prevalence abstinence, time to relapse to smoking, birth weight, fetal growth restriction, preterm birth. Main data analysis: outcomes will be analysed on an intention-to-treat (ITT) basis. The ITT population is defined as all randomised smoking pregnant women.

Introduction Maternal smoking during pregnancy is associated with adverse perinatal and postnatal health outcomes. The efficacy of nicotine replacement therapies in helping pregnant smokers to quit is not clearly demonstrated. therefore new interventions should be proposed and assessed. Financial incentives rewarding abstinence from tobacco smoking is one of the promising options. Objective To assess the efficacy of financial incentives on smoking abstinence among French pregnant smokers. Methods and analysis Participants: pregnant smokers aged ≥18 years, smoking at least five manufactured or three roll-your-own cigarettes per day, and pregnant for <18 weeks of amenorrhoea (WA). Setting: participants will be recruited, included and followed-up at monthly face-to-face visits in 16 maternity wards in France. Interventions: participants will be randomised to a control or an intervention group. After a predefined quit date, participants in the control group will receive €20 vouchers at the completion of each visit but no financial incentive for smoking abstinence. Participants in the intervention group will be rewarded for their abstinence by vouchers on top of the €20 show-up fee. The amount of reward for abstinence will increase as a function of duration of abstinence to stimulate longer periods of abstinence. Main outcome measure: complete abstinence from quit date to the last predelivery visit. Secondary outcome measures: point prevalence abstinence, time to relapse to smoking, birth weight, fetal growth restriction, preterm birth. Main data analysis: outcomes will be analysed on an intention-to-treat (ITT) basis. The ITT population is defined as all randomised smoking pregnant women. Ethics and dissemination The research protocol was approved by the ethics committee (Comité de Protection des Personnes, CPP) of the Pitié-Salpêtrière Hospital on 15 May 2015, and Amendment No 1 was approved on 13 July 2015. Results will be presented at scientific meetings and published.

No summary available.

Health shocks have contrasting consequences on employment trajectories, depending as much on factors related to the epidemiology of the diseases as on factors of labor market organization. Cancer thus has both transitory and lasting effects on the activity and employment situation of those who survive it. Our in-depth study of the case of the self-employed shows that they are characterized by responses to illness that differentiate them from salaried workers in the frequency and duration of sick leave, but also in the process of maintaining employment. Some of these results are reducible to the character traits of the self-employed, such as their attitude to risk. These results are also related to the ways in which the self-employed participate in the labour market and the conditions under which they work, which are often less protected by social insurance schemes than salaried workers, because they are left to their own discretion. The studies used are the French cancer survey "VICAN 2" financed by INCa, the employment survey, and the American "HRS" survey. First of all, this thesis emphasizes the need to do qualitative and quantitative studies only on the self-employed, who differ substantially from salaried workers. The results also highlight that risk aversion is not an innate and stable characteristic. Empirical work, supported by theoretical modeling, shows that health shocks can cause individuals to reconsider their risk appetite, either downward (stable chronic diseases) or upward (cancer survival).

This article analyzes the solidarity provided by the French health insurance system using a new tool that measures transfers between income groups through health care consumption and financing, applied to the Inès-Omar 2012 microsimulation model. The solidarity index is broken down according to the sources of financing (compulsory and supplementary insurance, out-of-pocket expenses) and discussed in terms of equity principles. Solidarity is less a matter of horizontal equity in the consumption of health care than of vertical equity in financing, guaranteed by the progressivity of compulsory insurance. Social inequalities in health care largely explain the importance of transfers received from public insurance by the poorest, even if barriers to access to care limit the solidarity of the system.

Breast cancer screening reduces mortality only if screening is performed regularly. We investigate the effects of socioeconomic and health characteristics and how the French screening system influences the regularity of screening. In particular, we examine whether the screening modality chosen (organized or individual screening) influences the regularity of screening. Our results suggest that organized screening increases the probability of regular screening. In addition, women with low incomes or who have experienced episodes of precariousness have less regular screening than more affluent women.

