Health Care Systems in Transition Written by Simone Sandier Valérie Paris Dominique Polton Edited by Sarah Thomson Elias Mossialos France 2004 The European Observatory on Health Systems and Policies is a partnership between the World Health Organization Regional Office for Europe, the governments of Belgium, Finland, Greece, Norway, Spain and Sweden, the European Investment Bank, the Open Society Institute, the World Bank, the London School of Economics and Political Science, and the London School of Hygiene & Tropical Medicine. Keywords: DELIVERY OF HEALTH CARE EVALUATION STUDIES FINANCING, HEALTH HEALTH CARE REFORM HEALTH SYSTEM PLANS – organization and administration FRANCE © WHO Regional Office for Europe on behalf of European Observatory on Health Systems and Policies, 2004 This document may be freely reviewed or abstracted, but not for commercial purposes. For rights of reproduction, in part or in whole, application should b e made to the Secretariat of the European Observatory on Health Systems and Policies, WHO Regional Office for Europe, Scherfigsvej 8, DK-2100 Copenhagen Ø, Denmark. The European Observatory on Health Systems and Policies welcomes such applications. The designations employed and the presentation of the material in this document do not imply the expression of any opinion whatsoever on the part of the European Observatory on Health Systems and Policies or its participating organizations concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. The names of countries or areas used in this document are those which were obtained at the time the original language edition of the document was prepared. The views expressed in this document are those of the contributors and do not necessarily represent the decisions or the stated policy of the European Observatory on Health Systems and Policies or its participating organizations. Suggested citation: Sandier S, Paris V, Polton D. Health care systems in transition: France. Copenhagen, WHO Regional Office for Europe on behalf of the European Observatory on Health Systems and Policies, 2004. European Observatory on Health Systems and Policies: WHO Regional Office for Europe Government of Belgium Government of Finland Government of Greece Government of Norway Government of Spain Government of Sweden European Investment Bank Open Society Institute World Bank London School of Economics and Political Science London School of Hygiene & Tropical Medicine ISSN 1020-9077 Vol. 6 No. 2 Health Care Systems in Transition iii Contents Foreword .............................................................................................v Acknowledgements ...........................................................................vii Introduction and historical background ..........................................1 Introductory overview ......................................................................1 Historical background ......................................................................5 Organizational structure and management ...................................19 Organizational structure of the health care system ........................19 Planning, regulation and management ...........................................28 Health care financing and expenditure ..........................................35 Main system of financing and coverage .......................................35 Health care benefits and rationing ................................................38 Complementary sources of financing ...........................................43 Health care expenditure .................................................................46 Health care delivery system .............................................................57 Public health services ....................................................................57 Primary and secondary ambulatory care .......................................61 Secondary and tertiary inpatient care ............................................68 Social care ......................................................................................79 Human resources and training .......................................................82 Pharmaceuticals ............................................................................92 Health care technology assessment ...............................................97 Financial resource allocation .........................................................101 Third party budget setting and resource allocation .....................101 Payment of hospitals ...................................................................104 Payment of health care professionals ..........................................109 Health care reforms ........................................................................115 Why embark on reforms? ............................................................115 Reform objectives ........................................................................115 Contents of the main reforms and related legislation ..................118 The implementation of reforms ...................................................128 Conclusions .....................................................................................133 List of abbreviations .......................................................................137 Bibliography ...................................................................................141 France Health Care Systems in Transition v Foreword he Health Care Systems in Transition (HiT) profiles are country-based reports that provide an analytical description of a health care system Tand of reform initiatives in progress or under development. The HiTs are a key element of the work of the European Observatory on Health Systems and Policies. HiTs seek to provide relevant comparative information to support policy- makers and analysts in the development of health care systems in Europe. The HiT profiles are building blocks that can be used: • to learn in detail about different approaches to the organization, financing and delivery of health services; • to describe the process, content and implementation of health care reform programmes; • to highlight challenges and areas that require more in-depth analysis; and • to provide a tool for the dissemination of information on health care systems and the exchange of experiences of reform strategies between policy-makers and analysts in different countries. The HiT profiles are produced by country experts in collaboration with the Observatory’s research directors and staff. In order to facilitate compari- sons between countries, the profiles are based on a template, which is revised periodically. The template provides the detailed guidelines and specific questions, definitions and examples needed to compile a HiT. This guidance is intended to be flexible to allow authors to take account of their national context. Compiling the HiT profiles poses a number of methodological problems. In many countries, there is relatively little information available on the health care system and the impact of reforms. Due to the lack of a uniform data source, quantitative data on health services are based on a number of different sources, including the WHO Regional Office for Europe health for all database, Organi- sation for Economic Cooperation and Development (OECD) Health Data and data from the World Bank. Data collection methods and definitions sometimes vary, but typically are consistent within each separate series. France vi European Observatory on Health Systems and Policies The HiT profiles provide a source of descriptive information on health care systems. They can be used to inform policy-makers about experiences in other countries that may be relevant to their own national situation. They can also be used to inform comparative analysis of health care systems. This series is an ongoing initiative: material is updated at regular intervals. Comments and suggestions for the further development and improvement of the HiT profiles are most welcome and can be sent to [email protected]. HiTs, HiT summaries and a glossary of terms used in the HiTs are available on the Observatory’s website at www.observatory.dk. France Health Care Systems in Transition vii Acknowledgements he French HiT was written by Simone Sandier (ArgSES), Valérie Paris (IRDES) and Dominique Polton (IRDES). It was edited by Sarah TThomson (European Observatory on Health Systems and Policies) and Elias Mossialos (European Observatory on Health Systems and Policies). The Research Director for the French HiT was also Elias Mossialos. The European Observatory on Health Systems and Policies is grateful to Martine Bellanger (National School of Public Health in Rennes) and Karine Chevreul (LSE Health and Social Care) for reviewing the report and to Yves Charpak (World Health Organization Regional Office for Europe) for his comments on the report. The authors of the HiT would like to thank their colleagues and friends Agnès Couffinhal, Pierre-Jean Lancry, Thérèse Lecomte and Arié and Andrée Mizrahi, who reviewed all or part of the first draft of this report and thereby improved it. They also thank the reviewers mentioned above and the Observatory staff for their helpful comments. The help and support of the French Ministry of Health is much appreciated. The current series of Health Care Systems in Transition profiles has been prepared by the research directors and staff of the European Observatory on Health