The French health care system (2024)

2021

Under the French health care system, care is provided at various types of facilities: private practices for non-hospital care, healthcare facilities for hospital-based care, health and social, and residential facilities for “vulnerable” elderly or disabled customers. It is grounded in the patient's and resident's freedom of choice: each patient is free to choose his/her primary care physician (médecin traitant), direct-access specialist, health care facility, or residential facility, either in the public or the private sector.

France's public health insurance system (l'Assurance Maladie) covers the following types of care if they appear on the official list of reimbursable care:

• hospital-based care and treatments in public or private health care, rehabilitation, or physical therapy facilities;
• non-hospital-based care provided by general practitioners, specialists, dentists, and midwives;
• doctor-prescribed diagnostic tests and care provided by medical laboratories and allied health professionals (nurses, physical therapists, speech therapists, etc.);
• prescribed pharmaceuticals, medical devices, and prosthetics which appear on the official lists of reimbursable products;
• prescribed medical transportation.

Additional information on the French social security system, how it is financed, and the rules for coverage of care is available on CLEISS' website.

I. How the French health care system is administered by public policy

a) At the national level: the ministries

The State directly finances and organizes the delivery of health and health and social services. This means that the ministers in charge of health and solidarity, public accounts, and civil service, have a wide range of responsibilities including:

• The administration and implementation of France's public health, health surveillance, and health safety policies in order to preserve and improve the population's state of health through programs to prevent chronic illnesses, combat the risk of infectious or environment-related diseases, and protect against threats to public health. To achieve these goals, the ministries use the public health agencies which they oversee, Santé publique France and the French agency supporting the performance of health and medico-social institutions (ANAP), as well as independent partners such as the French National Authority for Health (HAS).
• The supervision of all of France's health and supportive care facilities, and training for health care professionals. The State ensures that health care, health and social care, and ambulatory care facilities are readily accessible throughout France. The State also makes sure that these facilities' professionals work together in an effective and complementary manner, in order to provide an appropriate, locally-based response to the health-related needs of each region's population.
• Financing for health and health and social care facilities, setting rates for the provision of care and conducting health care cost control, and providing oversight for France's health insurance institutions. Every year, the French Parliament adopts a social security financing law: this law determines the national target for health insurance expenditure including non-hospital, hospital-based, and health and social care. Based on these budgetary amounts and on the government's strategic priorities, the ministers draw up their policies on public health and the delivery of care so that these priorities can be implemented.

France's Ministry of Health is principally tasked with:

• apportioning budgets among the various sectors of public health: hospitals, ambulatory care, mental health, health and social services for the elderly and those with disabilities, and apportioning the hospital budget among France's regions;
• determining how many hospital beds are needed and the quantity of advanced medical equipment, including costly medical technologies, to have available;
• setting fixed fees for care at public and private hospitals;
• approving the agreements signed between the French health insurance system and the private-practice health care professionals' unions;
• setting prices for medications and medical devices based on proposals submitted by the French National Authority for Health (Haute Autorité de Santé/ HAS);
• establishing safety standards for hospitals;
• selecting the priority areas for France's national health care programs.

In addition, inspection authorities such as France's Court of Auditors (Cour des Comptes) or the General Inspectorate of Social Affairs (Inspection Générale des Affaires Sociales) check that the social security financing law is properly executed.

b) At the regional level: France's Regional Health Agencies

France's Regional Health Agencies (Agences régionales de santé/ ARS) coordinate prevention and health and supportive care. They ensure that resources are managed in a consistent manner to ensure that all patients have equal access to safe, continuous, high-quality care. On this account, they have the following responsibilities:

• regarding prevention: to liaise with the competent authorities in order to implement a regional health policy on occupational health, school and university health, and mother-and-child well-being. On this account:
  • they organize health-related observation and monitoring in the region, particularly the collection, reporting, and processing of reported health events;
  • they help to set up responses to public health emergencies and manage public health crisis situations;
  • they draw up an annual hygiene compliance check schedule (samples, analyses, and verifications), and conduct the necessary inspections;
  • they plan and finance programs aimed at promoting public health, informing and educating the population about health, preventing disease, disabilities, and the loss of independence. They are also responsible for having these programs evaluated.
• regarding health and supportive care: to regulate, adjust, and organize the delivery of care in such a way as to meet needs related to prevention, promoting health, and health and social care and services, and to ensure the health care system works in an efficient and effective manner. On this account:
  • they help to evaluate and promote training programs for health care
    professionals, those involved in health-related prevention, staff who provide in-home or residential facility-based assistance with daily living activities for dependent elderly individuals and those with disabilities, as well as training for part- and full-time family caregivers;
  • they authorize the creation of France's health care facilities and health and social facilities and services, as well as the activities they conduct; they oversee how these facilities are run and allocate the resources that are within their competence;
  • they make sure that health prevention and health promotion services as well as the health care and health and social care are delivered throughout the region in such a way as to meet the population's health needs. In addition, they help to put together regional professional healthcare communities and set up a regional mental health charter;
  • they help to implement a one-stop assistance program for health care professionals to set up shop;
  • they provide quality oversight for health care prevention and promotion programs, quality and safety oversight for medical procedures, for the dispensation and use of health products, and for health and social care and supportive services, and conduct inspections as part of this oversight; they help to combat abuse and to promote good treatment at health and health and social care facilities and services;
  • they ensure access to health prevention and promotion programs, to health care, and to psychosocial services for individuals experiencing financial insecurity or exclusion;
  • they draw up and implement regional programs that are derived from or an addition to the national risk management and efficiency program for the French health care system.
    The programs are designed to verify and improve how patients access care as well as the practices of health professionals practicing ambulatory medicine or involved in France's health care and health and social care facilities and services;
  • at the facilities, they promote and facilitate the drafting and implementation of a culture-related policy;
  • they assess and identify the health care needs of individuals in detention. They determine and regulate the delivery of prison-based care;
  • they are in charge of organizing programs that assist professionals with the coordination of complex medical histories;
  • they promote programs designed to help target populations take charge of their own health. These empowerment programs are designed to familiarize the population with prevention and health education tools;
  • they work with France's universities and regional authorities to analyze training needs versus availability for professionals in the health care and health and social sectors;
  • they work together with all components of the health care system, France's universities, public scientific and technological institutions, or any other research institution, to help organize health-related research at the regional level;
  • pursuant to France's international agreements, and in concertation with the competent State authorities, they are authorized to roll out international cooperation programs designed to promote the exchange of best practices with their foreign partners.

As seen above, each ARS takes France's nationwide policies and adapts them to the
(population-related, epidemiological, or geographical) characteristics of its region by
drawing up regional health programs (programmes régionaux de santé/ PRS) which
comprise:

• regional prevention plans,
• non-hospital-based and hospital-based care organization plans,
• regional health and social organization plans for elderly or dependent individuals,
  those with disabilities, or those experiencing financial insecurity.

Combating inequality, improving equal access to health care and health and social services throughout the region, and better adjusting solutions to specific local characteristics and local needs constitute the objectives of these regional services.

c) France's State agencies or public organizations

The French biomedicine agency is a State-run national agency created by France's bioethics law. The Agency's scope covers organ, tissue, and cell retrieval and transplants, along with human reproduction, embryology, and genetics. It is France's top authority on all medical, scientific, and ethical issues in these areas.

It is tasked with:

• monitoring, assessing, and overseeing the therapeutic and biological activities that come within its scope, ensuring transparency for these activities, and helping to draw up the rules and regulations that apply to the activities under its control;
• issuing authorization for in vitro research on embryos and embryonic cells and for the storage of embryonic stem cells for research purposes;
• authorizing exchanges of reproductive cells and embryonic stem cells with other countries for research purposes;
• issuing authorizations to multidisciplinary prenatal diagnostic centers and to preimplantation diagnostic centers;
• licensing practitioners specializing in medically assisted reproduction, prenatal diagnostics, preimplantation diagnostics, and genetic testing;
• administering all retrieval and transplant activities;
• administering the national bone marrow donor registry;
• administering the files required in order to manage and monitor the therapeutic activities that fall within its scope, in a manner fully compliant with all applicable guarantees,
• Promoting organ, tissue, and cell donations, as well as gamete donation