The objective of this thesis, composed of six theoretical and empirical articles, is to identify the most effective ways to encourage drug users - legal and illegal - to adopt healthier habits by reducing their consumption. The first step is to assess the magnitude of the problem by measuring the social cost of drugs (tobacco, alcohol and illicit drugs) in France in 2010. Despite massive prevention campaigns, the worrying proportion of substance users, but above all, the high proportion of people declaring that they regret having started their consumption, lead us to reconsider the traditional paradigm of rational addiction, which is the basis of most research on addictions in economics. On the contrary, admitting a cognitive polyphasy in individuals with, on the one hand, a planner making his decisions as rationally as his cognitive capacities allow him to do so, and on the other hand, a doer seeking only to reach immediate satisfaction, allows us to build an original theoretical framework taking into account the short-term and long-term emotions of the agents, as well as the role of social norms on their addictive consumption decisions. The model built from this framework, as well as its analysis on a panel of French smokers, allows us to propose innovative policies aiming at reinforcing the motivation of individuals to stop their addictive consumption by reducing their self-control problems, by acting on their perception of the dangers linked to drug use, and by targeting a normative change of their consumption. Most of these recommendations are not applicable to illegal drugs because of their legal status. As a result, the only lever for defining a strategy to reduce the costs involved is the study of legal alternatives to the penalization of consumption, particularly with regard to cannabis, which is the most widely used illicit drug in France, but also in most developed countries.

This thesis focuses on the question of variability in cancer management practices and on the study of the determinants of social and spatial inequalities in access to care, with a particular focus on cancer patients. In recent years, public authorities have noted strong variability in the rates of recourse to certain types of treatment. The first chapter of this thesis asks the question of the determinants of differences in the use of prostatectomy as a treatment for prostate cancer. The results show a strong positive influence of variables relating to the supply of care, both at the level of the department and the region, and the fight against social inequalities in health is also carried out thanks to mechanisms such as the ALD. The second chapter looks at the determinants of the use of general practitioners and specialists, differentiating between visits to the latter that are related to ALD pathology and those that are not. For visits to general practitioners, the results show that a lower socio-economic status seems to be associated with a higher use of care. Finally, since 2004, an organized breast cancer screening program has been in place for all women aged 50 to 74. The objective of the last chapter is to examine the potential influence of the density of general practitioners and specialists on the rates of recourse to this screening over the period 2005-2012. It appears that a higher density of general practitioners is significantly associated with a higher utilization rate. Conversely, an increase in the density of specialists tends to have a negative impact. The estimates also highlight a spatial effect . medical densities in neighboring departments also have an effect on the use of organized screening.

This thesis proposes to study the existence of obstacles to the development of the private LTC insurance market in France. We study three candidates in turn to explain this weak development: individual preferences, self-insurance behavior and agents' myopia. To do so, we use the "Preferences and Wealth vis-à-vis Risk and Time" and "Health and Social Protection" surveys, both of which have introduced specific LTC modules in the waves of surveys used in this thesis. Our econometric analyses confirm the role of these three determinants of LTC insurance demand as barriers. While the existence of a poor perception of LTC risk argues for state intervention in the relationship between the French and the planning of their loss of autonomy, the role of individual preferences and self-insurance behaviour highlighted in this thesis reveals an economically rational choice not to take out LTC insurance.

