Interview: Yves Bur – Honorary Deputy and Mayor of Lingolsheim, France

Yves BurYves Bur reveals how the motivation behind his political engagement has been to raise awareness around the importance of improving the social security system. Bur also explains why having a real public health policy is another way of combatting the increase in health spending, and how France needs to reach a certain level of competitiveness to ensure it remains an attractive destination for the pharmaceutical industry. Bur is Honorary deputy at the French Assemblee Nationale and current Mayor of Lingolsheim in France’s Alsace region.

By profession you are a dental surgeon. What led you to become involved in politics?

Perhaps mouths were too small for me! I discovered a passion for public affairs first at the local level and then, in 1995, at the parliamentary level. I quickly became interested in everything related to solidarity, social security and health. It is at this point that I eventually specialized in social security financing (PLFSS, Projet de Loi de Financement de la Sécurité sociale). Within that sector I was analyzing the way the system functioned and where savings could be made. This also involved looking at the bigger picture beyond the health insurance system to issues such as family policy and the pension system. As such, my role was to safeguard the quality of prescriptions but also to try and set the French social security system on a trajectory of financial equilibrium, where spending was well managed and as efficient as possible. Unfortunately, to this day, this is still not the case. I found this observation point over all the key economic, social and organizational factors very interesting particularly in light of my professional background.

What is it that has motivated you during your political career?

I entered into local politics in 1983 for the municipality of Lingolsheim in Strasbourg and upon becoming deputy mayor I began to focus on social issues such as caring for the elderly and disabled people. In 1995 I was elected to the National Assembly where I enrolled in the Social Affairs Commission and participated in sixteen PLFSS bills. For ten years, I was the rapporteur for the PLFSS so I participated in the evolution of the system which has made a lot of progress but, at the same time, has also fallen victim to the tendency in France to not carry out thorough reforms and, thereby, allow the country’s debt to increase. The motivation behind my political engagement was to make others aware of our responsibility to improve the social security system. I believe it is immoral to leave a legacy of debt to future generations. Our children will be left to deal with everything that we do not take responsibility for today and this is something I would never do as a father or, therefore, as a politician.

What flagship measures have you supported throughout your political career?

Throughout my political career I have been very committed to public health because I believe that having a real public health policy is another way of combatting the increase in health spending. It is also a way of controlling the evolution of chronic diseases and the downward spirals which can result from them. The flagship measure which I am best known for introducing is the ban on smoking in public places. I also banned soda and confectionary vending machines in schools and I increased the tax on alcopops to the extent that there is now no market for them. In addition, the Minister of Health’s plan draws heavily from my final mandate in 2012 on the prevention of smoking.

What are the main challenges faced by the health system in France nowadays?

Despite the fact that public health is a fundamental subject and is at the heart of the UN’s project for the prevention of and fight against non-transmittable diseases, it is rarely discussed in France. In France more than 30 percent of the population smokes, an amount considerably higher than in the US and the UK where it is around 17 percent. This can be explained by a lack of political will. At the start of 2015, the French National Health Institution (INPES) had no budget set aside for tackling smoking. Nonetheless, smoking results in 78,000 deaths each year. Another factor, a real taboo, is that behind each packet of cigarettes is a tobacco dealer lobbying against reform. In 2010, I proposed neutral packaging for cigarettes and there are around 28,000 tobacconists protesting against the application of that reform. Another taboo subject is that of alcohol consumption which, although it has decreased a lot, causes 45,000 deaths each year. The results of alcoholism and smoking are costing the health system around thirty to forty billion euros. Obesity is also a health issue in France, even if it only affects around 10 to 12 percent of the French population, which remains lower in comparison to the 30 percent in Anglo-Saxon countries. The goal must be to live and be healthy for as long as possible and, in order to do this, we must be vigilant and act on all these factors as a vehicle for improving the health system. It is necessary to invest in public health. I have put into action several initiatives in my municipality such as distributing fruit to children in kindergarten and pre-school.

What impact will expensive innovations, such as Gilead’s Sovaldi, have on the financing of social security?