France's national blood authority EFS: EFS is France's single public blood transfusion authority. It is mainly tasked with ensuring that France is self-sufficient in sourcing blood products. It is also involved in a wide range of activities such as medical biology analyses (conducting various types of biological, hematological, and immunological analyses, tests which are essential both for a transfusion and for an organ, tissue, or cell transplant), cell and tissue therapy, or research (in emerging fields such as cell and tissue engineering, immunologic donor-recipient pairing, or the development of new microbiological risk detection and prevention technologies).

d) Health insurance schemes

detailed in section IV.

e) Medical associations and unions

France has medical associations for seven categories of health care professionals: physicians, pharmacists, midwives, dental surgeons, nurses, massage and physical therapists, and chiropodistspodiatrists. These associations are professional corporations instituted by French law. They both represent the profession and provide a public service by helping to regulate it and serving as a disciplinary authority for members. Association membership is mandatory for members of these professions to be able to practice.

Indeed, these medical associations are private corporate entities tasked with providing a public service. They play a double role:

• with regard to the French State, the association represents its profession. As such, State authorities can submit any plans to reform how the profession is organized or operates to the association;
• with regard to the profession, the association is principally tasked with ensuring compliance with its own internal discipline.

In order to perform the public service with which they are tasked, the associations are vested with two public powers:

• administrative/ regulatory: the associations enact certain rules that govern how their profession is to be practiced. For example, they can enact codes of conduct or ethics that set forth professionals' obligations. This task belongs to each association's board, which is also in charge of listings on the association's roster, meaning inductions into the profession and subsequent promotions. Board authorization is also required for certain occasions such as substituting for an absent colleague, opening a secondary medical practice or keeping one open, and more.
• disciplinary/ punitive: the association can find members of their profession guilty of personal misconduct. In this case, they exercise a self-regulatory power.

The unions are in charge of negotiations between health care professionals and the French health insurance system with regard to fees and all issues related to medical practice.

f) Health care system users, by way of patients' organizations

They are among the qualified members participating in the health care facilities' oversight committee. The role of this committee is focused on strategy and on the ongoing oversight of the facilities' management. Patients' organizations that are legally declared and focus on health and patient care quality can receive accreditation on the basis of the organization's actual, public work to defend the rights of patients and users of the health care system, as well as the training and information programs it conducts.

II. How care is organized

a) Public health

At national level, Santé publique France is an authoritative public health agency that provides scientific expertise with State oversight. It is tasked with improving and protecting the health of the population with a particular focus on three major areas:

• implementing a nationwide monitoring and early-warning system in order to identify and anticipate threats to public health and providing public authorities with necessary input for the decision-making process;
• adding to available information on the health of the population and population groups, behaviors, and any threats to public health, and designing strategic health prevention and promotion programs;
• promoting public health, taking action on environmental factors, testing and rolling out prevention programs, and responding to public health crises.

As a public agency providing scientific health expertise, Santé publique France is in charge of the following:

• epidemiological observation and monitoring the state of health of the population and population groups;
• monitoring any threats to public health;
• triggering the early warning system;
• promoting health and reducing risks to public health;
• rolling out health prevention and education programs;
• preparing for and responding to public health threats, warnings, and crises.

At municipal level, national public health directives are rolled out by prevention-based organizations such as:

• occupational health providers,
• school health providers,
• vaccination programs,
• mother-and-child wellness facilities (PMI),
• non-contagious (cancer) or contagious (HIV, hepatitis) screening centers.

France's municipalities are legally responsible for monitoring and purifying the water supply, keeping air and noise pollution down, providing sanitation services, protecting the population from exposure to radiation, and for housing, food, and industrial hygiene.

b) Non-hospital-based care

Outpatient care (or ambulatory care) refers to the care provided in private practices, clinics, health centres, during out-patient appointments at public or private hospitals, thermal spa treatments and laboratory analyses. Such care is provided by doctors, dentists and other licensed health workers (nurses, physiotherapists, speech and language therapists, orthoptists) as part of their independent practice.

