France

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.

Note

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.

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

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.