When looking at the historical context of the French and Italian health system, what financial challenges does the program have to ensure quality and equity of care prov

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8.1 INTRODUCTION

France, a leader among European countries, is a developed (industrialized) world power that has a good healthcare system and a strong economy. This Western European land area of 545,630 square km is nestled among six countries: The United Kingdom, Germany, Belgium, Switzerland, Italy, and Spain, and three major waterways: the Bay of Biscay, the English Channel, and the Mediterranean Sea.

According to the CIA World Factbook (CIA, 2009), in 2001 France’s population was approximately 59,551,227, of whom 65.19% were between the ages of 15 and 64. Slightly more than 16% of the population was 65 years and older. The majority of France’s residents are natives of France. However, France is home to some immigrants and has a particularly strong African and Southeast Asian presence. The proportion of France’s under 15-year-old age groups is 18% (UNO, 2004), and the over 60 population is 20% (WHO, 2004). The predominant language spoken in France is French. The largest ethnic groups are Celtic, Latin, and Teutonic. Other ethnic groups are Slavic, Northern African, and South East Asian. The largest religious group in France is Roman Catholic (WHO, n.d.). Overall life expectancy in France is 78.9 years, 83.01 years for women, and 75.01 for men. Total fertility rate is 1.75 children born per woman. The infant and neonatal mortality rate was estimated to be 4.46 deaths/1,000 live births and this number has steadily decreased over the years. France’s literacy rate is 99% for men and women. Women are well educated and are very competitive.

Like most other industrialized countries, French residents enjoy a universal healthcare system that is largely financed through national healthcare insurance and is ranked among the best healthcare systems in the world (WHO, 2000).

8.2 HISTORICAL

France, priding itself on its promise to take good care of its entire population, has had a form of National Health Care since 1945. The country has always had a threefold goal; to provide a single health insurer, make it compulsory for all employers and workers to pay premiums based on their salaries, and allow patients to choose their own doctors. However, doctors are permitted to charge additional fees and prescribe therapies, diagnostic procedures, and medications as they see fit, without interference from the national health insurance. Unlike some healthcare systems that offer universal health there are no long waiting periods to schedule elective surgery or see specialists in France.

Legislation in 1999 further refined the national health insurance plan mandating that anyone with a regular residence permit was entitled to health benefits without strings attached. This legislation also clarified that illegal residents would be managed by giving them full coverage if they could prove they lived in a French territory for more than three months and had no financial means to pay for health care (Gauthier-Villars). In a 2000 WHO ranking of the best healthcare systems worldwide, France was ranked number one. It has, over the past 30 years, been forced to reduce its healthcare coverage and incrementally increase its healthcare taxes. However, consumers still give France high marks for its healthcare delivery and quality.

8.3 STRUCTURE

Healthcare administration and oversight is provided by the Minister of Health and Solidarity. This cabinet position oversees the healthcare public services and the health insurance part of Social Security

The government pays for medical school for those seeking to pursue medicine as a career. Once licensed, most physicians work in private practice but their fees-for-services are paid by publically-funded insurance companies. General practitioners, commonly referred to as docteurs, are responsible for all aspects of care, including acute and chronic. They are key in providing treatment of diseases not requiring a specialist and they provide preventive services. General practitioners can be summoned by the samu, the emergency medical services to assist with emergency care.

Physicians make a modest net average annual salary of approximately €40,000 (Tanner, 2008), the equivalent of $51,243. This is approximately one-third that of physicians in the United States. Because French physicians charge relatively low fees for services, many earn more by increasing their patient load, or by prescribing more diagnostic tests and procedures—a technique, also popular in the United States, that inflates healthcare costs (Capell, July 2007, p. 12). Once physicians have practiced in a hospital for at least four years it is permissible for them to charge extra fees for consultations (Capell, July 2007). This is another way in which the salary can be increased. Approximately 90% of France’s general practitioners have an agreement with Assurance Maladie, the country’s largest buyer of medical services that prevents them from charging more than €22 ($32.00) for a consultation, and an additional €3.50 if they make a house call (Gauthier-Villars, 2009). Gauthier-Villars, quotes nurse practitioner Lanfranchi, as saying, “If you are in medical care for the money, you’d better change jobs” (p. 4).

Nurses in France receive professional training for three years to gain the basic entry level into practice. Advanced practice nurses are not included in the French model for nursing practice. In 2004, there were approximately 6.7 practicing nurses per 1,000 people in the population as compared to 3.37 physicians (OECD, 2008).