The issue of fuel poverty is of growing interest in the economic, political and social spheres. This thesis in economics focuses on the representation and analysis of the interactions of three fundamental items in the constrained expenses of households, namely health, housing, and energy, in order to reveal relevant levers for the implementation of actions to combat fuel poverty. This paper proposes an original theoretical and analytical analysis, by approaching this phenomenon in terms of equity, thus highlighting the existence of inequalities and justifying the implementation of complementary, or even new, measures in favor of greater equity between individuals with regard to the energy good. On the other hand, characterizing the dynamics of this phenomenon provides valuable information on the type of measures (i.e., bill payment assistance, innovative bill payment methods, housing renovation assistance) that can be put in place to counteract this phenomenon, and thus participate in the pursuit of the underlying equity objectives. Secondly, the analysis of the consequences of fuel poverty on other dimensions than those referring to energy (i.e., health) allows policy makers to question its multidimensional and porous aspect with other dimensions of social precariousness. This phenomenon is a vector contributing to the aggravation of other inequalities (i.e., health inequalities), which can thus compromise the pursuit of the equity objective of public decision-makers. Finally, the study of new and innovative means of payment for the energy good (i.e., prepayment), at lower costs, allows us to identify prepayment as a tool that can contribute to the achievement of the objectives of horizontal and vertical equity respectively.

This dissertation investigates the supply and demand factors associated with the use of breast cancer screening. Among the supply factors, I examine how the coexistence of organized screening alongside individual screening influences the content of the screening examination as well as the regular use of screening. In addition to demand factors such as socioeconomic characteristics, particular attention is paid to the possibility of explaining regular screening uptake by risk and time preferences as well as perceptions. Based on psychological regularities identified in behavioral economics and psychology, three nudge-type interventions are tested in a randomized field experiment aimed at increasing screening rates in the national program.

Improving access to health care for the population is now at the heart of poverty reduction policies. In this context, more and more countries in sub-Saharan Africa (SSA) are adopting policies to eliminate direct payments for care at the point of service. These policies aim to increase the demand for care by removing some of the financial barrier to accessing care and reduce the financial burden of illness that contributes to catastrophic expenditures. With the massive urbanization observed in the world and in particular in the countries of SSA, the management of the health of the peri-urban population has become more complex. The increase in the burden of morbidity linked to chronic diseases, plus that of communicable diseases which is still significant, makes it more difficult to control the health situation in these countries. The challenges posed by these changes have led to a renewed interest in the issues of access to health care and household health expenditures in urban areas. This thesis, based on data collected in the field, focuses on the demand for health care and the health expenditures of individuals in peri-urban areas. Chapter I presents the theoretical framework for analyzing the demand for health care and the specificities of this market, and presents Senegal. Chapter II presents the methodology for data collection and a detailed analysis of the types of illnesses identified, the therapeutic itinerary of patients and their health care expenditures. Chapter III focuses on the analysis of health care demand behavior related to acute symptoms reported by individuals. The analysis is carried out by estimating a multinomial probit. Chapter IV analyzes the determinants of individuals' health care expenditures with a Heckman model.

Objectives. The study investigates the life cycle patterns of educational inequalities in smoking according to gender over three successive generations.

No summary available.

This thesis provides six original insights into the professional integration of young people into the labor market on the one hand, and the use of subjective variables in health economics on the other. In the main developed countries, young people often encounter real and, since the 2008 crisis, increasing difficulties in entering the labor market. The first two chapters assess the effect of programs to help young people facing these difficulties, either by extending minimum income (chapter 1) or by strengthening the support program usually offered to them (chapter 2). The third and fourth chapters look at the level of unemployment at the time young people enter the labor market, analyzing its impact on their schooling rates (chapter 3) and on their earnings and employment rates over their entire careers (chapter 4). Moreover, the increasing use of subjective variables by economists raises the question of their reliability and their ability to measure the underlying phenomenon. The last two chapters of the thesis focus on the formulation of two subjective questions often used in health economics: the renunciation of care for financial reasons (chapter 5) and subjective health status (chapter 6). They assess the extent to which the wording chosen for the questions determines the responses obtained, and consequently use the split sample method, comparing the responses of several randomly constituted samples to which several sets of wording have been submitted.

