5. Provision of services
oth public and private providers deliver health care to the French population. Primary care is mostly delivered in the ambulatory care sector by self-employed professionals, while secondary care can be delivered both in the ambulatory and the hospital setting. From the late 1990s, GPs have gained a major role in the coordination of care, with the implementation of a semi-gatekeeping system that provides incentives to people to visit their GP prior to consulting a specialist. Drugs are dispensed by self-employed pharmacists, while the price of drugs, as in most countries in the OECD, is set administratively for all drugs covered by SHI. France is the third largest market for pharmaceutical drugs in the world. Hospital care is delivered by public, private non-profit-making and private profit-making hospitals. Long-term care for the elderly and disabled is provided through both residential care and home care. Mental health care is delivered by both the health sector and the social and health care sector. As in many other European countries, mental health care policy in France during the second half of the 20th century was influenced by a general movement towards community-based organization of mental health care services – the so-called “deinstitutionalization” process.
5.1 Public health
Public health policy and practice in France have historically been difficult to describe because they involve numerous actors and sources of funding. Further, large discrepancies exist between legislative texts and actual practice, which relies on the initiative of local actors. Nevertheless, reforms starting in 2004 have resulted in a more clearly structured organization of the field.
At the national level, the current system involves a number of institutions that provide multidisciplinary expertise in the field of health safety, two of which have broad remits covering many aspects of health safety: InVS, which is involved in surveillance, and INPES, which is involved in managing health crises and informing the population. Other specialized agencies provide expertise regarding specific types of risk and may exert policy enforcement duties (see section 2.3.3).
At the local level, municipalities are legally responsible for monitoring and purifying the water supply, controlling air and noise pollution, waste disposal, protection against radiation, hygiene in residential areas, food hygiene and industrial hygiene. Municipalities lacking the resources to carry out these functions are supported by the ARSs and their territorial delegations.
5.1.1 Surveillance of environmental and communicable disease threats
At the national level, the current system for the management of health risks involves a number of institutions that provide multidisciplinary and intersectoral expertise in the field of health safety (see sections 2.3.3, 2.5.5 and 2.6). On the one hand, there are specialized agencies that provide expertise regarding specific types of risk and may exert policy enforcement duties; on the other hand, two agencies have a broad remit that covers many aspects of health safety.
The specialist agencies include ANSM, EPRUS, ANSES, IRSN and the French Biomedicine Agency.
The two agencies with a broad remit are InVS and INPES. InVS has a mandate to monitor threats to population health, including infectious and chronic diseases and environmental and occupational health, as well as emerging threats of unknown origin that require continuous monitoring of health outcomes. InVS gathers surveillance data from various sources, including national monitoring systems that rely on networks of professionals, as well as a network of regional epidemiology units (cellules interrégionales d’épidémiologie). It reports all new epidemiological threats to the ministry in charge of health. INPES plays a major role in all issues related to communication and health, including strategies for dissemination of health alerts to population groups. In order to increase effectiveness, the planned 2015 Health Reform Law (see section 6.2) intends to merge these two institutions into a single agency.
The General Directorate of Health of the ministry in charge of health supervises the activity of the health agencies on a regular basis, issues regulations based on the advice provided by the agencies and deals with all emergencies regarding health safety. Moreover, the General Directorate of Health leads the Health Agency Networking Committee (Comité d’animation du système d’agences), a forum that brings together the directors of the major agencies involved in prevention and health security policy in order to develop a cohesive approach and strong leadership with respect to these policies. The Health Agency Networking Committee also includes HAS, HCSP, the National Institute for Medical Research (Institut national de la santé et de la recherche médicale) and the ARSs.
5.1.2 Occupational health
Employers are responsible for ensuring compliance with hygiene and safety standards through a Committee for Hygiene, Safety and Working Conditions (Comité d’hygiène et de sécurité des conditions de travail) and occupational health services (Services de santé au travail; SSTs) in companies. The Committee for Hygiene, Safety and Working Conditions represents the company’s employees in all issues regarding work conditions and safety; it verifies that regulations are correctly applied and makes proposals to improve working conditions.
