Access to Healthcare in Overseas France: specific situations require specific solutions

The specificities of the Overseas Departments and Regions – Overseas Collectivities (DROM-COM) have a major impact on the organization of their healthcare systems. Even if the objectives for improving the quality of patient care, as defined in the 2018-2022 national health strategy, apply there, additional efforts and specific measures will be needed to achieve them in Overseas France. In France, the coverage and organization of healthcare systems are highly heterogeneous from region to region. Added to these disparities are specific territorial challenges in Overseas France that may hinder or delay access to care for patients. Given the high demand for care services in these territories, with a population of nearly 2.2 million inhabitants and a wide range of pathologies, tailored actions will be necessary to reduce disparities and improve access to care for all patients. In this article, Alcimed discusses local challenges in access to care and possible levers to address them.

Demographic and epidemiological disparities

Firstly, the Overseas territories have particular population profiles. From a population that was generally younger than mainland France’s in the 2000s, the overseas departments and regions (DROM), and more specifically the West Indies, are now facing a sharp increase in the proportion of people over 60 years of age due to an accelerated aging of the population. Thus, according to projections for 2050, Martinique would become the oldest department in France and Guadeloupe the 6th, due to a low birth rate and a migration deficit in favour of mainland France. New medical needs are emerging, including the management of polypathologies and support measures to maintain autonomy. The demographic situations are slightly different in French Guiana and Mayotte, with a rapidly growing population, driven by a positive natural balance and a massive arrival of cross-border immigrants, for example from Surinam and Brazil in French Guiana.

Secondly, many chronic diseases, such as diabetes or high blood pressure, are more frequent than in mainly France, possibly due to unfavourable social conditions. For example, La Réunion has the highest rate of patients treated for diabetes, mainly type 2, in France (10.2%), with a comparable age structure. The prevalence of some genetic diseases is higher in the French Overseas Territories, where at-risk populations are concentrated, such as sickle cell anaemia, where the frequency of carriers of the sickle cell trait was 5.2% for Overseas France compared to 2.7% in mainland France in-between 2006 and 2010. Moreover, infectious risks, favored by climatic conditions and lack of equipment, are more prominent there. On the one hand, via vector-borne infections such as malaria and chikungunya which spread easily, e.g., following the 2005 epidemic, nearly 35% of the population of La Réunion was infected by the chikungunya virus. On the other hand, via non-vector infectious diseases, including hepatitis and HIV, with the French West Indies and Guiana having an HIV incidence rate of 59 per 100,000 inhabitants compared to 39 per 100,000 in Ile-de-France.

Medical demography imbalance

The overseas collectivities have the lowest density of clinicians in office-based or mixed settings, with 87.5 doctors per 100 000 inhabitants.

Due to a shortage of specialists, a heterogeneous distribution of healthcare structures and the frailty of medical resources (medical turnover, financial difficulties of hospitals, lack of equipment), healthcare services face difficulties in addressing a growing demand in the DROM-COM. In particular, due to the lack of private practitioners, hospital-centricity remains marked, with healthcare centers suffering from understaffing and management difficulties. The overseas collectivities have the lowest density of clinicians in office-based or mixed settings, with 87.5 doctors per 100 000 inhabitants. Appropriate diagnosis and treatment of certain pathologies are therefore often delayed, particularly in obstetrics and gynecology, mental health and some cancers care. In French Guiana and Mayotte, lack of social security coverage often represents a barrier to adequate care. The organization of care is therefore complex and inefficient, with patient management often limited to emergencies and resulting in significant medical evacuations, including for pathologies that could be managed locally

Unequal conditions of access to care

The high frequency of chronic diseases such as obesity and diabetes, as well as excess maternal mortality (4 times higher than in mainland France in 2012), perinatal mortality and infant mortality are all indicators of the social and economic inequalities that persist in Overseas territories. Depending on the territory, cumbersome displacements, long distances between the patient’s home and healthcare facilities, the language barrier in the case of multicultural populations as in French Guiana, and financial difficulties are all potential obstacles to adequate medical care and follow-up. In 2019, 45% of Mayotte residents aged 15 years or older reported that they had declined or postponed necessary medical care, mainly due to low income, long appointment times and difficulties in accessing healthcare services.

Overseas territories with strong potential to promote innovation in access to care

Thus, customized solutions must be implemented to address these specific challenges, meet  patients’ needs and optimize care pathways. To do this, all stakeholders must be involved, including institutions and public authorities, as well as healthcare professionals and drug manufacturers, and will leverage the unique assets of overseas territories.

These assets are first and foremost of an epidemiological and demographic order. The diversity of pathologies to which the DROM-COM are confronted constitutes a pool of strategic data to develop research and prevention. Thanks to its environment and biodiversity, the Biological Resource Center Amazonia offers a unique opportunity to gain a better understanding of certain diseases in French Guiana, the only French territory in Latin America. Blood collection centers (EFS) in La Réunion are other examples. The latter host a bank of rare and necessary blood because of phenotypic particularities, linked to its geographical position close to Africa, and local specificities (the “Bombay Réunion” groups for example).

Secondly, geographic isolation implies that institutions and healthcare providers must adapt to their local healthcare situation and resources. Even if overseas territories were attractive for healthcare professionals in 2021, with an increase of +7.3% and +6.9% in the number of practitioners in Mayotte and French Guiana respectively, it will be necessary to further develop comprehensive medical care, with good regional coverage, to address uncovered medical needs. Furthermore, recent investments in West Indies medical centers are promising in order to close equipment gaps, such as the recent acquisition of a PET scanner and a PET-MRI scanner at the Martinique University Hospital, to offer a new cancer patient pathway and to develop teaching and medical research.

Learn more about the challenges of optimizing patient pathways >

Finally, collaboration and sharing of resources are essential to ensure quality of care for patients in Overseas territories. The current dynamic to structure patient care pathways illustrates the willingness of healthcare professionals to organize themselves into local care networks to facilitate cooperation, in and out of the hospital, and the sharing of information to patients. Ongoing actions illustrate these local and regional collaborations, such as:

• The creation of public-private partnerships, such as the agreements established to foster team work, leveraging telemedicine, between prevention and care centers and Cayenne Hospital,
• Territorial organizations that are being set up, such as the Territorial Professional Health Communities (CPTS) for unscheduled care management. For instance, the Madinina CPTS in Martinique has been a pioneer since 2017. It provides liberal project leaders with the possibility to develop new care usages and co-construct innovative solutions,
• Pilots of access to heathcare service (S.A.S.), as in La Réunion, to optimize the patient’s pathway and to relieve the congestion of emergency services,
• Regional cooperation networks and actions set up in these territories in response to the 3^rd National Plan for Rare Diseases call for projects in 2019 for the creation of overseas rare disease platforms.

The DROM-COM offer a vast field of opportunities to support local actors in their willingness to test and implement new patient care pathways. This will first require a detailed investigation of the pathway, mapping of its stakeholders and understanding the current clinical practices. Moreover, given the acuteness of challenges encountered, along with existing assets on which to capitalize, Overseas France have unique possibilities to foster the creation of innovative care organization models. Our team is here to support you in deciphering this ecosystem and in identifying relevant solutions to improve access to care for overseas patients.

About the author,

Céline, Consultant in the Alcimed’s Healthcare team in France.