WITTWER Jerome

BACKGROUND: Malaria is one of the leading causes of morbidity and mortality in African countries. It is one of the leading causes of hospital visits and hospitalization in pediatric wards for children under 5 years old. Interestingly however, the economic burden of this disease remains unknown in these endemic countries including Gabon. The purpose of this study is to assess the direct hospital cost for the management of malaria in children under 5 years old at the Libreville University Hospital Centre (CHUL, Centre Hospitalier Universitaire de Libreville) in Gabon. METHODS: This research work is a retrospective study using a comprehensive review of medical records of patients seen at the CHUL over a two-year period extending from January 2018 through December 2019. The study focused on children under 5 years old, admitted for malaria in the paediatric ward of the CHUL. The analysis targeted specifically direct hospital costs, which excluded salary and wages of health care workers. The monetary currency used in this study was the CFA francs, as that currency is the one used in Central Africa (as reference, 1 Euro = 656 CFA francs). RESULTS: For the set timeframe, 778 patient records matched the study criteria. Thus, out of 778 admitted patients, 58.4% were male while 41.5% were female. Overall, the average age was 13.2 months (± 13.8 months). The total cost incurred by the hospital for the management of these 778 malaria patients was 94,922,925 CFA francs (144,699.58 €), for an average expense per patient topping at 122,008 CFA francs (185.99 €). The highest expenditure items were hospitalizations (44,200,000 CFA francs, 67,378.1 €), followed by drugs (26,394,425 CFA francs, 40,235.4 €) and biomedical examinations (14,036,000 CFA francs, 21,396.34 €). CONCLUSION: The financial burden for managing malaria in the paediatric ward seems to be very high, not only for the hospital, but also for families in spite of the government medical insurance coverage in some cases. These findings bring new insights as to the urgency to develop policies that foster preventive initiatives over curative approaches in the management of malaria in children in endemic countries.

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The Covid-19 crisis brought health to the forefront of public policy concerns and debates and highlighted the weaknesses of the European Union in preventing and managing a pandemic. The start of the vaccination campaign, despite its shortcomings, demonstrated the importance of a common policy for the block, allowing for de facto solidarity among member states through the allocation of vaccine supply based on respective national population sizes. In this note, we consider going further and pursuing a common European health policy. We propose that this policy be administered by a single European health agency with sufficient financial means to carry out its tasks. The Health4EU initiative, or health for all European citizens, that we are defending is not to create a European health policy that would replace national policies, but to add three complementary missions to these national policies. First, the agency would coordinate a policy of investment in human capital by facilitating the mobility of health care workers to enable them to follow or provide additional training in the field, thus helping to improve the match, in quality and quantity, between local health supply and demand. Second, the agency would ensure a strategic supply of medicines and equipment. It would give the EU a purchasing capacity, and therefore a negotiating capacity with health industrialists, which would allow it to exploit economies of scale. Finally, the agency would assist local authorities to improve their health and long-term care infrastructures, thus giving substance to a more ambitious European health policy that is concerned with reducing inequalities in access to care throughout Europe.

The implementation of the Millennium Development Goals (MDGs) has resulted in significant but uneven progress across countries. Sub-Saharan African countries are still characterized by high proportions of out-of-school children, high infant mortality and a high burden of communicable diseases, including malaria, in the overall disease burden. Added to this is a high level of fertility with its potential economic consequences. The Sustainable Development Goals also target malaria for elimination by 2030 and advocate for quality education for all, including early childhood care, which had been overlooked in the MDGs. This thesis analyzes aspects of development related to these global challenges. The first chapter analyzes the impact of malaria control campaigns on fertility in Mali using Demographic and Health Survey data from 2006 and 2012 and Malaria Atlas Project data from the same period. The results show that malaria has a negative effect on fertility (-0.24 children). Among the mechanisms that explain this effect (infant deaths, abortions), maternal education is the most important mechanism. The second chapter examines the relationship between malaria, household income and investment in education through a randomized controlled trial in a village in Mali. Surveys were conducted in July and December 2016 among the same households, with microscopy malaria screening of children aged 3 months to 5 years. Results show that relaxing malaria-related economic loss constraints (direct costs, care expenses, and/or lost productivity) allowed households to save 3194 F CFA (5 euros) and make additional expenditures of 2863 F CFA (4 euros) in children's education. The third chapter, also a randomized controlled trial, analyzes the effect of reminder messages and information to household heads on the use and adoption of the impregnated mosquito net strategy using a cell phone platform in Bobo Dioulasso, Burkina Faso. Surveys were conducted in 2013, 2016 and 2017 to collect data from the same households. The results show that the problem of inappropriate use of malaria preventive care, can be solved using the classic health awareness method or by disseminating information messages to heads of households through their dissemination by a cell phone platform. The effect was between 4.6 and 6 percentage points for text and voice messages respectively. The fourth chapter analyzes the impact and cost of a set of health and education strategies (micronutrients, SPC, deworming) on improving early childhood development. This was a randomized controlled trial with villages as the unit of randomization, conducted in 2016 in an area of high malaria transmission and high anemia prevalence, Sikasso in southern Mali. The cost of the different strategies was evaluated from a provider perspective for a relatively short time horizon. The integrated strategies did not have an impact on early childhood development. However, the cost of implementing these strategies was limited. In conclusion, malaria is a burden on economic development, through effects on fertility and income, potentially penalizing investment in education. Our results therefore contribute to the existing literature on the effect of malaria on economic development.

