JANUARY

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FRANCE What are the key entities for health system governance? The Ministry of Health sets and implements government policy in the areas of public health and the organization and financing of the health care system, within the framework of the Public Health Act. It regulates roughly 75 percent of health care expenditure on the basis of the overall framework established by parliament, which includes a shared responsibility with statutory health insurers for defining the benefit package, setting prices and provider fees (including diagnosis-related group fees and copayments), and pricing drugs. The parliamentary “Alert” Committee provides a midyear assessment of health care expenditures and proposes corrective measures in case expenditures exceed the target by more than 0.75 percent. The French Health Products Safety Agency oversees the safety of health products, from manufacturing to marketing. The agency also coordinates vigilance activities relating to all relevant products. The Agency for Information on Hospital Care manages the information systematically collected from all hospital admissions and used for hospital planning and financing. The remit of the National Agency for the Quality Assessment of Health and Social Care Organizations encompasses the promotion of patient rights and the development of preventive measures to avoid mistreatment, in particular in vulnerable populations such as the elderly and disabled, children, adolescents, and Organization of the Health System in France National level Parliament Alert Committee High Council for the Future of Health Insurance Statutory Health Insurance (National Union of Insurance Funds) High Level Council of Public Health National Health Authority Government/ Ministry of Health National Health Conference National Council for the Governance of Regional Health Agencies (SHI, MoH, National Solidarity Fund for Autonomy) Self-employed health professionals Regional level Regional Conference on Health and Autonomy Two coordination commissions: prevention and disability (local subsidiaries of the State, General Council, local SHI funds) Regional Health Agency Planning Planning Planning Regional Union of Health Professionals Hierarchical Advisor Negotiation Hospital sector services Health and social care sector for elderly and disabled Ambulatory care sector services Notes: SHI: Statutory health insurance. MoH: Ministry of Health. Source: Adapted from K. Chevreul, I. Durand-Zaleski, S. B. Bahrami et al., “France: Health System Review,” Health Systems in Transition, vol. 12, no. 6, 2010, pp. xxi–xxii. 64 The Commonwealth Fund
FRANCE socially marginalized people. It produces practice guidelines for the health and social care sector and evaluates organizations and services. The National Health Authority (HAS) is the main health technology assessment body, with in-house expertise as well as the authority to commission assessments from external groups. The HAS remit is diverse, ranging from the assessment of drugs, medical devices, and procedures to publication of guidelines, accreditation of health care organizations, and certification of doctors. Competition is limited to VHI, whose providers are supervised by the Mutual Insurance Funds Control Authority. What are the major strategies to ensure quality of care? National plans are developed for a number of chronic conditions (e.g., cancer, Alzheimer’s), rare diseases, prevention, and healthy aging, in addition to the 104 targets set by the 2004 Public Health Act. These plans establish governance (e.g., the cancer plan to coordinate research and treatment in cancer and establish guidelines for medical practice and activity thresholds), develop tools, and coordinate existing organizations. All plans emphasize the importance of supporting caregivers and ensuring patients’ quality of life, in addition to enforcing compliance with guidelines and promoting evidence-based practice. The National Health Authority publishes an evidence-based basic benefit package for 32 chronic conditions. Further guidance on recommended care pathways covers chronic obstructive pulmonary disease, heart failure, Parkinson’s, and end-stage renal disease (Assurance Maladie, 2015). SHI and the Ministry of Health fund “provider networks” in which participating professionals share guidelines and protocols, agree on best practice, and have access to a common patient record. Regional authorities fund telemedicine pilot programs to improve care coordination and access to care for specific conditions (e.g., stroke) or populations (e.g., newborns, the elderly, prisoners). The PAERPA (Personnes Agées en Risque de Perte d’Autonomie) program, established in 2014 in nine pilot regions, is a nationwide endeavor to improve the quality of life and coordination of interventions for the frail elderly. For self-employed physicians, certification and revalidation are organized by an independent body approved by the National Health Authority. For hospital physicians, both can be performed as part of the hospital accreditation process. To ensure the lifelong quality of their practice, doctors, midwives, nurses, and other professionals must undergo continuous learning activities, which are audited every fourth or fifth year. Optional accreditation exists for a number of high-risk medical specialties (e.g., obstetrics and gynecology, surgery, cardiology). Accredited physicians can claim a deduction on their professional insurance premiums. Hospitals must be accredited every four years; criteria and accreditation reports are publicly available on the National Health Authority website (www.has-sante.fr). CompaqH, a national program of performance indicators, also reports results on selected indicators. Quality assurance and risk management in hospitals are monitored nationally by the Ministry of Health, which publishes online technical information, data on hospital activity, and data on control of hospital-acquired infections. Currently, financial rewards or penalties are not linked to public reporting, although they remain a contested issue. Information on individual physicians is not available. What is being done to reduce disparities? There is a 6.3-year gap in life expectancy between males in the highest and males in the lowest social categories (DREES, 2015) and poorer self-reported health among those with state-sponsored or without any complementary insurance. The reduction of health inequities is a major target of the 2014 National Health Strategy, and the 2004 Public Health Act set targets for reducing inequities in access to care related to geographic availability of services (so far, only nurses have agreed to limit new practices in overserved areas), financial barriers (out-of-pocket payments will be limited by state-sponsored complementary insurance), and International Profiles of Health Care Systems, 2015 65
