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COUNTRY PROFILE: FRANCE
The reform also established teaching hospitals, by
means of agreements negotiated between regional
hospitals and faculties of medicine. Moreover, the
introduction of the principle of full-time employment of
doctors in hospitals represented a genuine transformation
of these institutions. This contributed a lot to improving
the French health system.
The hospital system
Hospitals in France can be public, private non-profit or
private for-profit. They can be specialized or non-specialized.
Public hospitals account for a quarter of all hospitals (about
1,000 out of 4,000) and two-thirds of the inpatient beds
(about 320,000 out of 490,000). They are legally
autonomous and manage their own budget. With an average
of 8.4 hospitals beds per 1,000 inhabitants, France is close
to the European average. In 1998, health care institutions
employed just over one million people, 80% of whom were
on the payrolls of public hospitals.
Self employed doctors
Self-employed doctors are free to work wherever they like,
whereas hospital work is dependent on post offered by
institutions. They are working in their own practices and
most of them work alone. However, almost all self-employed
healthcare professionals practice within the framework of
the national agreements signed by professionals’
representatives and the health insurance funds. In general,
patients pay the health care provider and they are
subsequently reimbursed by their health insurance fund at
the rate listed in the agreement.
Current challenges
Healthcare expenditure out of control
As in other countries, healthcare expenditure in France has
grown more rapidly than national wealth for many years.
The founding fathers of the social security system hoped
that the access to healthcare provided by statutory health
insurance would make it possible to maintain good health
among the whole population, and that as a result, the need
for treatment would diminish over time. In practice, the
pattern of development has been quite different, if not the
opposite, and the demand of health services lead to
unrelenting growth in expenditure on healthcare. The onset
of economic difficulties in the 1970s marked a turning point
in policies towards the provision of healthcare, which
became increasingly influenced by financial constraints.
In the past 25 years a succession of cost containment
policies (both on the demand side and the supply side) has
attempted to balance the accounts of the health insurance
system.
Measures to limit demand have been anticipated from the
outset, with consumers’ responsibility fostered through cost
sharing. The portion of the costs of treatment not
reimbursed by the health insurance was named “ticket
modérateur” precisely because of its intended aim of
moderating demand. Over and above the problems of equity
and access to treatment posed by this financial burden on
the patient, the theoretical effectiveness of this measure, in
terms of reducing expenditure, has been impaired by the
massive extension of complementary health insurance
coverage. However the 2003 reform raised the ticket
modérateur.
Measures to limit the supply of treatment have targeted
capacity as well as professional practices and charges for
goods and services. This type of control has been exercised
in two ways: by the medical map (carte sanitaire), which
until 2003 made the provision of hospitals beds subject to
authorization, and by the numerous clauses system, which
regulates access to medical training.
A lot of reforms tried to overcome this burning issue. The
so-called “Juppé reform” of 1996 for example took real
measures to limit the supply side but care professionals have
remained fiercely opposed to this policy and that side of the
“Juppé reform” failed.
This incapacity to control the healthcare expenditure is
mainly due to the complexity of the entire system.
Responsibilities and decision-makers are difficult to identify.
The complexity of the institutional organization
One of the aims of the “Juppé reform” was to clarify the role
of each healthcare system agent.
That important reform involved a more radical
reorganization of institutions and powers. To many, it was
seen as giving the state the control of the health care system
and it is true that some of the most significant measures
increased the role of the state, for example the reinforcement
of the role of parliament and the creation of regional hospital
agencies (ARH).
The ARH are responsible for hospital planning and
financial allocation to public hospitals. As for the
parliament, it votes on a national ceiling for health insurance
expenditure (ONDAM) for the year to come. This vote takes
place each year since 1996, and it is one of the great
achievements of the “Juppé reform”. Within the ONDAM, a
separate budget is defined for public hospitals. It is then
divided between regions and the ARH allocated individual
budgets to each hospital in a framework of regional resource
allocation. This was a response to the increase of health
expenditure.
Although a whole reform was needed, in practice this one
has been difficult to apply because of the series of conflicts
that has punctuated relations between medical unions,
health insurance and states authorities over the last 50 years.
Quality and safety challenges
In spite of the complexity of the French healthcare system
and the difficulty of managing it, until recently its
performance was not denied. This positive perception was
somehow dented by the “contaminated blood scandal”,
which drew attention to organizational weakness in the
system and led to the trial of three government ministers.
Since then, decision-makers and the public have been
increasingly concerned by safety issues. For instance, the
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