France

Health systems in transition France 69
Fig. 3.6
Percentage of total expenditure on health by financing agent, 2013
74% SHI
5% General government
7% OOP
13% VHI
0.6% Other
Source: Eco-Santé, 2014.
OOP payments are particularly important for optical care, dental care and
drugs. They have remained relatively stable since 2000 as a result of an increase
in public coverage and contrasting trends in VHI coverage. On one hand, VHI
coverage increased with the implementation of free public complementary
coverage for the less well off and with better coverage of medical devices (see
section 3.5.1). On the other hand, it decreased with the de-listing of drugs with
low SMR (see section 6.1.2) and the implementation of semi-gatekeeping and
of deductibles (see section 3.3.1) (DREES, 2012).
The respective contributions of financing agents vary across sectors and
over time. Since the early 1990s, around 92% of hospital expenditure has been
financed by SHI, but the share of outpatient care financed by SHI is smaller
and has decreased over time, from 77% in 1980 to 63% in 2010 (Fenina, Garrec
& Koubi, 2011). This can be explained, on the one hand, by the fact that in
outpatient care some professionals are allowed to charge patients above the
official SHI tariffs (extra-billing, see section 3.7.2) and, on the other hand, by
the fact that since the late 1970s, most reforms have significantly increased
patient user charges on medical goods and overall outpatient care.
The financial flows in the French health care system are depicted in Fig. 3.7
and described in detail in the following sections.