The French health care system raises many issues in primary care, both in terms of the territorial distribution of the supply of care and in terms of spending and the management of certain diseases. The development of advanced practice nursing - which allows an advanced practice nurse to perform certain medical tasks, complementary or substitutable to those of the physician, in the first or second line of care - is a response to these challenges. The objective of this thesis is to study the framework for regulating the quality of care delivered by a physician and an advanced practice nurse. It is composed of four chapters. The first chapter highlights the challenges of the French healthcare system to which advanced practice nursing responds and the obstacles posed by current French regulation to the development of the practice. The second chapter discusses, based on the literature, the liability regime that is effective in dissuading physicians and nurses from being imprudent. The third chapter is a theoretical study of the optimal liability rule to be applied to advanced nursing practice depending on the nurse's mode of practice. The final chapter reports on a laboratory experiment that analyzes the effect of collaboration between health care professionals on quality of care as a function of the accountability regime. The thesis demonstrates that advanced nursing practice should be regulated by a fault-based liability regime that allocates reparations for harm according to the interdependence of the behaviors of each of the two practitioners. In addition, the control exercised by the physician when the nurse practices in a salaried capacity leads to a better quality of care. Finally, the laboratory experiment shows, in the presence of a rule of responsibility, a decrease in the quality of care linked to interprofessional collaboration. This result should lead to the development of collaboration between health professionals with caution.

Objective. In 2010, the principle of proportionate universalism (PU) has been proposed as a solution to reduce health inequalities. It had a great resonance but does not seem to have been widely applied and no guidelines exist on how to implement it. The two specific objectives of this scoping review were: (1) to describe the theoretical context in which PU was established, (2) to describe how researchers apply PU and related methodological issues. Methods. We searched for all articles published until 6th of February 2020, mentioning “Proportionate Universalism” or its synonyms “Targeted universalism” OR “Progressive Universalism” as a topic in all Web of Science databases. Results. This review of 55 articles allowed us a global vision around the question of PU regarding its theoretical foundations and practical implementation. PU principle is rooted in the social theories of universalism and targeting. It proposes to link these two aspects in order to achieve an effective reduction of health inequalities. Regarding practical implementation, PU interventions were rare and led to different interpretations. There are still many methodological and ethical challenges regarding conception and evaluation of PU interventions, including how to apply proportionality, and identification of needs. Conclusion. This review mapped available scientific literature on PU and its related concepts. PU principle originates from social theories. As highlighted by authors who implemented PU interventions, application raises many challenges from design to evaluation. Analysis of PU applications provided in this review answered to some of them but remaining methodological challenges could be addressed in further research. Objetivo. En 2010 se propuso el principio del universalismo proporcional como solución para reducir las desigualdades en materia de salud. Aunque tuvo una gran resonancia, no parece haber sido aplicado ampliamente y no existen directrices sobre cómo aplicarlo. Los dos objetivos específicos de esta revisión sistemática exploratoria fueron: 1) describir el contexto teórico en el que se estableció el universalismo proporcional, y 2) describir cómo los investigadores aplican el universalismo proporcional y las cuestiones metodológicas relacionadas. Métodos. Se buscó en todas las bases de datos de la Web of Science los artículos publicados hasta el 6 de febrero de 2020 que tuvieran como tema “universalismo proporcional” o sus sinónimos “universalismo dirigido” o “universalismo progresivo”. Resultados. Esta revisión de 55 artículos permitió tener una visión global del universalismo proporcional en cuanto a sus fundamentos teóricos y su aplicación práctica. El principio del universalismo proporcional se basa en las teorías sociales del universalismo y el direccionamiento, y propone vincular estos dos aspectos para lograr una reducción efectiva de las desigualdades en materia de salud. Respecto de su aplicación práctica, las intervenciones basadas en este principio son poco frecuentes y dan lugar a diferentes interpretaciones. Todavía existen muchos desafíos metodológicos y éticos en relación con la concepción y la evaluación de las intervenciones relacionadas con el universalismo proporcional, incluida la forma de aplicar la proporcionalidad y la identificación de las necesidades. Conclusión. En esta revisión se llevó a cabo un mapeo de la literatura científica disponible sobre el universalismo proporcional y sus conceptos relacionados. Este principio se basa en teorías sociales. Tal como lo destacaron autores que implementaron intervenciones de universalismo proporcional, su aplicación plantea muchos desafíos, desde el diseño hasta la evaluación. El análisis de las aplicaciones del universalismo proporcional presentado en esta revisión respondió a algunos de ellos, pero los desafíos metodológicos restantes requieren ser abordados en futuras investigaciones.