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JANUARY 2016 2015 International Pro
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2015 International Profiles of Heal
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Table 1. Health Care System Financi
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Table 3. Selected Health System Per
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The Australian Health Care System,
Page 13 and 14: AUSTRALIA low-income adults, childr
Page 15 and 16: AUSTRALIA In 2013, the federal gove
Page 17 and 18: What is being done to reduce dispar
Page 19: References AUSTRALIA Australian Bur
Page 22 and 23: CANADA What is covered? Services: T
Page 24 and 25: CANADA funding to 145 not-for-profi
Page 26 and 27: CANADA Organization of the Health S
Page 28 and 29: CANADA provides recommendations to
Page 30 and 31: CANADA Health Council of Canada (20
Page 32 and 33: CHINA Private health insurance: Com
Page 34 and 35: CHINA is not substantially more exp
Page 36 and 37: CHINA Organization of the Health Sy
Page 38 and 39: CHINA References Chen, X. (2014).
Page 40 and 41: DENMARK In addition, nearly 1.5 mil
Page 42 and 43: DENMARK Social psychiatry and care
Page 44 and 45: DENMARK Quality data for a number o
Page 46 and 47: DENMARK portion is small, it makes
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Page 50 and 51: ENGLAND immunization, and vaccinati
Page 52 and 53: ENGLAND Hospitals: Publicly owned h
Page 54 and 55: ENGLAND Organization of the Health
Page 56 and 57: ENGLAND How are costs contained? Ra
Page 58 and 59: ENGLAND Organisation for Economic C
Page 60 and 61: FRANCE VHI finances 13.8 percent of
Page 62 and 63: FRANCE The average income of primar
Page 66 and 67: FRANCE inequities in prevention rel
Page 68 and 69: FRANCE Nolte, E., C. Knai, and M. M
Page 70 and 71: GERMANY There were 42 substitutive
Page 72 and 73: GERMANY The 16 state governments de
Page 74 and 75: GERMANY management system, by the s
Page 76 and 77: GERMANY What major innovations and
Page 78 and 79: INDIA Private health insurance: The
Page 80 and 81: INDIA provide after-hour care, reim
Page 82 and 83: INDIA are provided by other ministr
Page 84 and 85: INDIA How are costs contained? Ther
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Page 88 and 89: ISRAEL Together, these two types of
Page 90 and 91: ISRAEL Primary care physicians are
Page 92 and 93: ISRAEL Organization of the Health S
Page 94 and 95: ISRAEL • Using electronic health
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Page 98 and 99: ITALY during hospitalization (Thoms
Page 100 and 101: ITALY Some regions are promoting ca
Page 102 and 103: ITALY Organization of the Health Sy
Page 104 and 105: ITALY although the degree of evolut
Page 106 and 107: ITALY The author would like to ackn
Page 108 and 109: JAPAN What is covered? Services: Al
Page 110 and 111: JAPAN incentives for providers to c
Page 112 and 113: JAPAN Organization of the Health Sy
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JAPAN The author would like to ackn
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THE NETHERLANDS receive faster acce
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THE NETHERLANDS Hospital payment ra
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THE NETHERLANDS Organization of the
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THE NETHERLANDS References Organisa
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NEW ZEALAND provided in GP clinics.
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NEW ZEALAND management (e.g., clean
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NEW ZEALAND including such informat
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NEW ZEALAND largely through efficie
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132
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NORWAY Primary, preventive, and nur
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NORWAY Patients are free to choose
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NORWAY What are the major strategie
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NORWAY The National System for the
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142
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SINGAPORE Medifund is the governmen
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SINGAPORE Public hospital funding i
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SINGAPORE Public consultation: The
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SINGAPORE To keep demand for servic
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SWEDEN What is covered? Services: T
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SWEDEN Hospitals: There are seven u
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SWEDEN Care, which promotes use of
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SWEDEN What major innovations and r
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SWITZERLAND Insurers offer premiums
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SWITZERLAND Hospitals: About 70 per
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SWITZERLAND Organization of the Hea
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SWITZERLAND To control pharmaceutic
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UNITED STATES What is covered? Serv
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UNITED STATES Administrative mechan
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UNITED STATES The Institute of Medi
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UNITED STATES adopted at least a ba
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The COMMONWEALTH FUND Affordable, q
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