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Achieving Universal Health Coverage in France: Policy Reforms and the Challenge of Inequalities

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Achieving Universal Health Coverage in France: Policy Reforms and the Challenge of Inequalities Series France: nation and world 1 Achieving universal health coverage in France: policy reforms and the challenge of inequalities Olivier Nay, Sophie Béjean, Daniel Benamouzig, Henri Bergeron, Patrick Castel, Bruno Ventelou Since 1945, the provision of health care in France has been grounded in a social conception promoting universalism and Published Online equality. The French health-care system is based on compulsory social insurance funded by social contributions, May 2, 2016 co-administered by workers’ and employers’ organisations under State control and driven by highly redistributive http://dx.doi.org/10.1016/ S0140-6736(16)00580-8 fi nancial transfers. This system is described frequently as the French model. In this paper, the fi rst in The Lancet’s Series See Online/Series on France, we challenge conventional wisdom about health care in France. First, we focus on policy and institutional http://dx.doi.org/10.1016/ transformations that have aff ected deeply the governance of health care over past decades. We argue that the health S0140-6736(16)00379-2 system rests on a diversity of institutions, policy mechanisms, and health actors, while its governance has been marked This is the first in a Series of by the reinforcement of national regulation under the aegis of the State. Second, we suggest the redistributive two papers about France mechanisms of the health insurance system are impeded by social inequalities in health, which remain major University of Paris 1 hindrances to achieving objectives of justice and solidarity associated with the conception of health care in France. Panthéon-Sorbonne, Paris, France (Prof O Nay PhD); University of Dijon, Dijon, Introduction The French experience also shows that the objectives of France (Prof S Béjean PhD); Since the end of World War 2 in 1945, the French health- universality and equality cannot be met simply by Centre National de la Recherche care system has evolved as a social project driven by continuously extending health insurance coverage: they Scientifique (CNRS), Paris, France (Prof D Benamouzig PhD, two great principles: universalism and equality. The also need public eff orts to reduce social inequalities in Prof H Bergeron PhD); Sciences extension of health insurance coverage over seven health eff ectively. Although institutional mechanisms Po, Paris, France decades has made it possible to guarantee everyone guarantee solidarity in health-care funding, substantial (Prof D Benamouzig, access to the minimum of health care. The health social disparities continue to maintain inequalities in Prof H Bergeron, Prof P Castel PhD); Aix-Marseille insurance system is based on a redistributive philosophy social groups’ access to care. Similar to most developed University, School of intended to match households’ fi nancial contributions to countries with comparable institutional capacity, the Economics, Marseille, France their ability to pay and to guarantee individuals on low French system—although generous in its principles— (Prof B Ventelou PhD); and income access to good quality coverage. still has diffi culty reaching its egalitarian objectives. Institut National de la Santé et de la Recherche Médicale The social model of health is a feature of the French Many determinants of social inequalities in health lie (INSERM), Paris, France experience. Its aim is to promote justice and solidarity outside the health-care system—eg, education, social (Prof B Ventelou) while ensuring high-quality health care. The French class, and living and working conditions. Correspondence to: model, as it is often called, is based on a national system Here, we fi rst discuss how the French health-care system Prof Olivier Nay, University of of health insurance funded by employee and employer relies on a diversity of institutions, policy mechanisms, Paris 1 Panthéon-Sorbonne, UFR 11, 75005 Paris, France social contributions and co-administered by workers’ and and health actors. State-driven reinforcement of national [email protected] employers’ organisations under State supervision. This regulations has been extensive in the past two decades. model has inspired national reforms in developing Second, we focus on redistributive aspects of the French countries, supported by French international health health-care system. We address both funding mechanisms assistance, as discussed in the second paper in and key factors that might impede the social model of The Lancet’s Series on France.1 It is set apart most often health. We show how some social determinants are major from other European health protection systems in a obstacles to meeting the objectives of universality and reductionist opposition between Bismarckian and equality in access to health care. Beveridgean social insurance systems. Here, we show that it is diffi cult to relegate health French health-care governance: institutional governance in France to an institutional archetype. The change and policy reforms French system not only relies on various policy Historically, the French health-care insurance and mechanisms and health actors but also has been delivery system is one that involves State institutions, transformed profoundly over the past two decades. non-profi t groups, and the private sector. Beginning in Changes have aff ected health fi nancing, health-care the 1990s, government regulation played an increasing provision, and monitoring of national health strategies. part in the French system without, however, centralising These changes have been a result of public administration it. First, local participants retain substantial autonomy: reforms and reorganisation of labour, management, and health-care professionals have much freedom in their government bodies involved in health insurance. The work and are involved in the governance of hospitals and role of State institutions in regulating the health-care other health-care facilities; patients have the freedom to system has grown throughout these successive reforms. choose how they access the health-care system. Second, www.thelancet.com Published online May 2, 2016 http://dx.doi.org/10.1016/S0140-6736(16)00580-8 1 Series institutional diversity is maintained and local co- Institutional diversity in the French health system ordination among providers and payers remains In France, hospitals developed most considerably from the insuffi cient. Nowadays, State reinforcement in its 19th century. Moreover, in 1893, as assistance laws were supervision of the health system takes on complex, even passed in Europe, the Third Republic decided to guarantee hybrid, forms. It relies on introducing governmental access to health-care facilities to poor people. Concurrently, rules drawn from company management techniques and collective or private insurance schemes (sociétés de secours on what is known as the new public management.2 The mutuel, caisses syndicales, and caisses patronales) were Ministry of Health and health regulatory agencies also launched.6 However, one might judge that fi rst attempts to promote prevention programmes to make individuals establish a system covering health-care costs in France more responsible for dealing with their health risks—eg, date back to statutes that set up the fi rst compulsory social smoking,3 alcohol,4 and obesity.5 insurance, enacted in 1928 and 1930. Nonetheless, resistance by private practitioners limited implementation. Only at the end of World War 2 did a new plan emerge. Panel 1: Main health reforms in France since 1945 The National Council of the Resistance, which comprised representatives of all political parties, from Communists to 1945 Gaullists, set up a complete social insurance system Creation of the Sécurité Sociale (Social Security Act) covering health care, workplace accidents, old age, and 1958 family benefi ts.6,7 Since 1945, the French health-care system Major hospital reform; setting the civil servant status for doctors working in public has expanded gradually, broadening the population’s hospitals and creating teaching hospitals solidarity-based coverage through other compulsory funds. In 1945, the general social insurance system (régime général 1967 de la sécurité sociale, hereafter called the general fund) and Creation of specifi c risk-related funds, managing health, retirement, and family benefi ts; its health insurance fund (hereafter, the general health management of such funds is given to representatives of both employers and employees insurance fund) were established for the private sector. 1970 Several specifi c funds were added subsequently, most Act #70-1318, establishing policy methods for rationalising and balancing health-care importantly, the social insurance fund for farmers and delivery across French regions (carte sanitaire) and authorising clustering of hospitals agricultural workers in 1961 (mutualité sociale agricole) and the national fund for professionals and independent 1984 workers in 1966 (now the régime social des indépendants). Funding reform for public hospitals; global budgeting Nowadays, around 15 of these funds coexist (eg, for civil 1991 servants, students, the armed forces, seamen, members of Act #91-748, establishing policy methods for rationalising and balancing health-care the National Assembly, and authorised private-practice delivery across French regions (schémas d’organisation sanitaire) and making compulsory doctors). In France, employer and employee payroll taxes the development of strategic planning for hospitals (projets d’établissement) fund this mandatory coverage. Trade unions and employers’ organisations
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