The links between digital health and social and territorial inequalities are rarely studied. On these two markers of health systems and on the digital-inequality coupling, the policies of Western health systems have been even less studied, despite international injunctions to adopt "health (and equity) in all policies" strategies. This thesis studied the actions of governments and other actors involved in this digital-inequity coupling. Rooted in intervention research and political science, it relies on a mainly qualitative methodology of sociology of public action. The comparative analysis of public action between sub-territories in four countries (France, Canada, Spain and England), since 2015, is based on documentary study (official and stakeholder sources) and on interviews with key actors in the fields of digitalization and social inequalities in health. Health digitization policy has become institutionalized to varying degrees, in the four countries studied. However, equity in digital health has not been placed on the political agenda, despite the fact that digital health has the potential to increase inequalities in access, understanding and appropriation of ICT. In the four territories, when it is (rarely) addressed, digital inclusion is done so through a combination of instruments and groups of actors from various forums that co-produce public interventions on digital, inequalities and digital inclusion. Each mode of public action instrumentation varies across territories and is affected by existing local institutions, interests and actors' perceptions of them. This thesis proposes a conceptual framework for public action and policy implementation in digital health and equity in four territories. It is designed to provide keys for policy analysis in other contexts and to suggest strategies that could be implemented in the field.

■The Recovery Fund recently proposed by the EU Commission marks a sea-change in European integration. Yet it will not be enough to meet the challenges Europe faces. There has been much public debate about financing, but little about the sort of concrete projects that the EU should be putting public money into.■Here we propose a 10-year, €2tn investment programme focusing on public health, transport infrastructure and energy/decarbonisation. ■It consists of two pillars. In a national pillar Member States — broadly as in theCommission proposal — would be allocated €500bn. Resources should be focused on the hardest-hit countries and front-loaded: we suggest over a three-year horizon.■The bulk of the money —€1.5tn — would be devoted to finance genuinely European projects, where there is an EU value added. We describe a series of flagship initiatives that the EU could launch in the fields of public health, transport infrastructure and energy/decarbonisation. ■We call for a strengthened EU public health agency that invests in health-staff skillsand then facilitates their flexible deployment in emergencies, and is tasked withensuring supplies of vital medicines (Health4EU). ■We present costed proposals for two ambitious transport initiatives: a dedicated European high-speed rail network, the Ultra-Rapid-Train, with four-routes cuttingtravel times between EU capitals and regions, and, alternatively, an integrated European Silk Road initiative that combines transport modes on the Chinese model. ■In the area of energy/decarbonisation we seek to “electrify” the Green Deal. We call for funding to accelerate the realisation of a smart and integrated electricity gridfor 100%-renewable energy transmission (e-highway), support for complementary battery and green-hydrogen projects, and a programme, modelled on the SURE initiative, to co-finance member-state decarbonisation and Just Transition policies.■The crisis induced by the pandemic, coming as it does on top of the financial and euro crises, poses a huge challenge. The response needs to take account of the longer-run structural challenges, and above all that of climate change. The European Union should rise to these challenges in the reform of an ambitious medium-runrecovery programme, appropriately financed. An outline of such a programme isset out here by way of illustration, but many permutations and options are available to policymakers.

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BACKGROUND: For financial reasons, dental prosthetics is one of the major unmet dental healthcare needs [Financial-SUN (F-SUN)]. Private fees for dental prosthetics result in significant out-of-pocket payments for users. This study analyzes the impact of geo-variations in protheses fees on dental F-SUN. METHODS: Using a nationwide French declarative survey and French National Health Insurance administrative data, we empirically tested the impact of prosthetic fees on dental F-SUN, taking into account several other enabling factors. Our empirical strategy was built on the homogeneous quality of the dental prosthesis selected and used to compute our price index. RESULTS: Unmet dental care needs due to financial issues concern not only the poorest but also people with middle incomes. The major finding is the positive association between dental fees and difficulty in gaining access to dental care when other enabling factors are taken into account (median fee in the highest quintile: OR = 1.35. P value = 0.024. 95% CI 1.04-1.76). People with dental F-SUN are those who have to make a greater financial effort due to a low/middle income or a lack of complementary health insurance. For identical financial reasons, the tendency to give up on healthcare increases as health deteriorates. CONCLUSIONS: The results underscore the need for fee regulation regarding dental prosthetics. This is in line with the current French government dental care reform.

The recent advent of innovative and expensive therapies in various therapeutic fields raises important hopes from a public health perspective. However, providing equitable access to these innovations competes with other public investments that are also subject to strong social expectations. It therefore forces actors to define the maximum amount that the community is willing to spend for given health gains. The question then arises as to whether this maximum amount varies according to the circumstances surrounding individuals, such as the rarity of the disease, their lifestyles, and the social inequalities they have experienced throughout their lives. In this article, we focus on a particular priority, that given to the youngest populations, most often referred to, following Harris' work, as fair innings. We ask what might justify such prioritization. In this paper we examine three arguments. First, we propose to justify the fair innings criterion in the name of an objective of equalizing welfare opportunities in the population. Second, we propose to justify it on behalf of an objective of equalizing the time available to individuals to realize their life plans, in accordance with Rawls' theory of justice as fairness. Finally, we propose to justify it in the name of an objective of equalizing the time offered to individuals to accept death. There are, of course, many limitations to these three arguments and we highlight some of them. Our aim in this article is not to convince people of the superiority of one argument over the others. Rather, we seek to contribute to the discussion of prioritization criteria in health care by explaining what might justify one particular criterion: age.

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.

