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.