Shortly after a special issue already devoted to this theme in 2012, the present issue of Economics and Statistics returns to the issue of health. It brings together a selection of articles from the 35 Journées des économistes de la santé français (JESF) held at the Université Paris-Est Créteil in December 2013. These days regularly result in the publication of a special issue devoted to health in a peer-reviewed journal. After the Revue Économique and, on two occasions, the journal Économie Publique, it is the turn of Économie et Statistique to host these proceedings. The fact that this subject has been taken up again at such short notice is obviously due to its importance, both socially and fiscally, and we will come back to this in a first step. But the precedent for the journal is not limited to this special issue of 2012: the theme of "health" has always had a regular and important presence. After an overview of the data available to shed light on this theme, we will detail how each of the articles in this issue drew on this mass of data, whether or not they fall within the strict domain of official statistics, and what messages could be drawn from them.

Tunisia is experiencing a significant increase in health care spending and in the life expectancy of Tunisians. But these results go hand in hand with inequalities in access to care, motivating a health insurance reform implemented in 2007. The main changes aim at improving coverage for chronic diseases and generalizing insurance for private health care. This applied microeconometrics thesis examines the impact of the reform on access to care and out-of-pocket expenses. The evaluations are based on surveys of several thousand individuals in 2005 and 2010. The motivations for the reform are presented, before analyzing the choice of insurance and its influence on the use of public or private care providers in 2010, after the reform. An evaluation of the reform was analyzed using the difference-in-differences approach. Overall, the results show that this reform seems to have achieved several of its objectives: improved access to care for members of the National Social Security Fund (CNSS), better access to private care, and a reduction in out-of-pocket expenses and catastrophic expenses for people with chronic diseases.

How do social inequalities in tobacco consumption in France change with age and generation? In order to answer this question, data from the Baromètre santé collected in 2010 from 27,653 people were used to retrospectively reconstruct the smoking history of three birth cohorts (1941-1955, 1956-1970 and 1971-1985). The evolution of smoking inequalities is studied by comparing smoking prevalences calculated at each age by level of education, sex and generation and then using a relative inequality index estimated with logistic regressions. The results show that, after having been more frequent among the most educated, smoking has declined in these groups, while it continues to increase among the less educated. This analysis also confirms the generation gap between women and men in the spread of smoking, even though prevalence levels are now high for both sexes. The importance of social inequalities in smoking is evident at younger ages, for all cohorts and for both sexes. For the oldest cohorts, the inequalities diminish over the course of life until they are reversed for women. For the most recent cohort, inequalities remain at a high level throughout the life cycle and tend to increase after age 25 for women. Based on this finding, it may be effective to target smoking prevention policies by social group and life stage, and in particular to focus efforts on preventing entry into smoking in less educated settings.

This thesis proposes to analyze the effects of ruptures in occupational trajectories on the health status of individuals in Europe. We consider two breaks in the career path: one at the beginning of the career -- entry into the labor market in a deteriorated economy -- and the other at the end of the career -- the transition to retirement. Between these two critical periods, we are specifically interested in the impact on health of a break, this time anticipated: the fear of losing one's job. Our empirical analyses combine data from European and British surveys. In order to overcome the endogeneity problems inherent in any empirical analysis of the link between health and career trajectory, we apply exogenous shocks to the careers of individuals. We thus use a natural experiment (the 1973 oil crisis) and the institutional characteristics as defined in the legislation of each European country (legal retirement ages, degrees of employment protection, compulsory schooling rules). Our project aims to identify a causal link between the professional activity of individuals and their obesity category through the use of specific econometric techniques taking into account endogeneity and the use of data from the GAZEL cohort (which has been following 20,000 volunteers employed at EDF-GDF since 1989).