This article provides an overview of the organization of the financing of assistance to dependent elderly people in France. It restores the principles that have governed, since 1996, the construction of national public solidarity for the financing of independent living assistance, based on the historical foundation of social assistance, and analyzes, beyond theoretical principles, the actual global consequences of their implementation through a tangle of more or less coherent systems. Finally, it puts forward some recommendations for improving the economic efficiency and equity of public action in the field of autonomy support. At a time when the Covid-19 epidemic has just focused the media spotlight on collective accommodation facilities for dependent elderly people (EHPAD), we feel it is particularly important to guide, without sentimentality or haste, the reflection on the investments that the community is ready to make for the care and safety of dependent elderly people.

We study the incentive properties of physician contracts in different contexts and using different methods. In Chapter 1, we propose a "principal-agent" model in which there is adverse selection on the altruism of agents, limited liability and a technology provided by the regulator that can improve the quality of physicians' effort. In such a context (characterizing the health sector with access to personalized medicine for instance), we show that optimal contracts imply higher wages for altruistic agents and better quality effort-enhancing technology for selfish agents. In Chapter 2, we propose an experiment in which physicians can access personalized medicine techniques for free or at a given cost. We evaluate for different payment systems, the likelihood that physicians will make the decision to pay for access to personalized medicine, and we also focus on how they use these technologies, depending on whether they are free or costly to access. We find that physicians tend to make better use of personalized medicine techniques when they acquired it at a cost. In Chapter 3, we investigate the incentive properties of pay-for-performance systems. Using the same experiment from Chapter 2, we find that pay-for-performance systems enhance physicians' focus on what is relevant to the patient, but are associated with an erosion of their intrinsic motivation.

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?

The definition of health priorities in the context of universal health coverage emphasizes three values: improving the health of the population, ensuring equal access to and quality of services, and avoiding impoverishment or underutilization of services by users due to non-reimbursable expenditures. Allocative efficiency can be measured against any of these values, or against the whole, by different variants of cost-effectiveness analysis. In this thesis, we use Generalized Cost-Effectiveness Analysis, a standardized approach developed by the World Health Organization's Choosing Interventions that are Cost-Effective (WHO-CHOICE) program, which can be applied to all interventions in different settings. Using this approach, our dissertation provides a quantitative estimate of the allocative efficiency of resources for three groups of health problems: communicable diseases, non-communicable diseases, and traffic accidents, with a focus on two economically and epidemiologically different regions: East Sub-Saharan Africa and Southeast Asia. Our objectives are to inform health policy debates, to improve the global body of knowledge on the cost-effectiveness of different interventions by providing more information on the efficient allocation of resources for the three groups of health problems mentioned above, and to contribute to discussions on the development of universal health care programs.

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BACKGROUND: There is a growing interest in developing tailored non-pharmacological strategies to face patients' needs in dementia. Occupational therapy (OT) may contribute to promote self-empowerment of both patients and caregivers. France has implemented nationwide OT over a short-term period of 3/4 months. The main objective of the MatheoAlz study is to measure the impact of maintaining OT over 4 supplementary months on patients' neuropsychiatric symptoms. METHODS/DESIGN: The MatheoAlz trial (Maintenance of Occupational Therapy in Alzheimer's disease) is a multi-center, pragmatic randomized controlled trial testing maintenance of OT over 4 supplementary months compared to routine OT delivered as recommended. This paper describes the study protocol. MatheoAlz plans to enroll 240 dyads, i.e. dementia patients and caregivers, whose main inclusion criteria are: prescription for routine OT, patients with mild or moderate dementia, living at home, receiving support from an informal caregiver. The study will compare a control group of patients benefiting from 12 to 15 initial sessions of OT over 3/4 months and an intervention group of patients benefiting from these initial sessions plus 8 extra home sessions over 4 supplementary months. The main outcome is the patient's neuropsychiatric symptoms assessed by the Neuropsychiatric Inventory at 8 months. Several clinical outcomes and economic consequences are measured at 4, 8 and 12 months. DISCUSSION: This is the first trial designed to assess the specific impact of the maintaining OT on the patients' neuropsychiatric symptoms burden. The results will inform policymakers on strategies to implement in the near future. TRIAL REGISTRATION: This trial was registered at ClinicalTrials.gov on February 16, 2018, identifier: NCT03435705 .

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This doctoral thesis focuses on the challenges faced by rare disease patients. It is structured in three parts, each of which is dedicated to the issues of an actor at the heart of the diagnostic and therapeutic Odyssey of rare disease patients. The first part of the thesis focuses on the patient and his social network. Chapter 1 considers the sources of delay in access to diagnosis, and explores in particular the effect of social capital on the delay in obtaining a diagnosis. Chapter 2 discusses the negative externalities on maternal health of a diagnosis of a chronic disease in children. The second part of the thesis is dedicated to the pharmaceutical industry and focuses on R&D investment decisions targeting rare diseases. Chapter 3 assesses the causal effect of the Orphan Drug Policy on research effort, and Chapter 4 considers the inequalities in the allocation of R&D investments between rare diseases. Part 3 is dedicated to public policy makers and discusses the issues of evaluating the benefits of therapeutic innovation and defining the conditions of access to this innovation. Chapter 5 assesses the causal effect of therapeutic innovation on the longevity of rare disease patients. Chapter 6 is a critical discussion of the use of tools.

