1
CNAM AID FOR
OCCUPATIONAL RISK
PREVENTION: UNPROVEN
EFFECTIVENESS
FLASH AUDIT
March 2024
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SUMMARY
To encourage small companies to take steps to prevent accidents in the workplace, commuting
accidents and occupational illnesses, the French National Health Insurance Fund (CNAM) may
award subsidies.
For companies with more than 150 employees, on the other hand, incentives are provided
through the pricing of occupational accidents and diseases
contributions, based on the
workplace accident rate, i.e. the frequency and severity of incidents.
Two schemes coexist: customized prevention contracts supported by local funds, and
"prevention subsidies for very small enteprises (VSE)", which are targeted and paid out on a
one-stop
basis. The cumulative amount of this aid reached €383.8 million over the 2019
-2022
period.
In its thematic public report on public policies on occupational health prevention in companies,
published in December 2022, the Court made an initial critical assessment of the subsidy
scheme for very small enterprises. This flash audit, carried out in the context of a significant
increase in resources made possible by the creation in 2023 of an investment fund for the
prevention of occupational exhaustion, goes further in recommending a review of the scheme,
which suffers, in particular, from a lack of targeting of aid and insufficient evaluation of its
effectiveness.
Poorly-informed and insufficiently-targeted oversight
There have been very few assessments of the impact of prevention subsidies on the workplace
accident rate. Moreover, the distribution of the budget between regions is not linked to local
workplace accident rates. Finally, the distribution of subsidies between business sectors
depends only partially on their workplace accident rate. It is the mobilization capacity of the
players involved - companies applying for subsidies and professional federations capable of
signing and promoting national agreements on objectives (
conventions nationales d’objectifs
-
CNO) - and not the identification of the sectors with the greatest needs, that determines the
allocation of subsidies.
“VSE prevention” subsidies: difficult to implement and with uncertain
impact
“VSE prevention” subsidies are paid to companies with fewe
r than 50 employees according to
demand, within the limits of a provisional national budget. This places constraints on their
management, leading to their discontinuation if the budget is exhausted. Allocation conditions
are defined in reference documents that are consolidated belatedly, several months after their
effective date.
These subsidies finance work equipment, services and training that meet precise
specifications. Their variable number, purpose and duration make them difficult for eligible
companies to understand, contributing to a high rejection rate for grant applications.
Their budget is steadily increasing, despite the fact that their impact on the frequency and
severity of occupational accidents and illnesses has yet to be demonstrated.
Pending their targeting towards sectors with a high workplace accident rate, and the
development of a reliable method for assessing their impact, the Court recommends their
suspension in favour of awareness-raising campaigns aimed at small businesses in sectors
with a higher workplace accident rate.
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Tightly supervised prevention contracts that need to be better evaluated
Prevention contracts are signed between a company with fewer than 200 employees and a
local health insurance fund, with the aim of implementing a comprehensive occupational risk
prevention action plan in an establishment. They must form part of a national agreement on
objectives (CNO) defined by a joint body, the national technical committee of the sector.
The development of prevention contracts is therefore linked to the capacity for action of the
professional federations and the human resources available in the health insurance funds.
They are time-consuming to draw up, but easier to monitor as health insurance officers
systematically visit sites to ensure the proper implementation of the contract. These prevention
contracts help to reduce the frequency of workplace accidents in the beneficiary
establishments, in a proportion that is not significantly different from those observed in
companies as a whole.
An embryonic internal control system that needs to be strengthened
Control of the conditions under which prevention contracts and “VSE prevention” subsidies are
awarded has long depended on the systems put in place by the local health insurance funds'
authorising and accounting departments. The CNAM has only recently embarked on a
coordinated approach to internal control and the fight against fraud, which needs to be
strengthened.
The recent changes made to the conditions for the payment of “VSE prevention” subsidies
(e.g. the requirement to produce a bank statement to certify the reality of the expenditure)
would benefit from being supplemented. Photographs of the equipment in situ should be
required, and the names of the suppliers of the equipment purchased should be entered in the
computer application as a matter of course, in order to detect any de facto monopolies. Finally,
on-site visits should be made compulsory, as was the case until 2019.
Main conclusions of the audit
According to the few studies carried out, the two financial incentive schemes studied do not make it
possible to reduce the accident rate in small companies.
The development of coordinated actions, such as prevention contracts, which are based on the
commitment of the social partners, calls for a high level of involvement on the part of the CNAM to
reiterate the objectives pursued and to support their design and implementation.
An evaluation of the impact of these subsidies, which is virtually non-existent due to the methodological
difficulties involved, is essential in deciding whether to withdraw, maintain or promote each scheme, and
in adjusting the targets according to the size of the company or business sector. Finally, in addition to
verifying that the correct implementation of the expenditure, controls are based on processes that are
sometimes cumbersome and insufficiently conclusive.
They are limited to a search for proof of expenditure and evaluation of its impact, and suffer from a lack
of monitoring of suppliers, which makes it impossible to identify de facto monopolies.
These major shortcomings are a cause for concern in the context of the creation of the FIPU
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(investment fund for the prevention of occupational exhaustion), which is intended to provide an
additional €150 million a year to finance prevention, awareness
-raising, training and retraining initiatives
for employees who are particularly exposed to ergonomic risk factors.
1
Decree no. 2023-759 of 10 August 2023 on the fund for investment in the prevention of occupational exhaustion
and the occupational risk prevention account.
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Following on from an earlier recommendation
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, the Court calls on the CNAM to remedy the weaknesses
of the current system and, if these financial incentives are to coexist with the FIPU, to take account of
the observations made in this audit before the implementation of the latter, by targeting aid at the sectors
with the highest workplace accident rates, developing a robust method for evaluating their effectiveness
and implementing a strengthened internal control system covering, in particular, relations with suppliers
of prevention devices
.
2
Court of Accounts,
Les politiques publiques de prévention en santé au travail dans les entreprises
, December
2022. One recommendation concerned the continuation of evaluation work to provide a robust assessment of the
effectiveness of prevention programmes.
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Single recommendation
Suspend “VSE prevention” subsidies until such time as they are targeted at the sectors with the
highest workplace accident rates, a method for assessing their effectiveness is developed, and
tighter internal controls are implemented, covering relations with equipment suppliers in
particular.