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France - P4H Network
Current Health Expenditure (CHE) as % Gross Domestic Product (GDP)12.3%CHE/GDP
Out-of-pocket (OOPS) spending as % of Current Health Expenditure (CHE)8.9%OOP/CHE
Domestic General Government Health Expenditure (GGHE-D) as % General Government Expenditure (GGE)15.8%GGHE-D/GGE
Gross Domestic Product (GDP), in constant (2020) US$ per capita3TGDP (USD)
Population in thousands (K), millions (M) or billions (B)67.7MPopulation
Self-reported unmet need for medical care by sex (Total)2.2%Unmet Needs - Total
Self-reported unmet need for medical care by sex (Female)3.3%Unmet Needs - Female
Self-reported unmet need for medical care by sex (Male)2.2%Unmet Needs - Male

The P4H Network and the French National School for Social Security [École nationale supérieure de Sécurité sociale] (EN3S) have been collaborating to document and share knowledge about France’s SHP system and experience in SHP. France’s experience in social health protection (SHP) is one of the richest in the world. The results are noteworthy.

This page invites visitors to view four slides, located at the top of the page. They illustrate the health care ecosystem in France. The slides summarize health care provision, the social health insurance system, and the stewardship of financial risk coverage.

Below the slides, viewers can click on three timelines detailing the history of SHP from the perspective of stakeholders on progress in universal health coverage and changes in health insurance financing.

Below the timelines, readers will find five briefs in French on aspects of SHP in France.

Timely articles from EN3S’s newsletter, Sécu Hebdo, further enrich this page.

The individual is at the heart of the system

The individual is at the heart of the system

The individual is a patient who uses the healthcare system

The patient must reside in France (French nationality or not, but legally resident in the country). As such, they are insured.

If the patient is of French nationality but not resident in France (expatriate or frontier worker), then the European Union regulation on the coordination of social security schemes or bilateral agreements between countries apply.
If the individual is a foreigner in an irregular situation, then AME or urgent care benefits apply.

The individual is an insured person (and the members of his or her household), who finances the healthcare system

Resident in France (of French nationality or not, but legally resident in the country).

They are active or inactive (retired, capital income).

Households are not the only financial contributors to the system, since companies also contribute, either as employers (employer social security contributions), or as payers of various taxes (CSSS, payroll tax, “pharmaceutical” taxes, etc.).

The individual is a French citizen who elects his or her representatives, notably in presidential and legislative elections

They may or may not be insured (French citizens living abroad).
They may or may not be patients!

L’offre de soins

The city/hospital dichotomy structures supply, and drugs are specifically regulated

Half of care is provided in hospitals, and half in towns and cities

In terms of healthcare facilities, we distinguish between public and private establishments

In the city, a distinction is made between care provided by the medical professions, and that provided by paramedical professions.

The “city” category includes health centers, in the generic sense (beyond organizational innovations).

The healthcare system is supplied with drugs and medical devices, which are subject to specific regulations.

Companies belonging to the pharmaceutical industry, which supply the healthcare system with drugs and medical devices.

The French National Authority for Health (HAS) defines the scope of reimbursement, based in particular on the evaluation of medical service rendered.

The Comité économique des produits de santé (CEPS) negotiates the price of marketed drugs and medical devices with companies.


Simplifying assumptions have been used to illustrate the range of healthcare services on offer:

  • The diagram does not include care provided in the context of occupational medicine, school medicine, etc..
  • The diagram does not include medical-social establishments.

Gestion du système de financement

Health insurance, and CNAM in particular, at the heart of the financing system

Health care is essentially financed by insured persons/households and their employers

Part of the funding comes from health insurance contributions, which are currently paid solely by employers and the self-employed, and from the CSG, which is paid by the entire population (active, replacement, capital, games, etc.).

Another part comes from other social contributions, taxes and levies, paid either by households or by companies/employers.

Lastly, there is financing from State credits (Aide Médicale d’Etat-AME, urgent care, prevention, health security), which is more modest in financial terms, and is ultimately provided by taxes paid by households or companies.

They collect the bulk of social security contributions and CSG, as well as certain taxes (from complementary health insurance organizations, pharmaceutical laboratories, etc.).
The sums collected by the other basic schemes or by the OCs are much more modest.

The DGFiP also plays a role, either by collecting taxes earmarked for the health insurance scheme, or by collecting taxes that feed the State budget, part of which finances the system.

The major role of CNAM

Since 2016, there has been just one basic health and maternity insurance scheme, Protection universelle maladie (PUMa), managed by CNAM.

The other basic health insurance “schemes”, which manage and cover smaller populations (salaried employees and farmers, railway workers, miners, sailors, military personnel, notary clerks…), are integrated into the PUMa, except for a few specific expenses.

Other players play a less important role. In particular, supplementary social protection, managed for the most part by private organizations (with the exception of Alsace-Moselle), finances around one-sixth of all healthcare expenditure.

Steering the system is a complex, multi-player affair

Steering the system is a complex, multi-player affair

The role of the government is to provide overall direction

It prepares – at ministerial level – Social Security Finance Bills (PLFSS), Finance Bills (PLF) and Public Finance Programming Bills (LPFP).

It also supervises social protection organizations – also at ministerial level.

The Agences Régionales de Santé (Regional Health Agencies) – decentralized government departments – supervise (and very partially finance) healthcare establishments.

It creates specialized agencies such as the Haute Autorité de Santé.

Parliament plays its legislative role

It amends and votes through the PLFSS, PLF and LPFP, and ordinary laws relating to the healthcare system.

It monitors the application of laws.

It carries out evaluations of the healthcare system.

Social partners are part of the system’s governance

Professional unions are directly involved in negotiating medical agreements with the Caisse Nationale d’Assurance Maladie (CNAM).

Employees’ unions and employers’ organizations sit on and chair the boards of directors of the social security funds: they sign the COG (conventions d’objectifs et de gestion) with the French government, and issue opinions on draft laws and decrees…

Local executives are involved at local level

They sit on hospital boards.

They create health centers.

They play an important role in preventive health care.

They set up consultative bodies to bring together all the players involved.