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In a context of population ageing, public policies encourage the utilization of pro- fessional home care for the elderly living in the community. This chapter studies the determinants of professional home care use by the disabled elderly in the French con- text. It focuses on the e_ects of the regulation of the supply and the generosity of public _nancing. We use departmental variations in both the regulation of providers and the implementation of the main program devoted to the disabled elderly, the APA policy. We exploit an original survey on departmental practices matched with the HSM survey to estimate the determinants of formal care use, at the extensive margin. We _nd no e_ect of the departmental generosity while, on the supply side, when non-regulated providers | whose quality is uncertain and price is lightly regulated | dominate the market, the disabled elderly have a lower probability to use formal home care. Our results contribute to discuss both the questions raised by the decentralization of a national policy and the recent reform of the home care sector requiring all home care structures to be regulated.

Digital health care is booming, driven by a multitude of players and supported by public policies. It is leading to new uses for both patients and professionals. Its development is coming up against a particularly complex organization of the healthcare system, especially in primary care medicine1. It poses four challenges. First, it is an organizational challenge, requiring that its dissemination be considered in relation to the organizational realities in which it is embedded. Second, it is a socio-territorial challenge, given the weight of health inequalities. The third challenge is medico-economic, questioning its overall economic model and its sustainability. Finally, the fourth challenge is based on the new technical and legal issues it raises.

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.

The purpose of this doctoral thesis is to evaluate the potential effects of increased competition in the health care market. It pays particular attention to the effects of competition on the allocative efficiency of the health care system in terms of health care and health expenditures. Taken together, our results suggest that the canonical effects of competition do not necessarily apply to the health care market, and detail circumstances in which increased competition could harm social welfare. This thesis consists of an introduction and three chapters (academic papers), each focusing on a different aspect of health system efficiency. The first chapter analyzes the impact of competition on hospital care practices and their regulation through prospective pricing. The second chapter details the regulatory issues related to the incomplete nature of patient information when choosing which care procedure to adopt, starting with the decision to implement additional diagnostic tests. The final chapter of this thesis discusses the possible consequences of the asymmetry that may exist between public and private care providers in terms of coverage obligations and can be applied to the market for home care for the elderly.

Background: University students aged 18-30 years are a population group reporting low access to health care services, with high rates of avoidance and delay of medical care. This group also reports not having appropriate information about available health care services. However, university students are at risk for several health problems, and regular medical consultations are recommended in this period of life. New digital devices are popular among the young, and Web-apps can be used to facilitate easy access to information regarding health care services. A small number of electronic health (eHealth) tools have been developed with the purpose of displaying real-world health care services, and little is known about how such eHealth tools can improve access to care. Objective: This paper describes the processes of co-creating and evaluating the beta version of a Web-app aimed at mapping and describing free or low-cost real-world health care services available in the Bordeaux area of France, which is specifically targeted to university students. Methods: The co-creation process involves: (1) exploring the needs of students to know and access real-world health care services. (2) identifying the real-world health care services of interest for students. and (3) deciding on a user interface, and developing the beta version of the Web-app. Finally, the evaluation process involves: (1) testing the beta version of the Web-app with the target audience (university students aged 18-30 years). (2) collecting their feedback via a satisfaction survey. and (3) planning a long-term evaluation. Results: The co-creation process of the beta version of the Web-app was completed in August 2016 and is described in this paper. The evaluation process started on September 7, 2016. The project was completed in December 2016 and implementation of the Web-app is ongoing. Conclusions: Web-apps are an innovative way to increase the health literacy of young people in terms of delivery of and access to health care. The creation of Web-apps benefits from the involvement of stakeholders (eg, students and health care providers) to correctly identify the real-world health care services to be displayed.

In France, in 2014, healthcare expenses amounted to 190 billion euros. This amount, which grows year after year, is financed for 76.6% by a social insurance, compulsory and proportional to income, taking care of all residents - the Health Insurance . 13.5% is financed by supplementary insurance and 8.5% directly by households in the form of out-of-pocket expenses. The relationship between public and private insurance is characteristic of mixed systems, in which insurance can complement each other, but can also lead to inefficient interactions. In the first part, we study theoretically a system where public insurance can be complemented by supplementary and/or additional insurance. While there was confusion between these two types of insurance in the literature (Petretto, 1999), we find sometimes opposite effects between complementary and supplementary insurance. Since the marginal utility of the poorest is higher than that of the richest, we find that by simply using the sum of individual utilities as the social welfare utility function, the optimal public insurance rate is positively related to the redistributive character of the insurance.In this first section, we note that the split between what is in the domain of supplementary and supplementary insurance is a function of the definition of the public goods basket. The second chapter studies the optimal composition of this public basket. At the heart of the choice of criteria to be used to select socially reimbursed goods is the possibility of comparing preferences, which has been debated at length in welfare theory and formalized by Arrow's incompatibility theorem. The income-equivalence principle of Fleurbaey et al (2013) proposes to overcome this limitation. This ordinal criterion, defined as income in full health equivalent to income in poor health, allows for interpersonal comparisons. Adapting a theoretical model studying the definition of a social optimal basket (Hoel, 2007) and using the income-equivalent principle, we find that the presence of private insurance changes the ranking of goods that need to be socially covered and reduces the optimal social budget. While the second part of the paper revealed which treatments should not be reimbursed as a priority by the health insurance system in the context of a limited budget, the last chapter studies a market characterized by a very low participation of the social insurance system. The optical market is characterized by information asymmetries and product differentiation. Beyond financing health care expenditures, we wonder whether private insurance is able to reduce these market failures and control health care expenditures. In the context of the literature on managed-care and competition for the right to serve, the last part studies the impact of networks set up by private insurers in the optical market to reduce expenditure. Using a proprietary database assembled by the author on a network of contracted opticians set up by the National Education Mutual Insurance Company (MGEN), the effect of the network on the number of sales and the prices charged is tested empirically. The effect of network and market competition on prices for single vision and bifocal lenses is estimated in 450 groups of French municipalities. Empirically, we find that in-network competition significantly reduces in-network prices, while in-market competition affects out-of-network prices.