The SSTs are run by occupational physicians and have a general remit to ensure that employees’ health is not altered by their work by confirming their ability to do their jobs, monitoring their health and ensuring that the exposure to risks in the workplace is within regulatory standards. There must be at least one occupational physician per 3300 workers. Large firms finance and host their own occupational medical services, whereas smaller firms are affiliated with external non-profit-making SSTs. Nationally, there are 953 occupational physicians working directly for firms and 4594 physicians working for external services covering multiple firms. The number of occupational physicians has diminished in recent years, with a nearly 10% decline from 2010 to 2011, largely through retirement, despite an increase in the number of internships offered for this discipline (IGAS, 2013a).
At the national level, the ANSES is responsible for oversight of workplace safety. The 848 SSTs are subject to regional oversight.
Two successive national plans for occupational health have focused on security, prevention and protection of workers’ health. The first (2005–2009) resulted in structural reforms, including the fusion of two antecedent agencies to create ANSES and reinforced oversight of the SSTs to ensure financial transparency and better regional coverage of SSTs. The second (2010–2014) has focused on developing occupational health research and prevention measures, while reinforcing support for employers’ prevention efforts and coordination among the various national and regional partners.
5.1.3 Preventive services
Historically, the French health care system has been more oriented towards curative than preventive medicine. Moreover, certain prevention activities are hampered by fragmentation of responsibilities among the various actors involved, as is the case for alcohol and drug abuse prevention. Nonetheless, other key prevention services, such as immunization and perinatal care, are well organized.
Each year, the national immunization programme is determined by the General Directorate of Health of the ministry in charge of health on the basis of proposals made by the Technical Committee on Immunization of the HCSP (see section 2.3.7) (Ministry in charge of Health, 2014a).
There are only three obligatory immunizations for the general population: tetanus, diphtheria and poliomyelitis. Municipalities offer free immunization sessions and are responsible for controlling the immunization status of all children within their jurisdictions. Immunization is also controlled at entrance into day nurseries and schools. Recommended vaccinations include immunization against whooping cough, rubella, measles, mumps, chickenpox, Haemophilus influenzae type b, Streptococcus pneumoniae (pneumococcal vaccine), group C Neisseria meningitidis (meningococcal C vaccine) and hepatitis B. Immunization against human papillomaviruses is recommended for girls aged 11 to 14 years, and immunization against seasonal influenza is recommended for all people aged over 65 as well as individuals with certain health conditions. Finally, there are a number of additional mandatory and recommended immunizations for health care workers, depending on their specific exposure risks. Most of the immunizations are performed by self-employed GPs. Mandatory and recommended immunizations are covered by SHI.
Antenatal and postnatal care for mothers and infants is fully covered by SHI and can be provided by self-employed doctors or institutions. In addition, departmental PMIs, managed by the local assemblies, offer free consultations for children up to the age of six years, with particular attention on families in difficulty and run preventive health and social care interventions for children. Health services are funded by SHI pursuant to partnership agreements with the departmental PMIs. In 2012, the model agreement was expanded to include home visits by midwives in the case of pathological pregnancies and coverage of vaccinations provided by the PMIs to pregnant women and new mothers.
5.1.4 Health promotion and education programmes
INPES runs large-scale health education programmes and provides resources for committees at the regional and departmental levels that carry out field activities. The 2004 Public Health Act introduced objectives related to health education and created regional public health plans that incorporate health education activities.
5.1.5 National screening programmes
National screening programmes in France are centred upon cancer. The ministry in charge of health decides which programmes will be implemented and shares responsibility for implementation with the INCa. The 2004 Public Health Act created 90 local structures, mainly at the departmental level, to carry out mass screening programmes; 90% of these structures are private non-profit-making associations, and around 50% are funded by general councils, while the rest are funded directly by either the state or SHI. Tests and related physician visits are funded by SHI. InVS is responsible for evaluating these screening programmes.
Two mass national screening programmes have been deployed in France: one for breast cancer and the other for colorectal cancer. Breast cancer screening is targeted at all women aged between 50 and 74, who are invited by mail to undergo a clinical examination and mammography every two years. Colorectal cancer screening is aimed at all people aged between 50 and 74, who are invited by mail every two years to go to their GP for free screening material, a faecal occult blood test and explanations on the programme and on the process to use the test. If people do not go to their GP in the next three months, they receive a second letter of invitation. After two letters of invitation, the centre sends them the test material at home expecting that people will do it and mail it back for interpretation.
