Equality and Solidarity: A Manifesto for the French Health System

A group of senior academics and policy leaders in health released a "Manifesto for Equality and Solidarity in Health" this past September. The Manifesto has attracted a good deal of attention as it was signed by a long list of French opinion leaders and personalities (including a few well known actors). I learned of this during my last trip to France to teach and had the chance to listen to one of its main authors, Didier Tabuteau, discussed the Manifesto at one of the EHESP regular Thursday seminars in Reid Hall where I teach.

I had expected a more impassioned presentation that focused on the justice of an egalitarian health system rather than the recounting of the history of the financing of the health system and the effects of macro-economic trends and realities on its ability to continue to provide services to all but a few in the population.

But the emphasis on the realities of public finance for health care and how it interacts with the larger economy is just the kind of discussion that is occurring in the United States as we begin the understand the limitations of the Medicare system and its finances.

Tabuteau held that the "Secu," the French social security system that is the overall financing vehicle for health services in France, was not doomed to end up in a "hole"(trou). He argued that a continuous adjustment process was necessary to titrate the tax rates that would support healthcare and that titration would rise or fall with the economy.

One point he the authors made make in the Manifesto that he didn't touch on much in the presentation at the EHESP was the "crisis of identity of professionals." According to the authors, doctors and other health care workers are experiencing a "profound malaise" accompanied by a steep decline in their conditions of work; "primary care physicians are living through a crisis that is without precedent" and students choosing to enter the field of medicine are facing hard choices.

The Manifesto speaks of and condemns an "ideology of management" (idéologie gestionnaire) that is affecting prices and costs as "the number of private operators, notably international groups, are investing massively in the health field, seeking to find profits..."

The Manifesto ends with a series of recommendations, primarily to increase reimbursement for care, especially long term care; the "reconstruction of a better payment system (convention) for private doctors; a "re-founding" of the public hospital system and the institution of a "true system of sanitary security and collective prevention."

French survey reports a long wait for the doctor

Almost 60% of French people surveyed say they have given up going to see a specialist because the delay was too long for an appointment. This result from a poll by the IFOP (Institute Francais d’Opinion Publique) Jalma consulting firm, published in the Journal du Dimanche (JDD) and reported in Figaro, November 13, 2011.

According to those interviewed, it took an average of 103 days to see an ophthalmologist, 51 days a gynecologist, 38 days for a dermatologist, and four weeks for a cardiologist, otolaryngologist, psychiatrist or a rheumatologist.

Getting in to see a specialist in a hospital practice is also hard. A referral to a specialist means a wait of 31 days for a hospital-based cardiologist or 29 days for an office visit; seeing a hospital radiologist takes an average of 21 days or 13 days to see a radiologist in their office.

When the wait seems too long, people choose to go to the emergency room: 27% of respondents say they have used the ER for reasons of time or cost. Up to 58% of respondents say they have given up on at least one appointment with a specialist because of the wait; 33% have done so several times. Some 28% have given up because of geographic distance.

To see a general practitioner, the period is much shorter and is, on average, four days. However, 15% of respondents say they have not made an appointment with a GP because of the distance to the office.

The perception of delays is different depending on whether you ask patients or practitioners. Jalma conducted a parallel survey of 600 doctors who gave different results, reporting much shorter waits.

"There is a big gap between perception and reality for the French. The wait for an appointment described by the doctors are much shorter. This means that practitioners and their patients are not available at the same times," is how Matallah Mathias, president of Jalma, interprets the differences. He suggest that specialists need to adjust their schedules for their patients: "Many will hate this conclusion but specialists must make the change in how they operate to increase access," he argued.

The survey was conducted online from August 29 to September 4, 2011 with responses from a representative sample of 1001 people 18 years or older.

Indispensable reference work on French health system

A new comprehensive review of the French health system has been published as part of the "Health Systems in Transition" series from the European Observatory on Health Systems and Policies. It can be downloaded as a .pdf at a WHO site. The review is a full 294 pages long and is a very useful reference document for anyone trying to follow health policy in France.

The document was authored by my colleagues at EHESP, Karine Chevreul and Isabele Durand-Zaleski along with Stephane Barhami, Cristina Hernández-Quevedo and Philipa Mladovsky. Dr. Chevreul is the deputy head of the Paris Health Economics and Health Services Research Unit and a researcher in the Public Health Department of the Henri Mondor Teaching Hospital in Créteil and Dr. Durand-Zaleski is the director of those units. Both teach in the EHESP policy modules.

The volume provides a good review of recent policy changes in France that touch on health and health care. The following figure from the book gives a sense of the relative "outputs" of the French health system compared to the OECD average.