Mainland Thus, the population state of health can

Mainland France also known as
Metropolitan France has a population of 64,4 Million in which 19.48 % is aged
above 65 years according to WHO. Overall, although there are indicators that
show that the health status is good, like life expectancy which is estimated at
79 Years for Men and 85 years for women, there is also a high number of premature
deaths due to accidents and unhealthy habits. Thus, the population state of
health can be described as mixed. The French health care system covers the
resident population and it is a mixture of public and private scheme. This
system is evolved from a labour based Bismarckian system. Statutory health
insurance (SHI, assurance maladie) covers the whole population through a
variety of schemes. There is a mixture of schemes applying for the delivery of
care, such as public coverage in hospitals and physicians for instance, payment
at point of care, out of pocket (OOP) funding as well as additional voluntary
health insurance (VHI). With all the above a wide range of services is provided
to the population (Chevreul et al 2015).


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There are a lot of reforms that
the French health care system has underwent over the past decades, two of them
though were quite important. The introduction of universal medical coverage
also known as CMU (Couverture maladie universelle) was one important act, as it
allowed to all the people living in the country being eligible for SHI (The
commonwealth fund, 2013). Another important reform in the social protection
system is the ‘Hospital, Patients, Health and Territories Act in 2009 which is
an attempt to achieve decentralisation, improving the connection between
ambulatory and hospital sectors.


The responsibility of the
healthcare system is taken at a national level. The budget is presented
annually, as well as the financing details for the healthcare system for the
following year. The ministry of health is responsible for the health policies,
overseas management of resources and is the one responsible for setting the
targets for the health care expenditure. Over the last decades, health care
expenditure in France rose rapidly in comparison with the economy as a whole.
More specifically, the gross domestic product (GDP) per capita is $38.000 and
the expenditure on health was 11.5% of GDP in 2014(WHO, 2017) in comparison
with 10.4% in 1995. Since 1996, there is in place one main resource allocation
mechanism ONDAM which controls the SHI expenditures in health care. Since 2010
ONDAM the cost-containment measures have been more intense and consequently the
targets have been underspent. France has been ranked by WHO third among
European countries for health care expenditure as a proportion of GDP (Chevreul
et al 2015).  The pooling of the funds
are arranged in a national level. The allocation of the national budges is
voted every year by the Parliament and it is allocated in 4 sections: the
public and non-profit hospitals, for-profit hospitals, out-of-hospital care and
geriatric care (The Commonwealth Fund, 2013) . The main body responsible for
collecting compulsory funds is the Union for the recovery of Social Security
Contributions and Family Allowances. All the revenue collection flows into a
single pool run by the Central Social Security Agency and then they are
allocated among different national branches like SHI; family allowance etc. Through
employees and employers contributions, as well as through specific taxation (e.g.
tobacco), taxes on pharmaceutical companies, General Social Contribution (CGS) the
revenue collection is achieved (Chevreul et al 2015).

In 2014, 76.6% of personal health
care expenditure was financed by SHI. Since January 2016, all residents are
eligible for SHI coverage and it is granted by PUMA (Protection universelle
maladie or universal health coverage). Non EU visitors have only emergency care
coverage and visitors from within the EU are covered by an EU insurance card.
Finally, undocumented immigrants who have applied for residency are financed by
the state. Other services like Voluntary Health Insurance (VHI) which is
complementary and it is provided mainly by not-for-profit employment-based
mutual associations. The contracts regarding cost package coverage are
different (The commonwealth fund, 2013). VHI financing of total health
expenditure is estimated 13.5% (Mossialos et al. 2017). In order inequitable
access to VHI contracts to be minimised, CMU provides to 4.3 million people
vouchers that can be used instead of VHI (The commonwealth fund, 2013). Out of
Pocket (OOP) accounts for 7. % of total expenditure and there has been an
increase for residential long-term care services and this raises questions
about the equity in access to such services (Chevereul et al. 2015).

Equitable or Inequitable?

What makes French system
equitable is that there is that the whole population is mandatory covered with
a health care insurance as well as the fact that there is high quality of
services. Also, it is makes it more equitable because it is affordable in the
term that if a patient nee to pay the majority of the cost will be reimbursed
and last but not least is that patient have the opportunity to choose their
doctors and that they can go straight away to a specialist if they want to
instead of waiting for GP to send them (Rodwin, 2003).

Health inequalities are known in
France more specifically according to Chevereul et al, there is a disparity in
life expectancy (up to 6 years) between educated and non-educated men. The
unemployment rate is 10.1% and the long-term unemployment rate is 44.4% which
is a strong socio-economic factor affecting the healthcare financing system.
(OECD, 2017).   There are also inequities of access in the
health care system such as the shortage of health care professionals. More
specifically, it has been notices that there is a bigger density of healthcare
professionals in certain areas while in other areas like Northern and Eastern
regions are short. Also, cost containment measures includes a reduction in
coverage resulting in shift to private expenditure (Chevereul et al. 2015).

 Quality and efficiency of care

In terms of quality of care as
mentioned above there is a high life expectancy in France in comparison to
other countries. Infant and maternal mortality rates have also decreased significantly
since the late 70s. Also, France’s overall mortality rate is among the lowest
within the European Union (Chevereul et al 2015). Furthermore regarding patient
satisfaction a survey on 2003 has shown that the two thirds of the population
are fairly satisfied with the system (Rodwin, 2003) and a later survey conducted
by Commonwealth fund in 2016 showed that 54% of people thought that the system
worked well and maybe minor changes are needed and 41% of people stated that
fundamental changes are needed (Mossialos, 2017). Various things are being done
to ensure quality of care in France at the moment like creating disease
management programs, disease registries, making the immunisation programs
mandatory and available through National Health Insurance, Public reporting,
etc. (Chevreul et al 2015).

Improving the efficiency of the
system is of crucial importance because this ensures the financial viability of
the system. Thus, preventing any further deficit growth and any related burden
on future generations or avoiding economy and access of care to be affected. At
present time as mentioned above ONDAM is the main resource allocation mechanism
for expenditure and distribution across the system. Although as mentioned above
since 2010 cost-containments measures have been successful, the financing
system is not efficient enough as according to HCAAM the country’s growth rate
will not be able to keep up with the health expenditure by the middle of this
century. It is estimated that the SHI deficit will reach 41 billion euro by
2040. Because of this possible outcome the government is emphasising to improve
the lack of coordination in the health care system as well as measures like setting
a budget based on the targets of the indicators in order to empower the control
of the expenses and combining it with a high level of care. For SHI, the
targets of quality and efficiency is focused in the following areas. Giving
people the opportunity of equal access of care, prevention programs, improving
the quality and efficiency of care provided by various services, and maintaining
the financial system sustainable (Chevreul, 2015).  

Recommendations for
improvement and challenges

Taking into consideration the
above target areas a recommendation for improvement for France would be
focusing more in GP services and maybe ‘pay for performance’ as well. To be
more specific the system should give more incentives, money incentives for
instance, to GPs to treat conditions as much as possible within the primary
care section and not to push patients to use more hospital care as this works
well to Netherlands which helps to decompress the system. The challenge though
of such an intervention is that there need to be more spare funding available
(for the incentives) for the first few years as programs like these take some
time to show results (Mossialos, 2017).