Organized screening programmes for cervical cancer have been piloted in a number of departments. The 2014–2019 Cancer Plan called for a national screening programme for cervical cancer for all women aged 25 to 65 years (INCa, 2014). However, the HAS recommends opportunistic screening because of the difficulties in targeting the populations of women who have not adhered to the recommended screening regimen (HAS, 2013).
Public health programmes in France are often targeted either by population (PMI services for women and children) or by disease (mass screening programmes for breast cancer and colorectal cancer). Providing such services free reduces financial barriers to access but does not ensure participation. Breast cancer and colorectal cancer together account for 16% of cancer deaths in France (Table1.4), underscoring the need for efforts to ensure early diagnosis and treatment. In 2012, participation in the mass breast cancer-screening programme was just over 50%, lower than the 70% participation rate considered the minimum acceptable level according to European guidelines. Nonetheless, 30% of the breast cancer cases in France each year were detected through the screening programme (INCa, 2013). Participation in the mass colorectal cancer screening programme was even lower (30%), and a study of factors influencing patient participation recommended actions targeted at patients under 60 years, men and individuals living in deprived areas (Le Breton et al., 2012).
The French government has launched an ambitious national prevention plan covering all population groups.
Measures target different age groups with different objectives. For young children, key propositions include prescription of physical activity by GPs to overweight children and information campaigns on endocrine disruptors. For adolescents, measures target mainly risky sexual behaviors and addictions, by providing free condoms, and by easing access to outpatient clinics for young adults. For the adult population, the government aims to reduce tobacco consumption (through extensive coverage of smoking cessation treatments), hepatitis C (through better treatment outside of hospitals) and cervical cancer (through organized screenings). Disabled and older individuals are also covered with the objective of improving regular follow-ups with a systematic annual medical check-up in health and social care institutions and dental care in nursing homes.
The plan also covers a number of transversal measures, such as educating the general population on first-aid interventions, better labelling of food products and extended possibilities for pharmacists to administer vaccines.
While most stakeholders approve these measures, modalities of implementation and governance remain unclear.
More information (in French): http://solidarites-sante.gouv.fr/systeme-de-sante-et-medico-social/strategie-nationale-de-sante/priorite-prevention-rester-en-bonne-sante-tout-au-long-de-sa-vie
The Ministry of Health, in collaboration with the Ministry of Higher Education, has announced that medical students will have a three-month compulsory participation in health prevention activities from the next school year (September 2018). The proposition is largely supported by students’ unions and the national implementation will start after the completion of a pilot programme, which is currently underway in four cities.
Initially aimed at medicine, pharmacy, dentistry and nursing students, the programme will be extended to all health students (around 50,000 students) in 2019. They will be in charge of participating in health promotion and prevention activities in schools, work places, nursing homes, prisons, etc. in four main areas: alcohol and tobacco consumption, nutrition, physical activity and sexual-affective health.
This compulsory training will be rewarded by "credits" as a classic teaching unit but it will not be remunerated. A national committee will be set up to coordinate the programme while, concurrently, regional committees, involving regional health agencies and local education authorities, will benefit from a leeway to adapt actions to local needs.
More information (in French): http://solidarites-sante.gouv.fr/actualites/presse/dossiers-de-presse/article/dossier-de-presse-le-service-sanitaire
Starting on the 1st January 2018, eight mandatory vaccinations for children under two years old will be added to the three currently compulsory vaccines covering tetanus, diphtheria and poliomyelitis.
Until now, these new vaccines were recommended but not mandatory and include immunization against whooping cough, rubella, measles, mumps, Haemophilus influenza type b, pneumococcus, meningococcal C and hepatitis B. All mandatory vaccines will be fully reimbursed.
This measure aims to deal with the insufficient rates of immunization coverage for recommended vaccines in the country, which have led to outbreaks, avoidable hospitalizations and subsequent deaths, particularly among young people.