This paper assesses the impact of eligibility for a free means-tested complementary health insurance plan, called Couverture Maladie Universelle Complémentaire (CMUC), on doctor visits. We use information on the selection rule to qualify for the plan to identify the effect of eligibility and adopt a regression discontinuity approach. Our sample consists of low-income individuals enrolled in the Health Insurance Fund and recipients of social benefits from the Family Allowance Fund of an urban area in Northern France. Our findings do not show significant impacts of the CMUC threshold on the number of doctor visits within the full sample. Among the subsample of adults under 30 years old, however, eligible individuals are more likely to see a specialist and have, on average, significantly more specialist visits than non-eligible individuals. This specific impact of the CMUC cut-off point among young adults may be explained by the fact that young adults are less likely to be covered by a complementary health insurance plan when they are not recipients of the CMUC plan.JRC.I.1-Modelling, Indicators and Impact Evaluatio.

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Background: Improvement of coordination of all health and social care actors in the patient pathways is an important issue in many countries. Health Information (HI) technology has been considered as a potentially effective answer to this issue. The French Health Ministry first funded the development of five TSN (" Territoire de Soins Numérique " /Digital health territories) projects, aiming at improving healthcare coordination and access to information for healthcare providers, patients and the population, and at improving healthcare professionals work organization. The French Health Ministry then launched a call for grant to fund one research project consisting in evaluating the TSN projects implementation and impact and in developing a model for HI technology evaluation.

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To analyse the impact of a risk factor on several epidemiological indicators of death and dementia. the example of sport practice is presented.A population of 3670 non-demented subjects living at home and aged 65 and older from the PAQUID study were followed for 22 years. Sport practice was documented at baseline. Dementia (according to DSM-III-R criteria) and death were assessed at each visit. Analyses were performed with an Illness-Death model, providing results on the risks of dementia and death, probabilities and life expectancies.A total of 743 subjects (20.2%) participated in regular sport practice. During the follow-up, the proportion of death was lower in the elderly people practicing sport (EPPS), whereas the proportion of incident dementia cases was the same. The adjusted model showed a decreased risk of dementia (HR = 0.84 (0.72-1.00)) and of death for non-demented subjects (HR = 0.61 (0.51-0.71)) for EPPS but a similar risk of death with dementia in both sport groups. The probability of remaining alive without dementia was higher in EPPS, whereas the probability of dying was lower. The mean lifetime without dementia was 3 years higher for the EPPS, but the mean lifetime with dementia was the same.A preventive measure on a protective factor that is more effective for preventing death than dementia could lead to an increased lifetime without dementia. however, the number of demented cases may remain unchanged, even if the risk of developing dementia is reduced. This dynamic is important to forecast the need for health care and social services for the elderly.

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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The French legislator integrated the efficiency criterion into the determination of the price of reimbursable drugs in 2012. The efficiency of drugs must be documented for products likely to provide a significant therapeutic benefit and to have a significant impact on health insurance expenditure. It aims to measure the marginal health gain produced by an intervention, compared to the cost and effectiveness of another substitutable intervention. The thesis is based on an empirical analysis of the delegation relationships at work in the regulation of drugs, with a view to their access to reimbursement and the setting of their price in France. It is based on an analysis of three applications of efficiency assessment, reflecting a progressive deepening of the economic evaluation of health care interventions in three distinct institutional contexts. Their comparison allows us to identify the issues raised by the implementation of regulation, the factors of its effectiveness and the associated risks with regard to the theoretical framework of the theory of incentives by asking the following questions: 1) Does the information produced by the economic calculation expose the decision-maker to a risk of manipulation of the tool? 2) Is the contribution of the economic calculation improved in a constrained process of evaluation? 3) Can complementary approaches enrich the economic evaluation and improve its use by revealing other determinants of the health decision? The work in this thesis highlights the contribution of the efficiency criterion to improving the information available to decision-makers. The real risk of regulatory capture can be limited by a more transparent evaluation process and by clarifying the issues at stake in the decision and the objectives of the regulation.

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.