Health care providers and producers of health-related goods and services. This includes:

• Medical and pharmaceutical professions (doctors, pharmacists, dental surgeons, and midwives), licensed health workers (nurses, physiotherapists, speech and language therapists, etc.) with various methods of exercise (private-practice, salaried or mixed).
• Multidisciplinary health care networks (multidisciplinary residential facilities – MSP) and regional professional health organizations (CPTS) incorporating doctors, nurses, and other professionals (social workers, administrative staff, etc.) that are created to promote access to care and provide coordinated, continuous, and multidisciplinary care at residential care facilities or health centers.

The health care professionals who work at these facilities mainly provide primary and preventive care. They are required to draw up a health charter that shows how they work together to provide care. Residential care facilities are required to sign a multi-year performance and means contract with the regional health agency (Agence régionale de santé/ ARS) before they can receive any funding from that agency.

Multidisciplinary health care networks (communautés professionnelles territoriales de santé or CPTS) bring together all health care stakeholders (ambulatory professionals, whether in private practices or salaried, health care facilities, preventive care or health-promoting stakeholders, medical and social facilities, social care establishments, etc.) wishing to work together within a given area, to address one or several health care issues they have identified. A health care plan is a pre-requisite for a contract to be entered into between said professionals and the regional health agency (Agence régionale de santé or ARS).

France's coordinated healthcare pathway system (parcours de soins coordonnés) requires each French-insured individual over age 16 to designate and register a primary care physician (médecin traitant) with their local health insurance fund. The primary care physician acts as the gatekeeper for access to care. They are the patient's first stop on the care pathway and refer the patient to other healthcare professionals (specialist or hospital-based physicians, etc.) if necessary. The primary care physician coordinates all of the patient's care and centralizes all information on the care the patient receives and their state of health by managing their medical file.

Patients are free to choose their primary care physician (médecin traitant) This role can be filled by a general practitioner or specialist physician practicing anywhere in France, and the patient can change primary care physicians at any time. If the patient does not follow the coordinated healthcare pathway and sees a specialist without first consulting their primary care physician, this specialist appointment will be reimbursed by the French health care system (l'Assurance maladie) at a lower rate.

Specialist care is also provided in hospital establishments by specialist practicians as part of out‑patient appointments (ambulatory), without any hospital admission. These appointments are provided in the same manner as any ambulatory appointment and are included in the healthcare pathway, i.e., prescribed by general practitioners.

c) Hospital-based care

Health care facilities offer different types of services (hospital-based or health and social). These can be either public or private.

Hospitals can belong to one of several categories: public facilities, chartered private non-profit facilities (such as private hospitals or cancer treatment or dialysis centers) and private for-profit facilities. They provide general care (medicine, surgery, obstetrics) and/or more specialized care (psychiatry and mental health) through the diagnosis, monitoring, and treatment of patients with illnesses or injuries as well as pregnant women:

• They help provide emergency medicine. Throughout France, they offer emergency rooms, emergency medical response services (SAMU) for call assignment, and mobile emergency and resuscitation teams (SMUR) which respond to the calls;
• They conduct preventive and health education programs;
• They provide care, including palliative care, with or without accommodation, on an outpatient basis, or in the home;
• They contribute to the coordination of care by working with members of the health professions who are in private practice and with health and social facilities and services;
• They help to implement France's health policy and vigilance programs designed to bolster public health;
• They focus internally on the ethics of medical accommodation and care;
• They can develop alternatives to hospitalization which can be used to avoid full-time hospitalization or shorten hospital stays. These alternatives include: ambulatory surgery, telemedicine (e.g. long-distance appointments, examinations, or monitoring), in-home hospitalization, in-home nursing care, or temporary accommodation at a residential facility for dependent elderly people;
• They implement a continuous improvement policy for the quality and safety of care as well as a risk management program designed to prevent and treat any adverse events connected to their work;
• They conduct teaching and professional training as well as scientific and medical research (public hospitals).

France's regional hospital groups (Groupements hospitaliers de territoires/ GHT) are a contract-based program, which became compulsory in 2016, among each region's public health care facilities, by which they agree to coordinate to form a strategy based on shared, proportionalized care for each patient that is documented through a shared medical charter.

