Activities and Organisational Structure
A Mixed System
The first key feature of the French health system is its mix of public and private providers (hospitals, for example, on the one hand and private clinics and practitioners on the other). Another characteristic is the large component of cost sharing. Health care costs are not borne directly by patients but paid for by the statutory health insurance scheme (in the form of reimbursements or direct payment by the health insurance funds), while the different health insurance funds are financed by contributions based on professional earnings and other forms of income.
The state is the main actor of the health care sector. It plays a direct role in the funding and provision of health care and regulates the relations between funding institutions, patients and health professionals.
The state is thus responsible for (either directly or through specialist bodies):
- planning health care (increasingly at the regional level),
- general public health policy, including preventive healthcare, health watch, policies to combat diseases and tobacco, alcohol and drug addiction,
- training health actors (doctors, nurses, paramedical staff, etc.) – another aspect that the regions are now involved in,
- appointing hospital doctors and hospital accreditation,
- setting hospital budgets (with the assistance of the health insurance scheme),
- participating in the funding of hospital modernisation programmes,
- monitoring quality standards in hospitals,
- drugs policy (authorisation, pricing and monitoring),
- guidelines and supervision of health care and health prevention bodies, as well the system of health care supply as a whole.
Beginning in the nineteen eighties, a number of bodies were set up to improve health safety and prevention, exercising some of the responsibilities of the state in this area:
- National Biomedicine Agency (ABM)
- French Food Safety Agency (AFFSA),
- French Health Products Safety Agency (AFSSAPS),
- French Environmental Health Safety Agency (AFSSE),
- National School of Public Health (ENSP),
- French Blood Donors Institute (EFS),
- French National Health Authority (HAS),
- National Institute for Health Education and Prevention (INPES),
- Health Watch Institute (InVS),
- French Nuclear Protection and Safety Institute (IRSN).
Health watch activities are implemented among others by the Communicable Diseases Computerised Surveillance Network (RNTMT).
Social security funding and operating mechanisms are determined by parliament, which each year passes a Social Security Funding Act (LFSS).
Consultation on health system operation is provided through a National Health Conference, and conferences are also held at the regional and territorial levels.
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Health Insurance
- Statutory health insurance coverage
Subscription to a health insurance scheme is compulsory. Social protection in the area of health is essentially the role of the Assurance maladie, the health insurance branch of the social security system (which also includes a family benefits branch and an old-age pensions branch), operated by the “social partners” under the supervision of the state. The entire population thus has health insurance coverage, generally on a work-related basis (as a beneficiary) or as a dependant of a beneficiary.
In France, health insurance is administered by several different schemes. The principal scheme is the general social security scheme (Régime général) which provides coverage for salaried workers in commerce and industry, and their dependants (about 80% of the population in all).
The scheme operates through three different tiers:
- the National Health Insurance Fund for Salaried Workers (CNAMTS),
- 16 regional health insurance funds (CRAM),
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128 local health insurance funds (CPAM) in mainland France and 4
general social security funds (CGSS) in the overseas departments.
The agricultural scheme (MSA) covers farmers and agricultural employees and their dependants (about 9% of the population).
The social security scheme for the self-employed (RSI) comprises the different funds managing health insurance coverage for non-agricultural self-employed people: entrepreneurs, artisans, tradespeople, self-employed professionals, etc. (about 6% of the population).
Other smaller schemes, also operating on a work-related basis, cater for certain specific categories of the population (miners, railway workers, seamen, etc.).
Health insurance is funded by contributions based on professional earnings and a tax levied on all income (including investment income) known as the CSG (contribution sociale généralisée).
For the payroll contributions component, the burden is shared by employees and employers.
To qualify for cover an individual must generally have worked at least 120 hours during the previous month, or 600 hours in the previous six-month period. Different rules apply for self-employed people.
- Complementary health insurance coverage
Some cases such as serious illness, maternity or industrial injury qualify for total (or quasi-total) coverage of health care costs. The rest of the time, the health insurance system reimburses only part of the cost (which will vary depending on the type of service provided), leaving the remainder, or ticket modérateur, to be borne by the patient.
Over time, to cover the portion of cost borne by the patient, various complementary health insurance systems began to emerge.
Today, there are three types of complementary health insurance:
- the mutual benefit funds (mutuelles), which began to develop at the end of the nineteen century and today cover about 40 million people,
- the private insurance companies, which are increasingly targeting the health market,
- the provident institutions, which are co-managed by representatives of employers and employees and have a smaller share of the insurance market than the above two types of organisation.
In most cases, complementary insurance is provided through the workplace, in which case contributions are shared by employers and employees.
- The Universal Medical Coverage programme
The Universal Medical Coverage programme (CMU, couverture maladie universelle) extends eligibility for social security health insurance to low income people on the basis of legal residence in France.
In practice, CMU beneficiaries are of two kinds:
- people who are not eligible for, or who have exhausted their rights to benefit (an increasingly rare situation, which still occurs however),
- people on low incomes who have health insurance coverage, but cannot afford complementary coverage. The mechanism that applies in this case is the Complementary Universal Medical Coverage programme (CMU complémentaire).
For beneficiaries of the minimum guaranteed income (RMI, revenu minimum d'insertion) entitlement to the CMU is automatic. Overall, there are about 4.3 million CMU beneficiaries, mostly under the CMUC programme.
