Why the French “health pass” did nothing to resolve COVID vaccine inequalities

In a recent study published on the medRxiv * preprint server, the researchers determined the factors influencing local heterogeneities in the 2019 coronavirus disease (COVID-19) vaccination rates and the influence of the French health pass on these heterogeneities using extensive data nationals of France.

To study: The French national “health pass” has not resolved the inequalities in vaccination against Covid-19 in France. Image Credit: rarrarorro / Shutterstock.com


Although France has a demonstrated history of vaccine reluctance which was confirmed during the COVID-19 pandemic, acceptance of COVID-19 vaccination in France has gradually increased throughout 2021.

Social and territorial inequalities are known to influence people’s attitudes towards vaccination. For example, according to surveys carried out in 2020, vaccination rates in France are influenced by the level of education of the people questioned, their income and their confidence in the authorities.

To improve COVID-19 vaccination rates, French President Macron announced the establishment of a domestic health pass (the sanitary passe) July 12, 2021, which was fully implemented on August 9, 2021. The health pass was required in most public places, such as outdoor and indoor dining rooms and medical facilities. However, to date, detailed information on the impact of the French health pass on vaccination inequalities has not been fully assessed.

About the study

In the present study, the association between socio-economic and geographic factors, COVID-19 vaccination and the implementation of the health pass in France was determined using comprehensive national data.

Vaccination, socio-economic and geographic data were collected from the National Health Insurance Fund (Health Insurance) public datasets. The Assurance Maladie provides public datasets of in-depth weekly COVID-19 immunization first-dose vaccination at district level across the country and at suburban level for the metropolitan areas of Marseille, Paris and Lyon .

The study included data from 63,601,670 people from 1,552 districts in mainland France. These districts were associated with the five geographic indicators and the 176 socioeconomic indicators obtained from the same public datasets.

The relationship between being a district in the lowest quartile of the first-dose vaccination rate and above the median value of each indicator was determined. Subsequently, the odds ratios (OR) of the socio-economic and geographic indicators and their 95% confidence interval (CI) were determined on three time stamps that took into account the effects before and after the implementation of the passport- health.

The vaccination rates for the two socio-economic and geographic indicators with the highest OR on the same dates were calculated. The analyzes were carried out using R software (v4.0.3).

Study results

The rate of income from unemployment benefits and the proportion of overcrowded households were found to be most associated with local immunization rates. To this end, the ORs of unemployment and overcrowding at weeks 27, 31 and 37 were 12.6, 13.3, 11.9 and 11.6, 12, 15.7, with a 95% CI of [8.7; 18.9], [9.1; 20.0], and [8.2; 17.6], respectively.

The differences in immunization rates based on percentile points between the first and fourth quartiles of the unemployment and overcrowding indicators remained similar over the weeks. At weeks 27, 31, and 35, the difference in immunization unemployment rate was 7.6, 8, and 7.9 with a 95% CI of [6.6; 8.7], [7.0; 9.0], and [6.9; 8.9], respectively. The difference in vaccine overpopulation rate at weeks 27, 31, and 35 was 6.9, 7.6, and 8.2 with a 95% CI of [5.7; 8.1], [6.6; 8.8], and [7.2; 9.1], respectively.

Local vaccination rates according to the quartile of the two main indicators (Overpopulation rate, left and Unemployment rate, right) and over time (weeks 27, 31, 35, with increasingly dark shades)


The results of the study show that many disadvantaged areas in France had more than ten times the probability of being among the districts with the lowest vaccination rates. Low vaccination rates in France were associated with economically poor populations, indicating that the health pass did not resolve vaccination inequalities.

Districts with a large portion of overcrowded housing or unemployment benefits constituting a large portion of local income were powerful determinants for low immunization rates.

Previous studies have shown that most deprived areas have disproportionate rates of COVID-19 infection and hospitalization throughout the pandemic. This study provides strong evidence for the strong impact of social inequalities on the management of COVID-19.

The economically backward districts were the least vaccinated and at risk, despite the establishment of the domestic health pass. Overall, this study highlights the urgent need for new immunization guidelines that address social inequalities.

*Important Notice

medRxiv publishes preliminary scientific reports which are not peer reviewed and, therefore, should not be considered conclusive, guide clinical practice / health-related behavior, or treated as established information.

Comments are closed.