This thesis is based on the assumption that, in order to influence drug use, it is necessary to analyze in detail the determinants of the entry into drug use during adolescence. The tools provided by economic science can shed new light on these determinants. After presenting an overview of public policies to combat tobacco and alcohol in France, we focus on four main themes. First, we look at the monetary resources available to adolescents and show that the amount and origin of these resources are key factors in adolescent drug use. We then study the complementary or substitution relationships that link tobacco and alcohol use. We show that a policy of taxing spirits reduces the consumption of spirits and tobacco by European adolescents, but that the results differ according to the group of European countries. Next, we examine the influence of peer group. We highlight that the likelihood that an adolescent will use drugs increases with the number of peers perceived to be drug users and decreases with peer group size, desire for higher social status, and quality of peer relationships. We conclude with a theoretical analysis highlighting that, beyond traditional policies based on increasing the costs of drugs, considering the benefits of drug use offers new avenues of reflection for primary prevention public policies.

No summary available.

The Aide à l'acquisition d'une complémentaire santé (ACS) is a scheme, in the form of financial assistance, set up in 2005 to promote access to health care for people with incomes just above the ceiling for eligibility for the Couverture maladie universelle complémentaire (CMU-C). Despite its increase in coverage, non-use of the ACS is significant, with only 22% of eligible individuals having claimed their right in 2011 (Fonds CMU, 2012). In this context, understanding the reasons for non-take-up seems essential to improve the effectiveness of the system and enable people on low incomes to access complementary health insurance. Following a social experiment, a survey was carried out in 2009 in Lille among people potentially eligible for the ACS in order to better understand their characteristics and their motivations or obstacles to using the system. The results of this survey show that the population identified as eligible for the ACS in Lille is faced with economic and social difficulties and has significant healthcare needs. However, the ACS take-up rate is low, with only 18% of people having taken steps to obtain it. The reasons most often given for not taking up the ACS are: the belief that they are not eligible, lack of information, the complexity of the procedures and, for those not covered, the price of the complementary health insurance, even after deducting the health check.

This thesis addresses social inequalities in health behaviors such as health-related lifestyles (specifically, obesity and alcohol consumption) and health service utilization, in several OECD countries. This work is based on a micro-econometric approach and uses a large number of national databases. The objectives of this thesis are to: (1) compare social inequalities in health behaviors across countries with different characteristics, (2) shed light on the understanding of social disparities in health behaviors, and finally (3) examine how self-reporting may affect the measurement of health behaviors, and thus affect the measurement of inequalities.

Background: Even if health status of immigrants constitutes an important public health issue, the literature provides contradictory results on the existence of a ‘healthy migrant’ effect in Europe. This study proposes to explore the heterogeneity of the health gap between migrants and natives across four European countries. Data and methods: Based on several harmonized national health interview surveys, the association between migratory status and self-assessed health was firstly explored separately in Belgium, France, Spain and Italy. To explore whether differences in health gap between countries reflect differences in health status of immigrants between host countries or whether they are because of differences in health status of natives between host countries, the association between the host country and health was secondly analysed separately among a pooled sample of immigrants and one of natives, controlling for socio-economic status and country of origin. Results: After controlling for socio-economic status, immigrants report a poorer health status than natives in France, Belgium and Spain, whereas they report a better health status than natives in Italy, among both women and men. A North–South gradient in immigrants’ health status appears: their health status is better in Italy and in Spain than in France and Belgium. Conversely, health status of natives is poorer in Italy and in Belgium than in France and in Spain. Conclusion: Differences in health gap reflect differences in health status of both natives and immigrants between host countries. This suggests differences in health selection at migration and in immigrants’ integration between European countries.

This paper is based on a randomised social experiment conducted in order to understand the low take-up rate of a Complementary health-insurance voucher program for the poorest in France (the Aide Complémentaire Santé: ACS). We explore two of the main hypotheses put forward to explain low enrolment: a lack of information about the program and a voucher amount considered to be too low. A sample of eligible individuals living in an urban area in Northern France were randomly split into three groups: a control group who benefited from the standard level of financial aid. a group benefiting from an increase in the value of the voucher. and a third group benefiting from the same increase along with an invitation to an information meeting regarding ACS. We show that the voucher increase has a small but statistically significant effect on ACS take-up. The invitation to the meeting appears to cancel out the positive effect of the voucher increase. Using an instrumental variable model to control for potential selection bias, we find ambiguous evidence of the meeting attendance on ACS take-up. This study confirms the difficulties that are faced in increasing the health insurance coverage of poor populations via subsidy programs.