The idea is to encourage each region's health care facilities to pool their medical teams and share out their activities to ensure that each facility has a well-defined role to play in the region. GHTs organize how the facilities complement one another by taking account of each facility's unique characteristics and what it contributes to the delivery of care. They are a way to improve how care is organized in each region and to draw up a medical charter that is in line with the population's needs.

• By drawing up a shared medical charter, the goal is to help create regional-based care networks and set up a proportional delivery of care in order to guarantee equal access to safe, high-quality care.
• The objective is to guarantee all patients better access to care through stepped-up cooperation among public hospitals on the basis of a medical charter.

d) Emergency care

Hospitals' on-site emergency medical response teams (SAMU) and 24-hour care providers administer emergency pre-hospital care. Emergency medical response teams can be contacted by dialing the free nationwide emergency number, 15, from any phone, anywhere in France. When a call is placed, the information is shared with the emergency police (17) and fire (18) call centers to ensure that medical emergencies are handled appropriately. France's medical and fire call centers also respond to calls to the European emergency number 112.

Emergency calls which are placed to the medical call center are handled by specialized receptionists with physician supervision and support. Whatever measures are taken are determined by level of urgency. If emergency care is needed on-site, the medical emergency call centers can send a mobile emergency and resuscitation team (SMUR), a fire rescue first response team, or an on-call general practitioner. Otherwise, if necessary, the patient is advised to take an ambulance to the nearest hospital emergency room. The “continuity of care” system is designed to deal quickly and appropriately with patients' needs which arise at night or on weekends or holidays when non-hospital medical facilities are closed.

Upon arriving at the hospital, patients requiring emergency care are handled by a specific department commonly known as the “emergency department” (service d'urgences), which is in charge of handling all those experiencing a real or perceived emergency, 24/7, without selection; this hospital department is one of the structures involved in directing and sorting patients.

A patient may arrive at the emergency department in one of two ways:

• either the patient is taken there by a mobile emergency and rescue team (SMUR), a fire rescue first response team or a private ambulance;
• or the patient travels there by his own means, in some cases on the instructions of a general physician.

The emergency department is in charge of processing, referring and, in some cases, treating the patient, without distinction between a medical, surgical or psychiatric pathology. Any person attending the emergency department must be examined.

To fulfil their duties, emergency departments have:

• a reception and referral area where patients are sorted,
• a reception room for life-threatening emergencies where those experiencing a life‑threatening emergency are cared for,
• a consultation area,
• an observation area, where patients await the results of their tests which will determine their future orientation within the healthcare pathway,
• a short-stay hospitalisation unit, where patients cannot stay for more than 24 hours. The patient must then be transferred to the appropriate specialist department as soon as possible. This means that prior coordination with the establishment's other departments is vital to determine the availability of beds.

e) Long-term care

Health and social care facilities include residential facilities for dependent elderly people (établissem*nts d'hébergement pour personnes âgées dépendantes/ EHPAD) as well as facilities for people with disabilities.

They are designed to provide support and care for “vulnerable” individuals experiencing financial insecurity, social exclusion, disability, or dependency. The public and social services they provide are as follows:

• assessment and prevention of social, and medical- social risks (information, inquiry, advising, guidance, training, mediation, and compensation);
• administrative or court-ordered protection for children and families, youths, disabled people, and the elderly or those experiencing difficulties;
• educational, medical- educational, medical, therapeutical, teaching, and training programs tailored to the person's needs and level of development, their potential, any changes in the person's health, and their age;
• school integration and social and job adjustment programs, social and job readaptation, entry, and re-entry programs, employment support, information and counseling on technical support, and work support;
• assistance programs for the various activities of daily living, and support and care programs, including palliative programs;
• programs promoting cultural and social development, as well as work-based integration programs.

Residential or temporary eldercare is offered by numerous providers with varying levels of care. These include independent-living facilities (foyers logements) which offer a range of non-medical services (such as meals and laundry) but basically no medical care, retirement homes (residential facilities for dependent elderly people: établissem*nts d'hébergement pour personnes âgées dépendantes/ EHPAD), which house elderly residents and also offer medical care, long-term assisted-living units which care for heavily dependent patients with severe illnesses requiring constant medical monitoring, and intermediate services which provide short-term care for medically fragile elderly patients who are not housed in a residential facility. Care can be provided on a daily basis (day care) or for a temporary period (temporary care).

