Social Inequalities in Preventive Care and Healthcare System Organization: The Case of Gynecological Cancers Screening in France

Socioeconomic inequalities in health are high in France compared to other developed countries. This is unexpected considering that the National Health Insurance offers universal access and free care for disadvantaged people. Considering the case of gynecologic cancers screening, we intend to analyze the genesis of these health inequalities in relation to the features of the healthcare system.

Screening status was analyzed according to socioeconomic status among a random sample of 1819 women with logistic mixed models. We observed marked social gradients for cervical cancer, but lower ones for breast cancer for which an organized screening program alongside the individual one exists. However, the last prescriber was socially differentiated: gynecologists for the upper class, organized screening for the lower and GPs for the middle.

The modeling role of the healthcare system in producing inequalities through social norms it contributes to establish can be specified. Organized screening contributes to catch up patients with low social status. Gynecologists often ask for unregulated fees and receive patients with good socioeconomic level, whom they tend to overscreen. GPs are supposed to have a gatekeeper function toward specialists, but direct access to gynecologists is possible without referral. Although GPs involvement would be necessary to improve participation and lower inequalities, they lack legitimacy and tend to divest of these screenings. In addition to this suboptimal task division, information sharing and coordination between professionals are limited. This confusing situation has been settled by socio-historical processes, without any global vision of the interactions and perverse effects it would induce. Few people (patients, physicians or policymakers) are aware of the contribution of such an organization to inequalities. Despite the pressure on health funding and the bad demographic perspectives, it seems difficult to remodel professionals’ routines or to re-regulate the screening of women on a more equal basis.