In France, despite the preponderant role of compulsory health insurance in the financing of health care expenses (75.9% on average in 2012), access to health care is strongly dependent on the possession of a complementary health insurance contract, and its quality, of which 5% of the population remained without in 2012. The generalization of access to supplementary health insurance is thus at the heart of the national health strategy set out in 2013 by Marisol Touraine and the first measure negotiated in the framework of the National Interprofessional Agreement (ANI) of January 2013 will consist in generalizing company supplementary health insurance and improving its portability on January 1, 2016. This article proposes to study the expected effects of this measure on the generalization of complementary health insurance in France and its consequences in terms of well-being on the one hand, and on inequalities in access to complementary health insurance on the other. Using the 2012 Health and Social Protection Survey, we simulate the impact of the introduction of the ANI on the proportion of individuals who remain uncovered by a complementary health insurance plan in the general population and according to health status, socio-economic status, time and risk preferences and the reason for not having coverage. We show that the rate of non-coverage, estimated at 4% after the generalization of company supplementary health insurance and at 3.7% taking into account portability, will always remain higher for the most vulnerable populations, and in particular the unemployed. On the other hand, the ANI will reduce the link, all other things being equal, between non-coverage and preferences with regard to time and risk. This measure therefore risks countering non-coverage by choice without eliminating non-coverage for financial reasons.

The growing literature indicates that poor living conditions (unhealthy housing, education access, labor market access.) or low socio economics status are majors determinants of health and health inequalities (Jusot, 2006). Regarding poor living conditions, a section of energy economics concerns the fuel poverty concept. In France, fuel poverty was deÖned in the Article 11 of the national commitment to the environment (Grenelle II) of 12 July 2010: " an household who has di¢ culties disposing of the necessary energy satisfy his basic needs due to the inadequacy of his resources or his living conditions is in fuel poverty under this Act ". The french deÖnition of fuel poverty appears as a interaction between households, their socio-economic situation and their dwelling. This one can create some cumulatives e§ects or constitute a ripple e§ect. Moreover, the fuel poverty can considered as a part of the Precar- iousness framework as the food precariousness, the health precariousness, the Önantial precariousness. So, the fuel poverty can interact with the others types of precariousness. In this way, the fuel poverty constitute a additional source of weakening for individuals. In more general terms, the fuel poverty con- tribute to increase vulnerability to Poverty.

No summary available.

The results highlight the evolution of the diffusion of smoking between social groups and by gender. After having been more frequent in the most educated groups, smoking decreased among them and declined later among the least educated groups. This analysis also confirms the one-generation lag in the diffusion of smoking among women compared to men, even if inequalities are now strong in both sexes.

The way to treat the correlation between circumstances and effort is a central, yet largely neglected issue in the applied literature on inequality of opportunity. This paper adopts three alternative normative ways of treating this correlation championed by Roemer, Barry and Swift and assesses their empirical relevance using survey data. We combine regression analysis with the natural decomposition of the variance to compare the relative contributions of circumstances and efforts to overall health inequality according to the different normative principles. Our results suggest that, in practice, the normative principle on the way to treat the correlation between circumstances and effort makes little difference on the relative contributions of circumstances and efforts to explained health inequality.