Residential facilities for medically fragile elderly individuals are currently financed in part by the French health insurance system, which covers the cost of medical care, in part by the local-level conseils généraux, which cover personal expenses related to the loss of independence, and finally by the residents themselves, who mainly cover their own room and board.

In-home care: intermediate-level care providers bring temporary care to dependent patients as well as respite services for their caregivers. This type of care increases engagement and self-sufficiency for dependent individuals. French health insurance -financed in-home care is mainly provided by independent doctors and nurses and, to a lesser extent, by in-home nursing care providers (services de soins infirmiers à domicile/ SSIAD), which provide non-medical (hygiene) and medical (bandaging, distributing medications, injections) nursing care. In-home service providers (services d'aide et d'accompagnement à domicile/ SAAD), which are offered through France's social welfare programs, cover household help and other in-home services to aid with ordinary and instrumental activities of daily living (home maintenance, laundry, meal preparation, self-care, and help with dressing and undressing).

Multi-service in-home nursing care providers (services polyvalents d'aide et de soins à domicile or SPASAD) provide assistance with both daily tasks and nursing care. They provide services which match the duties of in-home nursing care providers (services de soins infirmiers à domicile or SSIAD) and the duties of in-home service providers (services d'aide et d'accompagnement à domicile or SAAD). They promote coordinated support for both the assisted person and the sector's various stakeholders.

The person's needs are assessed in order to create an individual support, assistance and care plan which is jointly developed and implemented by in-home support and care staff, to provide more coherent comprehensive care.

f) Pharmacies

The French pharmaceutical market has three different components: prescription-only and prescribable drugs, which are both mainly dispensed by retail pharmacies, and hospital-only drugs.

The drug distribution chain is highly regulated for wholesalers and pharmacies alike. Full-line wholesalers have “public service” status and are subject to regulatory oversight by the French National Agency for medicine and health product safety (ANSM) with regard to the range of drugs supplied, inventory levels, delivery times to specific local areas, and their profit margins. Pharmacies hold a monopoly on the distribution of drugs dispensed on the basis of a medical prescription. In general, retail pharmacies are required to belong to a qualified pharmacist or a group of pharmacists partnering to form a company: these pharmacists or companies cannot be the owners of more than one pharmacy. The State sets an official maximum number of pharmacies, determined both by the size of the population being served and the distance to the nearest pharmacy. Pharmacists receive financial incentives to dispense generic drugs.

Direct-to-consumer drug advertising is subject to prior authorization and restricted to products that meet three requirements: they must be able to be dispensed without a doctor's prescription, they must not be covered by the French health insurance system, and no restriction on advertising can have been included in the product's marketing authorization. Vaccines are the only exception to this rule.

Over-the-counter drugs can be sold online but only by pharmacists, who must be working directly through a brick-and-mortar pharmacy and have authorization from their regional health agency (ARS) to conduct online sales.

Doctors, dentists, midwives, and pharmacists are required to report any adverse events associated with a medication to their regional drug safety center (centre régional de pharmacovigilance), which will then conduct the necessary investigations and notify the manufacturer. Patients and patient organizations can report any adverse events directly. Approved adverse event reports must be submitted to the European Medicines agency within 2 weeks.

III. How to contact a French health care provider

• the website Annuaire santé is a service offered by France's health insurance system (l'Assurance Maladie). A French-accredited health care professional (doctor, nurse, pharmacist, etc.) or facility (hospital, private clinic, etc.) can be found using a number of search criteria (name, specialization, location, type of procedure).
• France's national directory of health and social facilities (FINESS) can be searched by topic or geographic location.
• France's various types of medical and social care facilities can be consulted online on the CNSA (National Solidarity Fund for Autonomy) website.
• the website for France's National Council of Thermal Treatment Facilities (CNETh), www.medecinethermale.fr, contains a directory of thermal treatment facilities in France.