The authorities had not predicted that the Sovaldi innovation would arrive so soon or that it would be so costly. However, innovation is not just limited to medicines but also includes new technologies such as chemotherapy, radiotherapy and operations. The initial cost of these innovations is often very high but it is important to look at the whole picture. With interventional radiotherapy, only three days of hospitalization are required whereas, in the past, patients had to spend around ten days in hospital followed by three weeks of treatment. In the case of Hepatitis C, the patient was hospitalized and could not work at all but, with Sovaldi, after 6-7 weeks of treatment they will be cured. Therefore, instead of saying “it is outrageous that this drug costs 50,000 euros” (USD 57,000), we should be taking into consideration the balance between innovation and the real cost; in other words the savings that can be made in the long term. In terms of the socio-economic impact, the fact that shorter treatment times mean a person can return to work sooner is an element which is often overlooked. When considering the issue of financing innovation, it is necessary to look at how the system is organized and how this should evolve in order to be more efficient. However, in France we tend to brush any uncomfortable topics, such as reducing hospital personnel, under the carpet.

What is your assessment of the National Plan of Action for Generic Medicines adopted last March and the potential for funding innovation through the savings?

The savings made through generics should not be used as a way to reduce the expenditure on healthcare but should be orientated to other areas such as innovation and better management. In comparison to other European countries, such as the UK and Germany, France is around fifteen years behind and, as a result, has lost billions of euros. The French generic market is worth around 30 percent of the market, in comparison to almost 60 or 70 percent in many other European countries. In addition, there is no reason why a generic should cost any more than 30 percent of the cost of an original drug because all that money is going into the pockets of the laboratories and the pharmacists. I was one of the first to raise this issue. We are also behind in terms of biosimilars. Voltaire said that “France is behind but always gets there in the end” but the problem nowadays is that the world is advancing a lot faster than during his time. We have lost a lot of money on generics and, I believe the generic policy has been a failure because doctors continue to think that they are not real medicines. It is unacceptable that this remains the case and that we continue to have so many problems when generics are accepted in other countries and could be the source of considerable savings.

Has the relationship between the health authorities and the pharmaceutical industry, which used to be quite fraught, evolved over the last few years?

It is true that the relationship between the authorities and the laboratories is complicated because drugs have been used by the government as the variable for making savings. The government is seen as Uncle Sam because it needs to make two billion euros (USD 2.26 billion) worth of savings each year to finance the health insurance so it only pays half. In terms of public opinion, the mediator and diops health scandals along with other molecules have tarnished the image of laboratories. However, there is no reason to be pessimistic because French people are rather paradoxical: they think that laboratories earn too much money but, at the same time, they consume a considerable quantity of medicines, one of the highest per capita in the world actually!

In terms of France’s competitiveness, what are its main assets and what can be done to make it more attractive to investors?

France has always been an important production site, creating around 100,000 jobs, and pharmaceutical products have always been an important export for France. The French pharma industry benefits from many assets, such as the fact it only takes a year after arrival for a drug to become available to everyone. In addition, medicines are a vector and motor for our research centers and universities.

However, France has, to an extent, been left behind in terms of competitiveness as companies are choosing to go to countries such as Ireland, which are more attractive fiscally. I believe that France does not require much in order to regain its attractiveness for large laboratories and there are many ways in which we can achieve this. More generally, France needs to reach a certain level of competitiveness once again to make it attractive to all sorts of industries including the pharmaceutical industry. We need to continue facilitating research; the Crédit d’Impôt Recherche (CIR) (tax credits for organizations undertaking R&D activities) were an excellent propellant for the industry. Additionally, a long term agreement between the state and the laboratories should be put in place to increase predictability. It is also important to take the entire eco-system into account and ensure that we have strong universities, dynamic laboratories and local autonomies which allow movement. Moreover, the discussions that laboratories have with American buyers must not be easier than those that they have with the French social security. Finally, we need to have a long term vision for the next twenty years, rather than just for the next five years.

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