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Print version ISSN 0042-9686
Bull World Health Organ vol.82 n.3 Genebra Mar. 2004
Ailing French health care system to go under the knife
The French public health system once praised by WHO as the best in the world is overburdened, wasteful and in urgent need of an overhaul, says a government-commissioned report released in January. The diagnosis lays the groundwork for the second of two "modernization" packages this one targeting the social security system that reimburses medical expenses, the other aimed at the public hospitals themselves long planned by French Health Minister, Jean-François Mattei.
Written by the High Council for the Future of Health Insurance, a 53-member panel set up last October that included politicians, medical professionals and health insurers, the report highlighted several problems. In particular, a projected €10.9 billion (US$ 13.7 billion) shortfall in the public health insurance budget in 2004, which could balloon to nearly €66 billion (US$ 82.9 billion) by 2020.
Beyond finances, the Council also pointed out troubling medical aspects of a system lacking oversight and accountability. For example, the report noted that "nothing justifies" the consumption of two to four times more analgesics, antidepressants, and tranquillisers in France compared to its neighbours. The associated costs and dangers are "considerable," amounting to over €16 billion (US$ 20 billion) per year and 350 hospitalizations a day due to toxic interactions between prescription drugs. Remedying the situation, the Council wrote, "requires extremely decided actions" and "active participation from all the players in the 'medicine chain': the State, laboratories, drug makers, physicians, pharmacists, public and private health insurers and the patients themselves."
The report also discusses "grave inadequacies" in the way the health insurance system is currently managed. Compartmentalization, "confusion about who is in charge of what," and a "sometimes ridiculous accumulation of administration" were cited as major obstacles to efficiency.
Only three years ago, France's public health system was hailed the best in the world by WHO. It provides universal coverage while allowing relatively unhindered access to both public and private doctors, services and institutions, generally without long waiting lists. Reimbursement of obligatory medical services averages 76%, but for the sickest patients, costs are 100% paid for up front.
The High Council report warned that the current system of refunding medical expenditures "probably promotes some of the problems." As a result, the French are bracing themselves for changes that will likely curb their liberal access to medical specialists, treatments and drugs. They will probably have to pay more, too.
Days after the report was delivered, Mattei called for bilateral discussions and set up working groups to detail possible remedies for the ailing health insurance system. The discussions, which are to conclude in early April, will focus on eight topics ranging from the good use of medicines to sharing medical records. The ministry is scheduled to outline the reforms by July.
Meanwhile, after months of negotiations, several unions of medical professionals have agreed to participate in writing the decrees that will govern the implementation of another set of reforms called "Hospital 2007." These aim to revitalize French public hospitals as well as make them more cost-efficient.
"The last sweeping reform of French public hospitals was in 1958," says gynaecologistobstetrician, André Nazac, president of a union representing various medical professionals including assistant clinical directors and young doctors, which has signed its support to Hospital 2007. "Staying in the situation we have now would be more serious than what might happen [with Hospital 2007]. So, we prefer to participate in shaping the law rather than wait until it is written and say we don't agree."
"Hospital 2007," which will be phased in over 3 years starting in June has triggered work stoppages and protests among some medical professionals, since Mattei, a doctor himself, first outlined its goals in 2002. It proposes to tear down compartmentalization within hospitals by creating mulitdisciplinary "poles" or service units. It also calls for each public hospital to set up an executive committee made up of administrative and medical personnel to direct treatment, teaching and research priorities. Funding will be restructured to give the most active departments and services a larger share of the budget. Other changes will range from updating purchasing and pricing procedures to reducing the wait in emergency rooms. A system of evaluation and promotion based on competency may also be inaugurated.
Problems with the French public health care system became increasingly apparent in recent months. When Europe sweltered under a heat wave last August, for example, more than 15 000 people died in France, dwarfing the number of deaths in neighbouring countries. In December, a nationwide flu and bronchitis epidemic led to a shortage of hospital beds.