IV. How the health care system is financed

In France, the financing of the health care reimbursem*nt system is organized into two main levels: compulsory health insurance schemes and supplementary health insurance schemes.

a) France's compulsory basic health insurance schemes

They are characterized by compulsory membership and contributions. This means that they are dependent on widespread solidarity on the basis of income-proportional contributions, and access to care that is determined in accordance with needs.

The main social security schemes (the general scheme, which has incorporated self-employed workers, plus the agricultural scheme), are grouped together within the National health insurance fund Union (Union nationale des caisses d'assurance maladie/ UNCAM), the role of which is to:

• Conduct the agreed policy which determines the connections between the health insurance system and private-practice health care professionals
• Determine the range of services that are eligible for reimbursem*nt
• Set the rates for coverage of care.

France's compulsory health insurance schemes focus heavily on “major risks,” i.e. the health risks that have the greatest impact on members' income, either because their conditions require long-term and/or costly care, or because they require extensive use of expertise and technology, both in terms of equipment, techniques, and staff, and in terms of hospital-based expenses.

b) The supplementary schemes (mutual funds, insurance companies, and providence funds)

These supplementary schemes are dependent on solidarity that is limited to members. They offer rates of coverage that vary depending on the member's type of policy. They are used to pay the share of the member's health care expenses that is not covered by the compulsory basic scheme (tickets modérateurs [co-payments], franchises [flat out-of-pocket charges], forfaits hospitaliers [daily hospital charges], coverage for opticals, orthotics, equipment, etc.).

If customers do not have supplementary group coverage through their employment, they can take out supplementary insurance from a mutual fund, a providence fund, or an insurance company.

c) Public financing sources (the State)

They are mainly used for prevention and medical and pharmaceutical research, training for health professionals (doctors, dentists, pharmacists, and qualified medical workers), supplementary universal health coverage (complémentaire santé solidaire/ CSS), endowments for military hospitals, emergency medical care, and benefits awarded to those covered by State medical aid (aide médicale d'État/ AME).

d) French households

Finally, a share of the expenses may be paid out-of-pocket by the patient.

V. What type of oversight is conducted for health care professionals?

a) France's regional health agencies

for risk-prevention purposes, France's regional health agencies (ARS) have broad inspection-verification powers in three areas: health safety, how facilities and services are run, and medical procedures and practices.

Inspection-verifications are conducted in the following areas:

• Health safety, risk prevention, and public protection (drinking and recreational-use water, living accommodations, public facilities, and the outside environment),
• Health prevention and promotion,
• Ambulatory care,
• Hospital-based care,
• Health care professions,
• The medical and social sector.

The goal is to conduct inspection-verifications that coincide with France's national health policies.

Health safety

This pertains to all risks connected to health care work, to products consumed (food and health products) and to living environments (water, air, and soil).

The inspection-verifications conducted by the agencies focus on:

• Health care and health and social facilities (infectious waste, Legionella bacteria,
• Private health care practices, tattoo parlors, and public facilities (asbestos, recreational-use water, noise levels, etc.),
• Private individuals (living accommodations, carbon monoxide),
• Public or private technical equipment (water catchments and tanks).

How France's health and health and social care facilities are run

France's regional health agencies (ARS) ensure that health and health and social care facilities and services are run smoothly in terms of: staff, on-call medical services, staff qualifications, etc.

• In health care facilities, inspection-verifications focus on how and where health care is provided (e.g. inspection of the intensive care unit, the maternity ward, the emergency room, the operating room, etc.).
• In health and social care facilities, the goal is to identify and prevent risks of abuse.

Medical procedures and professional practices

In partnership with the French health insurance authority (l'Assurance maladie) and/or the relevant medical Associations, the regional agencies conduct inspection and awareness-raising programs for health care professionals on the following topics related to the safety, quality, and appropriateness of care:

• drug prescriptions,
• prescriptions for medical transportation,
• medical justification for services,
• compliance of medical practices with the recommendations for best practices issued by the health agencies.

b) The French National Authority for Health (Haute Autorité de Santé/ HAS)

The HAS accredits doctors to practice at France's health care facilities. On this account, the HAS is in charge of the following:

• gathering and analyzing declarations of events considered as medical risk-inducing from doctors and medical teams applying for accreditation;
• working with the professionals and organizations involved, using scientifically proven methods, to draw up or approve multi-criteria standards for the quality of care and professional practices;
• publicizing these standards and promoting their use by all appropriate means;
• setting up the accreditation process for doctors or medical teams with regard to standards for the quality of care and professional practices;
• using all appropriate means to secure the approval of methods and ensure the consistency of programs aimed at improving the quality of patient care.