More information (in French): http://solidarites-sante.gouv.fr/actualites/presse/communiques-de-presse/article/a-partir-de-2018-les-enfants-de-moins-de-deux-ans-devront-etre-vaccines-contre
France has the highest smoking prevalence among the countries of Western Europe and North America, and after more than 25 years of decline, it is estimated to have increased again between 2005 and 2010 (Cadier, Durand-Zaleski, Thomas and Chevreul, 2016). The latest data however show that this prevalence stabilised at 34.1% among individuals aged 15-75 in 2014 and that regular smoking even decreased slightly, from 29.1% in 2010 to 28.2% in 2014 (Guignard et al., 2015). Tobacco consumption is the first most common cause of avoidable mortality in the country, with more than 70,000 annual deaths from smoking-related diseases (Ministry of Health, 2014). The costs of treatment for such diseases are almost fully covered by statutory health insurance (SHI) through a dedicated scheme for long-term chronic illnesses (affections de longue durée, ALD). In 2010, those costs amounted to 5.6 billion, accounting for more than 3.0% of the SHI annual budget (Cour des Comptes, 2012).
To face this major epidemiological and economic burden, decision-makers have been developing a number of dedicated health policies, including: a tobacco ban in bars, pubs, restaurants, hotels, casinos and nightclubs since 2008 (Guignard et al., 2015), a national smoking reduction programme (Programme national de réduction du tabagisme, PNRT) issued in 2014 (Ministry of Health, 2014), an entire month dedicated to the promotion of smoking cessation whose first edition took place in November 2016 (Tabac-info-service.fr, 2016) and, very recently, the introduction of plain cigarette packaging and the augmentation of applicable taxation on tobacco products to ensure an increase in prices (LegiFrance, 2016, 2017). However, additional funding has been identified as necessary to develop on-going promotion and prevention actions (Ministry of Health, 2014).
Impetus for the reform
The 2017 Social Security Finance Act of 23 December 2016 (Loi n°2016-1827 de financement de la sécurité sociale pour 2017) lays the foundations for the creation of a fund for the fight against tobacco consumption. The fund was created within the general SHI scheme (Caisse nationale d’assurance maladie des travailleurs salariés, CNAMTS) on the 1 of January 2017. Starting in 2018, a new social contribution will be directed at collecting financial resources for this fund directly from tobacco retailers for a total annual amount estimated at €130 million.
Content of the reform
The objective of the fund is to contribute to the funding of local, national and international actions aimed at reducing tobacco consumption. Those actions are in line with the key priorities of the PNRT (Ministry of Health, 2014) and fall within the World Health Organization framework convention on tobacco control (WHO, 2003). Actions can be part of four focus areas: 1. protecting young people and preventing them from starting to smoke; 2. helping smokers to quit; 3. increasing actions targeting priority population groups to reduce social inequalities in health; 4. supporting applied research and the evaluation of actions to prevent smoking and provide care to smokers. Specific calls for proposals will select the different projects supported by the fund within those focus areas.
Cadier, B., Durand-Zaleski, I., Thomas, D., & Chevreul, K. (2016). Cost Effectiveness of Free Access to Smoking Cessation Treatment in France Considering the Economic Burden of Smoking-Related Diseases. PLoS ONE, 11(2) (https://www.ncbi.nlm.nih.gov/pubmed/26909802, accessed 21 March 2017)
Cour des Comptes (2012). Rapport d’évaluation. Les politiques de lutte contre le tabagisme. Paris, Cour des Comptes
Guignard, R., Beck, F., Wilquin, J.-L., Andler, R., Nguyen-Thanh, V., Richard, J.-B., & Arwidson, P. (2015). Evolution of tobacco smoking in France: results from the health barometer 2014. Bull Epidémiol Hebd, 17–18:281–288
Ministry of Health (2014). Cancer Plan. Objective 10. National smoking reduction programme. 2014-2019 (http://social-sante.gouv.fr/IMG/pdf/pnrt2014-2019_uk.pdf, accessed 21 March 2017)
Legifrance (2016). Décret n° 2016-334 du 21 mars 2016 relatif au paquet neutre des cigarettes et de certains produits du tabac, 2016-334 (https://www.legifrance.gouv.fr/eli/decret/2016/3/21/AFSP1603141D/jo/texte, accessed 21 March 2017)
Legifrance (2017). Arrêté du 8 mars 2017 prévoyant la mise en œuvre de la majoration des minima de perception, prévue par l’article 575 du code général des impôts (https://www.legifrance.gouv.fr/eli/arrete/2017/3/8/AFSS1706532A/jo, accessed 21 March 2017)
Tabac-info-service.fr (2016) (website). Moi(s) sans tabac (http://mois-sans-tabac.tabac-info-service.fr, accessed 21 March 2017)
WHO (2003). WHO Framework convention on tobacco control. Geneva, World Health Organisation