Gaining health : analysis of policy development in European ...

Chapter 4
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The low cardiovascular mortality and morbidity have been
studied by a number of researchers. The so-called “French
paradox”, first described by Samuel Black in 1819, refers
to the fact that people in France have a low incidence of
coronary heart disease, despite their diet being rich in
saturated fats. It is believed that France’s relatively high red
wine consumption is a primary reason for this paradox but
also that nutrition, the moderate consumption of beer and
distilled spirits, the regularity and quality of physical activity,
the climate and many other factors may play a role (4).
1.3. The main features of the health system
The French health system has a good reputation. In fact,
The world health report 2000 ranked France as having the
best health care system in the world (5). The positive
characteristics are the high level of access to health care
and service utilization, an abundant availability of choice
without any significant waiting lists and the high level of life
expectancy.
The French health system is based on a national social
insurance system complemented by elements of tax-based
financing and complementary voluntary health insurance. 3
The health system is regulated by the state and the statutory
health insurance funds. The state sets the ceiling for
health insurance spending, approves a report on health and
social security trends, and amends benefits and regulation.
There are three main schemes within the statutory health
insurance system: the general scheme covering about 84%
of the population (employees in commerce and industry
and their families); the agricultural scheme covering farmers
and their families (7.2% of the population); and the scheme
for self-employed people covering 5% of the population.
3
The general principle is that health care costs are reimbursed by the
statutory health insurance system. However, there is usually a discrepancy
between the actual amount paid by patients and the amount they
are reimbursed by their health insurance fund. A complementary health
insurance scheme can be subscribed to on a voluntary basis to cover this
discrepancy.
In 2004, an insurance fund was established specifically for
dependent elderly people.
In January 2000, universal health coverage was introduced,
introducing the right to statutory health insurance coverage
on the basis of residence in France. Furthermore, those
whose income is below a certain level (currently 1.8% of
the population) are entitled to free health care.
In 2002, total expenditure on health care was estimated
at 9.7% of GDP, of which 7.4% was public and 2.3% private
expenditure (6). Expenditure on prevention is estimated at
2.4% of all health costs (4).
There are around 10 physicians and nurses per 1000
inhabitants, which is above the EU average. The number of
nurses is double the number of doctors, though this favourable
proportion has slightly changed recently (4).
2. France’s approach to developing policies
to tackle NCD
A special historical characteristic of the French public health
system is that the all-embracing term noncommunicable
diseases is not widely used. Public health experts, policymakers,
administrators and practitioners prefer to refer
to the individual conditions rather than refer to them as
a category. This is mainly because of the strong traditions
and identity of each field and the existence of separate,
well-established public health working groups with different
interests.
The major instrument of strategy is the Public Health Act of
2004. Although the primary role of the Act was to reorganize
and restructure the decision-making and administrative
system related to public health, the Act can be considered
as a broad, complementary general framework for the
Case studies: policy development in countries for tackling noncommunicable diseases