Two methods are generally considered for the evaluation of health policies. The cost-benefit approach is based on the sum of individual willingness to pay: it respects individual preferences but gives priority to the preferences of the richest people because their willingness to pay is generally higher. The cost-effectiveness approach selects policies that provide the highest overall health gain for a given total cost. It does not benefit high-income individuals, but it may have other undesirable effects, such as favoring treatment of a minor condition that will benefit the most people over a major condition that affects few. A variant of cost-benefit analysis avoids these pitfalls. It consists of weighting the willingness to pay by coefficients that vary in the opposite direction to an indicator of individual well-being combining income and health status. The indicator chosen is health equivalent income: this is the individual's actual income minus the amount he or she would be willing to forego in order to be in perfect health. For a given income, it therefore decreases when health deteriorates. Unlike subjective utility indices, it has the advantage of being based solely on the ordinal preferences of individuals. This approach is implemented through a survey conducted on a representative sample of the French population. Given their financial constraints, low-income individuals attach less relative importance to their health status. However, the coefficients obtained nevertheless allow us to overweight the least privileged individuals who have a combination of low income, poor health and a strong preference for improving their health. These coefficients can then be used to evaluate any policy for which individual willingness to pay is known.

The way to treat the correlation between circumstances and effort is a central, yet largely neglected issue in the applied literature on inequality of opportunity. This paper adopts three alternative normative ways of treating this correlation championed by Roemer, Barry and Swift and assesses their empirical relevance using survey data. We combine regression analysis with the natural decomposition of the variance to compare the relative contributions of circumstances and efforts to overall health inequality according to the different normative principles. Our results suggest that, in practice, the normative principle on the way to treat the correlation between circumstances and effort makes little difference on the relative contributions of circumstances and efforts to explained health inequality.

This thesis focuses on the measurement and understanding of inequalities of opportunity in health, i.e., inequalities attributable to factors that are not the responsibility of individuals, such as their background. We are specifically interested in the contribution of health behaviors in the construction of these inequalities. We develop our analysis through three axes: (i) the measurement of the respective importance of living conditions in childhood, level of education and health behaviors in the explanation of health inequalities. (ii) analysis of the mechanisms involved in the intergenerational transmission of health behaviours, using the example of smoking and health care habits. (iii) the measurement of differences between European countries in inequalities of opportunity in health. The empirical analyses combine prospective data from a British cohort with retrospective data from a French survey and a European survey. The results highlight the contribution of childhood living conditions and educational level to health inequalities, both directly and indirectly through health behaviors.

The Aide complémentaire santé (ACS) or "health voucher" was introduced in 2005 to encourage households whose standard of living is just above the CMU-C ceiling to acquire supplementary health coverage through a subsidy. Although the number of beneficiaries has slowly increased since its introduction, the use of the ACS remains low. Two hypotheses can explain this state of affairs: (1) lack of information on the existence of the system, how it works and the steps to take to benefit from it. (2) an insufficient amount of aid, as the complementary health insurance would remain too expensive even after deduction of the aid. In order to test the validity of these two hypotheses, a controlled social experiment was set up by the University of Paris-Dauphine in Lille with a sample of 4,209 insured persons potentially eligible for the ACS. An increased amount of aid and differentiated access to information on the system were offered randomly to certain insured persons. The results show robustly that increasing the amount of the "health check" slightly improves the ACS take-up rate and makes it possible to better target those who are actually eligible. However, the ACS remains a complicated system that has difficulty reaching its target: in total, only 17% of insured persons have applied for the ACS. Only 9% of policyholders invited to attend an information meeting actually did so, and the invitation to the meeting largely discouraged other policyholders, thus cancelling out the effect of the increased cheque. Finally, only 55% of the insured who applied received the aid, the others having been refused the aid because, in most cases, their resources were too high. The difficulty in targeting the eligible population and the resulting significant uncertainty about eligibility are certainly obstacles that add to the complexity of the process.