In the context of a rapidly ageing population, this thesis explores the links between health and care methods for dependent elderly people and addresses the issue of financing dependence. Meeting the assistance needs of dependent elderly people is a central objective of public policy. Chapter 1 estimates the effect of informal (i.e. family) and formal (i.e. professional) home help on the mental health of dependent elderly people in France. The results show that informal help reduces the risk of depression and that formal help can improve general mental health. Recent studies recognize that helping a dependent relative has negative effects on the health of caregivers and emphasize the importance of supporting them. Chapter 2 focuses on the effect of social support on the health of informal caregivers. Finally, given the financial and fiscal pressure on public systems, Chapter 3 examines the extent to which Europeans would be able to finance their periods of dependency on the basis of their income and their financial and real estate assets. It also looks at the role of lifetime mortgages. The simulations show that only a small proportion of individuals would be able to finance all their LTC expenses. On the other hand, real estate assets could play an important role in financing LTC.

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.

The purpose of this thesis is to carry out an economic analysis of the field of informal help for young adults living at home and suffering from severe neurological disease. The research question posed concerns the articulation between the organization of informal help and the kinetics of neurological pathology. The methodology is based on the construction of four neuro-pathological and economic models on the one hand, and on the constitution of four representative cohorts, each comprising a hundred "caregiver-helper" pairs on the other hand. Thus, the models of brutal pathology with stabilized residual disability, progressive pathology with increasing disability, pathology with rapid deficit kinetics, and hereditary degenerative pathology are respectively illustrated by head trauma, multiple sclerosis, brain tumor and Huntington's disease. Our work (1) highlights the economic characteristics of informal caregivers (young spouses) who are heavily involved in the production of care, (2) demonstrate the strong predetermination of the kinetics of neurological pathology on informal caregiving behaviors through different temporal indicators that must be taken into account for economic analysis (3) show the need to use a two-dimensional measure (subjective and objective) in the analysis of the burden of informal caregivers. Such a measure underlines on the one hand the insufficiency of recourse to public professional help and on the other hand the impact on caregivers of cognitive-behavioral disorders (invisible handicap) and of the neuro-palliative phase at home of a serious neurological pathology. These results open perspectives for the implementation of public action measures in France in the complex field of neurological disability.

In France, 75% of establishments specialized in the care of dependent persons are now EHPADs. Created with the aim of rationalizing the offer, this agent questions its capacity to be efficient. In this thesis, the behavior of EHPAD directors is analyzed in order to identify new levers for improving the performance of these institutions. The main hypothesis is that directors adopt alternative management practices, which can be explained by differences in their professional characteristics. An exploratory analysis confirmed the existence of a wide range of managerial behaviors. Statistical analyses conducted on the basis of an original survey matched to the EHPA survey made it possible to draw up a typology of managers' management methods and to highlight the importance of managers' training in explaining their management strategies in the field of human resources. These results open up new public policy perspectives for improving the efficiency of the sector.

This dissertation studies the aid policies for dependent elderly people at home in Japan, in order to draw lessons for France. We develop our study through three axes: i) the analysis of the differences between the Japanese and French systems in the organization of public aid and in the aid actually perceived by the persons in loss of autonomy, ii) the examination of the potential barriers to the access to public aid in Japan, iii) the study of the consequences of informal aid on the employment of senior women in Japan In this perspective, we conducted two qualitative studies comparing Japanese and French policies, followed by two micro-econometric studies of individual and family caregiving behavior in the Japanese context. This work thus highlights the specificities of the policies implemented in the two countries, and underlines the advantages and weaknesses of the Japanese model.

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 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.

Risky health behaviours substantially increase medical and social costs. We document the extent to which a sample of European students (from Denmark, France, Italy and Sweden) consider that individuals should assume the financial burden of paying the costs of risky behaviour. We test the acceptability of different ways of financing costs because of ill health that is more or less associated with risky behaviour in accordance with a normative framework relating to responsibility‐sensitive fairness. We find that the majority of students agree with assuming financial responsibility for risky behaviours and that there should be compensation for unfavourable circumstances. Students agree that two individuals with the same responsibility variables should make an equal financial contribution and that more effort in maintaining health for given circumstances should be rewarded with a lower financial contribution. The specific health context and the type of risky behaviours involved matter in determining perceptions of justice in health financing. Copyright © 2014 John Wiley & Sons, Ltd.

The purpose of this research is to study the financial access to complementary health care and to health care for low-income populations in France. We are particularly interested in the Aide complémentaire santé (ACS) scheme, which was introduced to encourage households whose resources are just above the ceiling of the Couverture maladie universelle (CMUC) to acquire complementary health insurance. Based on a social experiment and a new sample of households eligible for these schemes, we are able to shed light on three questions: (i) Understanding and reducing non-use of the ACS. (ii) Behaviour in the use of complementary health insurance and care. (iii) The existence of a threshold effect of the CMUC. The results of this thesis will be used to improve the effectiveness of these schemes and, more generally, of future public policies aimed at improving equity in access to care.

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In the economic literature, many studies attempt to explain why individuals insure themselves so little against LTC. On the supply side, various possible obstacles to the development of the LTC insurance market have already been pointed out in the literature. Recent estimates show, however, that supply-side limitations are not sufficient to explain the slow development of the market: even if insurance were less expensive and the coverage offered more extensive, the majority of individuals would still not take out insurance. It is therefore necessary to look for explanations on the demand side of LTC insurance. This article aims to enrich the existing literature by empirically studying the role of risk perception in the decision to take out LTC insurance, based on direct observation of individual preferences (risk aversion, preference for the present) made possible by the 2012 wave of the "Preferences and Wealth in relation to Time and Risk" (PATER) survey. In addition to the effect of socio-demographic characteristics, the econometric estimates carried out highlight the role of individual preferences in LTC risk coverage behaviour. Preference for the present is thought to play an important role in the perception of LTC risk, while risk aversion explains the fact of insuring against this risk among those who envisage the possibility of one day being in a LTC situation.

