France

xx
Health systems in transition
France
through various schemes, covers the resident population. Which scheme applies
depends mainly on where people work; the schemes do not compete. Delivery
of care is mixed, including private, fee-for-service (FFS; rémunération à l’acte)
physicians, public hospitals, private non-profit-making hospitals and private
profit-making hospitals.
Management of the health system is split between the state and SHI. Since
the mid-1990s, reforms have aimed to devolve power from the national to the
regional level, in particular for planning. Regional institutions were created to
represent the main stakeholders: SHI schemes, the state, health professionals
and public health actors. However, to improve the system’s governance,
responsiveness to needs and efficiency, the 2009 Hospital, Patients, Health and
Territories (HPST) Act (Loi No. 2009–879 du 21 juillet 2009 portant réforme
de l’hôpital et relative aux patients, à la santé et aux territoires) merged most
of these institutions into a single regional health agency (agence régionale de
santé; ARS). Cutting across the traditional boundaries of health care, public
health and health and social care sectors, the ARS aims to ensure that health
care provision meets the needs of the population by improving links between
ambulatory and hospital sectors, and between health and social care sector
services, while keeping within national health expenditure limits.
With increasing health care expenditure and an increasing deficit of SHI (and
corresponding increase in tax financing), the role of the state in planning and
regulation has increased since the mid-1990s. At the regional level, the ARSs
coordinate ambulatory and hospital care for the population as well as health and
social care for the elderly and the disabled through a regional strategic health
plan (Plan stratégique régional de santé; PSRS) based on population needs.
This is a first attempt at regional planning of the ambulatory care sector.
In general, in the ambulatory care sector, patients pay providers directly and
are reimbursed by SHI, although there are exceptions for the most expensive
care as well as for households with low incomes; currently 35% of ambulatory
payment is paid directly from the insurer to the provider. Quality of care is
regulated at the national level. Hospitals must undergo a certification process
every four years but there is no formal recertification or relicensing process
for health professionals. However, doctors, pharmacists, dentists and midwives
are required to undertake lifelong learning through continuing professional
development (développement professionnel continu; DPC).