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Health Care Provision
Provision of health care by private practitioners and hospitals is regulated by the Public Health Code. For midwives, pharmacists, general practitioners and dental surgeons, professional organisations exist, which monitor adherence to medical ethics and may grant or withdraw the right to practise.
- Health care institutions
Health care institutions include hospitals (public or private) participating in the public hospital service, and for-profit private clinics. France has about 3,000 health care establishments, about a third of which are public and the remainder, private.
As specified by the Public Health Code, France’s public hospitals are legally autonomous and manage their own budget. Their activities are neither industrial nor commercial and they may be municipal, departmental, interdepartmental or national in status.
There are several categories of hospital:
- 31 regional hospitals (CHR, centres hospitaliers régionaux), 29 of which are also teaching hospitals (CHRU, centres hospitaliers universitaires),
- 562 general hospitals (centres hospitaliers généraux),
- 349 local hospitals, located in small towns and rural areas.
There are also a small number of national hospitals such as the Quinze-Vingts and National Hospital of Saint-Maurice.
France also has a health service for military personnel, operating under the supervision of the Ministry of Defence and governed by special provisions.
The main remit of this body is to provide support to the armed forces, both in France and abroad.
The various establishments participating in the public hospital service must fulfil certain obligations in terms of continuity of care and equal access to health care. They provide acute, follow-up, preventive and palliative care.
In particular, the public hospital service participates in:
- graduate and post-graduate teaching,
- research in the medical, pharmaceutical and dental health fields,
- continuing training of practitioners and training of midwives and paramedical staff,
- preventive medecine and health education programmes,
- provision of emergency care.
Private health care institutions include non-profit establishments - usually participating in the public hospital service (the Red Cross hospitals for example) – and for-profit establishments (private clinics).
For many years financed by a system of per diem rates, then a system of global budgets, public hospitals will henceforth be funded through diagnosis-related payments (similar to the US DRG system), which are progressively being put in place. Private clinics, which are currently remunerated on a per diem and fee-for-service basis, will be required to adopt a similar mechanism, with a view to aligning public and private-sector funding mechanisms.
- Health clinics and treatment centres
Health clinics and treatment centres are operated by the municipalities, mutuelles or by humanitarian organisations. Most have public-sector status, are staffed mainly by salaried doctors, and provide both general and specialist care. A noteworthy public health programme in this area are the mother and child welfare services (PMI, services de protection maternelle et infantile), set up by the départements to provide regular check-ups for pregnant women and infants.
- The health professions
France employs about 1.7 million health-sector professionals. They include members of the professions governed by the Public Health Code and other socio-professional groups.
The health-sector professions can be divided into two main categories:
- the medical professions (general practitioners, specialists, dental surgeons, pharmacists etc.),
- the paramedical professions (nurses, nursing auxiliaries, physiotherapists, laboratory technicians, X-ray operators, etc.).
In terms of activity status, the health professions comprise:
- the salaried health professions (which include doctors and paramedics working in public or private hospitals),
- the self-employed professions (doctors and paramedical staff).
The biggest of the health professional groups (accounting for 47% of all health sector jobs) works in the public hospital sector. This sector has witnessed a significant increase in staffing levels, which have grown by 31.3% between 1985 and 2002, with women playing an increasingly preponderant role (76% of all jobs).
Nurses, nursing auxiliaries and clerical and technical staff account for about three-quarters of all health sector staff.
Staff employed in public hospitals have a special status as state hospital sector employees. Civil servant status does not apply to doctors and pharmacists employed in public health institutions. University hospital doctors have dual status as civil servants due to their teaching and research responsibilities, and state hospital sector employees due to their medical work. In the private non-profit and for-profit hospitals, health professionals are governed by private-sector labour law, or self-employed as in the case of practitioners working in clinics.
Independent (private) medical practice is governed by a certain number of principles: freedom for doctors to set up practice where they choose, fee-for-service remuneration of doctors, and freedom of patients to choose their doctor. In 1998, 75% of all general practitioners and 68% of all specialists worked in private practice. A numerus clausus system fixes the number of medical and dental students to be admitted to medical school each year (5,700 medical students in 2004). Some branches are experiencing difficulties attracting students however, in particular paediatrics, obstetrics, anaesthesia and psychiatry. There are also wide disparities in the geographical distribution of doctors. Though the national average is 335 doctors per 100,000 inhabitants, this figure is 424 for the Paris region and 416 for the Provence-Alpes-Côte d’Azur region, while Picardy has only 251 doctors per 100,000 inhabitants. Specialists too are in greater supply in the big cities.
Private practitioners are remunerated on a fee-for-service basis and are allowed to combine private practice with salaried work.
- The pharmacy sector
Pharmacists train in faculties of pharmacy. The production and distribution of medicines is regulated by government. Prices and reimbursement rates are determined by departmental order. Although pharmacies are private undertakings, they must comply with government demographic norms which determine where they may operate.
- Medication
France is one of the world’s biggest consumers of drugs and the biggest in Europe. Since 1990, spending on drugs has more than doubled, and since 1997, prescription drug purchases account for the bulk of outpatient health care consumption.
The amount spent annually on pharmaceuticals is thus more than €27 billion. As a consequence, both the government and the statutory health insurance system are working actively to promote the use of generic drugs, which are identical to their brand counterparts (patented in the public domain) but less expensive. In 2004, only 6% of reimbursable drugs and 13% of drugs sold over the counter were generic, as compared to between 30% and 50% in certain European countries. Generics have however generated savings of several millions of euros for the health insurance fund.