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.

Economic theory leads one to assume that health insurance increases medical consumption by generating ex-post moral hazard, i.e. the purchase by individuals of care whose value is low in relation to its total cost. Some economists point out that all or part of this consumption surplus may also result from the solvency of the demand for care as a result of reimbursements, thus reflecting better access to care. Understanding which of these effects predominates is an important issue in terms of equity and efficiency of the health care system. This thesis aims to measure the magnitude of the effect of supplementary health insurance on medical consumption in France and to understand its nature by drawing on three articles. The first article analyses the effect of being covered by a complementary health insurance on the use of doctors, the second evaluates the impact of the CMU-C on the medical consumption of its beneficiaries, and finally the third studies the effect of a supplementary health insurance allowing to complete the reimbursements of the basic contract of a civil servant mutual insurance company. By focusing on complementary and supplementary insurance, these articles allow us to study the effect of a marginal variation in the level of coverage on different categories of the population.

Despite the stated objectives of respecting the principle of horizontal equity, social inequalities in the use of health care are observed in countries with socialized health care systems.This thesis proposes, through four studies, to contribute to the analysis of public policies in the health care system, from the point of view of equity in the use of health care services. The introduction describes the social inequalities in the use of health care in France and the main mechanisms that may be at the origin of these inequalities within the French health care system. The first chapter studies the links between financial barriers to access to health care and health status. It shows that foregoing care for financial reasons is associated with a worse future health status.The second chapter proposes an analysis of the doctor-patient interaction and its role in the formation of inequalities in the use of care. We study the categorizations made by doctors about their patients according to their social situations. We then show the relationship between these categorizations and the practices observed. The first one proposes an analysis of the reform and its context, in particular the role of the different actors. The second proposes a study of the consequences of the reform on financial access to specialist care.

Recent developments in welfare economics open the way to evaluation methods based on other models of social justice than utilitarianism. The feasibility of these methods in the daily practice of evaluating health interventions raises questions: the objective of this thesis is to contribute to answering them. To this end, we have focused on three practical cases. The aim of Chapter I is to compare the evaluation methodologies of three public evaluation agencies, the NICE (Great Britain), the IQWiG (Germany) and the KCE (Belgium), in order to identify the social justice positions that result from them. Chapter II proposes to study the moral dilemma that arises from the phenomenon of preference adjustment in the evaluation of two disability compensation schemes. Three options are put forward to solve this dilemma, based on egalitarian theories of social justice. Finally, Chapter III demonstrates the feasibility of the health-equivalent income approach, developed by Fleurabey, in public decision support, concerning antihypertensive treatments in primary prevention.

In the face of an aging population, the expected increase in the demand for long-term care raises the question of the role that our societies wish to entrust to families in the care of dependent elderly people. In this research, we conduct three micro-econometric analyses of individual and family caregiving behaviors. Three major results emerge. First, the evidence of an interdependence of caregiving behaviours within the family leads us to question the idea of a programmed decrease in informal care. Secondly, the reduction in the supply of work beyond a certain volume of assistance points to the limits of a public policy aimed at both increasing the activity of older people and keeping the oldest populations at home. Finally, the use of public assistance for caregiving has a relatively modest effect of crowding out family assistance.

The purpose of this research is to theoretically assess the extent to which fiscal federalism, understood as the joint intervention of national governments and a supra-national fiscal authority, can address fiscal externalities in the European monetary union. In general, the focus is on the policy interactions that arise from the relationships between the different levels of fiscal authority. In the first two chapters, we focus on a mechanism for correcting the effects of cyclical shocks on national economies, in a framework where the fight against excessive deficits is of crucial importance. In the third chapter, we assess the interest of a mechanism to correct the effects of tax competition on the redistributive measures implemented in each country. We then show that central government intervention, in the form of financial transfers, allows national governments to pursue their specific objectives while correcting the fiscal externalities that affect their decisions. These financial transfers, which are allocated according to the specificities of each country, thus make it possible to respond in part to the limitations of the organization of European public finances.

This thesis proposes a reconstruction of the concept of standard of living, as a measure of material well-being, based on the notions of "modes of functioning" and freedom of choice. The objective of this reconstruction is to lead to the estimation of standard of living indicators that allow interpersonal comparisons without neglecting individual characteristics too radically. On the basis of this definition, the calculation of an equivalence scale is undertaken, but unlike traditional scales, this one will make the cost of the child a function of household resources. An attempt is then made to integrate the stock of wealth into the standard of living of households, an attempt that leads to the estimation of new dispersion characteristics of the distribution of the standard of living of the French population. Leisure time is the last variable taken into account in the measurement of material well-being. Rejecting the traditional measure of "full income", an alternative is considered considering that the set of choices of the household (on the space "monetary resources-leisure time") defines more precisely its standard of living. Finally, an estimate of the distribution of total wealth is proposed in a last chapter.