With a view to the continuous improvement of the quality and safety of care, all of France's public and private health care facilities are required to undergo an outside evaluation process known as certification.

This process, which is conducted by the French National Authority for Health (HAS), is designed to provide an independent assessment of the quality of a facility, or in other cases, of one or more of a facility's internal units, setups, or activities, through the use of indicators, criteria, and standards pertaining to the procedures, best clinical practices, and results of the facility's various wards and activities.

c) The French national agency for medicines and health products safety (ANSM)

ANSM is the decision-making authority over health product safety, from manufacture to sale. It has four major responsibilities:

• scientific assessment,
• laboratory oversight and regulating advertising,
• inspection of industrial sites,
• providing information to health care professionals.

ANSM has decision-making authority over medicines (all medicines (before and after marketing authorization) and raw materials, blood-derived medications, narcotics and psychotropic substances, vaccines, homeopathic products, both plant-based and pharmaceutical preparations, pharmacy and hospital formulations), biological products (organs, tissue, cells for therapeutic use, cellular and gene therapy products, labile blood products and ancillary therapeutic products), medical devices (therapeutic, diagnostic, in vitro diagnostic, and in technical facilities and medical software programs), cosmetic and tattoo products and other health products (biocides).

ANSM performs a number of activities in France and on behalf of the European Union:

• the scientific and technical assessment of the quality, efficacy, and safety of use of medicines and biological products;
• the ongoing monitoring of health products' foreseeable or unexpected adverse events;
• the inspection of facilities involved in manufacturing, importing, distribution, and drug safety, and those conducting clinical trials;
• In-laboratory release testing for batches of vaccines and blood-derived medicines, testing of products already on the market, sampled during inspections, seized by the courts or customs authorities.

These actions give rise to health policy decisions which are taken on behalf of the French State:

• Marketing authorizations, and marketing authorization withdrawals or suspensions
• Clinical trial authorizations
• Individual temporary authorization for use of a medicine (ATU) and cohort ATU
• Temporary recommendations for use of pharmaceutical specialties
• Release of batches of vaccines and blood-derived products
• Product or batch recalls
• Prohibition of medical devices on the French market
• Import authorizations
• Prior authorization or prohibition of advertising.

ANSM also advances information for patients, health care professionals, professional contact persons and scholarly associations, and the press.

d) The French Agency for Food, Environmental and Occupational Health & Safety (ANSES)

ANSES assesses food, environmental, and workplace risks through its surveillance, early-warning, research, and investigation programs. Its monitoring, vigilance and surveillance work provides input for risk assessment. This means that ANSES fully addresses all types of risks (chemical, biological, physical, etc.) to which a person may be subjected, intentionally or otherwise, at all ages and stages of life, including through exposure at work, while travelling, while engaging in leisure activities, or via their diet. ANSES also assesses the effectiveness and risks of veterinary medicinal products, plant protection products, fertilizers, growing media and their adjuvants, as well as biocides, with a view to delivering marketing authorizations. It also provides assessments of chemicals.

ANSES is also in charge of occupational safety oversight nationwide and is responsible for preventing and protecting worker health.

e) France's Institute for Radiological Protection and Nuclear Safety (IRSN)

IRSN's field of expertise covers all risks linked to ionizing radiation used in industry or for medicine, as well as naturally occurring radiation. IRSN contributes to radiation protection training directed at health sector professionals and workers exposed to occupational hazards. It contributes to round-the-clock health surveillance in radiation protection by monitoring environmental radiation, as well as managing and processing dosimetric data for workers exposed to ionizing radiation. IRSN also manages the national inventory of radioactive sources.