Heterogeneity in time and risk preferences has been proposed as one of the mechanisms involved in the educational gradient in smoking, but this mechanism has scarcely been explored empirically. Subjective scales were introduced in the 2008 French National Health, Health Care and Insurance Survey in order to elicit measures of time and risk preferences for a representative sample of 5188 men and 5684 women. Men and women were treated separately. First, logistic regressions were used to test the associations between preferences and education and between preferences and smoking. Second, nested logistic models were built to investigate the mediating role of preferences in the educational gradient in smoking, with an econometric treatment of the rescaling problem. Preference for the present and risk loving were found to be: inversely related to educational level. strongly related to each other, and. strongly associated to current smoking, even after adjustment for educational level. There was a weakening of the educational gradient after the control for preferences, which supports the role of these two preferences as partial mediators in the educational gradient in smoking. Among men, time preference was more strongly associated with smoking than risk aversion, while the reverse was found for women. We provide convincing evidence in favour of the mediating role of time preference and risk aversion in educational inequalities in smoking and highlight the connection between those two dimensions. Gender patterns are discussed and potential implications in terms of designing targeted anti-tobacco programmes are delineated.

This chapter aims to quantify and compare inequalities of opportunity in health across European countries considering two alternative normative ways of treating the correlation between effort, as measured by lifestyles, and circumstances, as measured by parental and childhood characteristics, championed by Brian Barry and John Roemer. This study relies on regression analysis and proposes several measures of inequality of opportunity. Data from the Retrospective Survey of SHARELIFE, which focuses on life histories of European people aged 50 and over, are used. In Europe at the whole, inequalities of opportunity stand for almost 50% of the health inequality due to circumstances and efforts in Barry scenario and 57.5% in Roemer scenario. The comparison of the magnitude of inequalities of opportunity in health across European countries shows considerable inequalities in Austria, France, Spain and Germany, whereas Sweden, Poland, Belgium, the Netherlands and Switzerland present the lowest inequalities of opportunity. The normative principle on the way to treat the correlation between circumstances and efforts makes little difference in Spain, Austria, Greece, France, Czech Republic, Sweden and Switzerland, whereas it would matter the most in Belgium, the Netherlands, Italy, Germany, Poland and Denmark. In most countries, inequalities of opportunity in health are mainly driven by social background affecting adult health directly, and so would require policies compensating for poorer initial conditions. On the other hand, our results suggest a strong social and family determinism of lifestyles in Belgium, the Netherlands, Italy, Germany, Poland and Denmark, which emphasises the importance of inequalities of opportunity in health within those countries and calls for targeted prevention policies.

This research proposes to study the inequalities in health and health care utilization between the native and immigrant populations. Particular attention is paid to the role of social capital, which implies an influence of social networks or social interactions on health status and health care utilization. We adopt a micro-econometric approach and build our reflection around three themes: (i) the identification of immigration-related inequalities in health status and health care utilization, (ii) the understanding of the mechanisms that generate these inequalities, and finally (iii) the evaluation of the causal impact of social capital on the health status and health care utilization of immigrants. In terms of public policy, analysis of the mechanisms generating inequalities suggests that several levers of action are possible. Given the protective role of social capital on health, the development of specific local actions appears necessary to increase social integration and social support for immigrants. The importance of supplementary health coverage in determining inequalities also demonstrates the need to simplify access to State Medical Aid and Universal Health Coverage in order to promote prevention and access to care for immigrants.

This thesis proposes an empirical analysis of the influence of income and income inequalities on mortality in France. To compensate for the lack of information on income in the available demographic data, this analysis was carried out using a case-control survey constructed from two tax databases: the 1988 Wealth at Death survey and the 1990 Household Tax Income survey. This approach makes it possible to identify the determinants of the probability of death in 1988 by comparing the characteristics of a sample of deceased persons with those of a sample of survivors. An initial analysis, carried out using a method of indirect estimation of mortality, shows that the survival function increases with income at each age. The exploitation of the case-control survey confirms the existence of a very strong correlation between income and mortality, after controlling for occupation. The protective effect of income exists at each level of the income distribution. The results indicate an excess mortality associated with poverty but also a less expected effect, an under-mortality associated with higher incomes. A multilevel analysis shows that the level of income inequality in the region of residence is in itself a determinant of mortality after control for health care provision. This thesis suggests that the risk of death depends very strongly on the absolute level of resources of the individual, but also more broadly on his or her economic and social environment.