8.4 FINANCING

France, like the United States, relies on both private insurance and government insurance which is generally obtained through the person’s employer. Everyone pays compulsory health insurance to non-profit agencies that participate in annual fee-setting negotiations with the state. There are three main funds that, when combined, provide coverage for approximately 96% of the population. The compulsory premium is automatically deducted from all employees’ pay. The 2001 Social Security Funding Act sets the rates for health insurance covering the statutory healthcare plan at 5.25% on earned income, capital, and winnings from gambling, and at 3.95% on pension benefits and other allowances (WHO, 2000).

France spends approximately 11 percent of its GDP on health care. Health care is funded through taxes proportionate to the person’s income which funds Assurance Maladie, a state health insurer that has operated in the red since 1989. Budgetary shortfalls are predicted to exceed €9 bill ($13 billion) in 2011 (Gauthier-Villars, p.2). When a person visits a doctor in France, 70% of the bill is covered by the national insurance program. The remaining 30% is covered by supplemental private insurance, which literally everyone has because it is affordable, and in almost all cases is paid for by employers. The entire cost of care is paid by the national insurance program for persons with long-term chronic illnesses, diabetes, cancer, and heart diseases. Also 100% of major surgeries are covered.

Approximately 65% of hospital beds in France are publically operated, 15% are private non-profit, and approximately 20% are privately run for-profit hospitals (WHO, 2000). There are also private and public funded clinics, doctor offices, and special centers called Protection Maternelle et Infantile (PMI) discussed under the Preventive section.

8.5 INTERVENTIONAL

There are emergency services, an abundance of emergency vehicles, and acute care provided in all three types of hospitals (public, non-profit, and for-profit). According to Aiken and colleagues (Aiken et al., 2001), as hospital workloads increase, so does mortality, and as nursing education increases mortality decreases. This has led many to advocate for a minimum of a college/university earned baccalaureate degree to become a professional nurse. In an investigation into nursing education in 19 European countries, it was found that nurses in France receive three years of professional training (RN 4 cast, 2009–2011).

Fundamentally, all health providers (medical, nursing, and other health professionals) should focus on achieving the very best outcomes for their patients. However, the French government pays a role in attempting to maximize provider practices. In an attempt to ensure quality services ANAES (Agence Nationale d’ Accreditation et d’Evaluation en Santè) translated as The National Agency for Accreditation and Health Care Evaluation, is a government body that issues recommendations and practice guidelines in an attempt to ensure that provider practices reflect quality healthcare services. In fact, ANAES publishes practice guidelines.

Ambulatory care is provided basically by general practitioners, over 60% of them work in solo independent practices. This care is provided in a variety of settings including the home. France has a collaborative agreement with Canada directed at nursing practice outcomes with an emphasis on access as the foundation of this collaboration.

8.6 PREVENTIVE

Prevention of illness is a key factor in the economic growth, development, and productivity of any nation. France is no different; with its quality outcomes and longevity as a measure of its healthcare system, France is a leader in prevention. Some researchers consider another factor in determining longevity. This factor is called amenable mortality, more simply put, a measure of deaths that could have been prevented with good health. The health challenges are many and resources are scarce but France’s preventive initiatives are admirable. France ranks number one on disease prevention, the United States ranks last (Shapiro, 2008). General practitioners are essential to providing preventive services. They make home visits when patients cannot come to their offices, and are especially responsive to the needs of children and older adults. They also engage in epidemiological surveying of diseases to predict outbreaks and to contain diseases.

Other significant preventive measures include a track record of excellence for their attention to prenatal and childhood care. There are thousands of healthcare facilities strategically located in some of the poorest communities in France as well as in communities largely inhabited by immigrants. These facilities, called Protection Maternelle et Infantile (PMI) focus on ensuring that every mother and child in the country receives basic preventive care, in other words, promoting health and preventing illness. Children are evaluated by a team of private practice pediatricians, nurses, midwives, psychologists, and social workers. A social worker pays a visit to the home when children do not show up for follow-up visits. Incentives are also given to pregnant mothers for attending pre- and postnatal visits. Again, the focus is on keeping children healthy and preventing illness. General practitioners also make home visits especially to follow up on children.

In spite of these prevention initiatives there are a number of specific challenges that threaten preventive efforts in France. There is a lack of initiatives to standardize sewage (waste) and preserve the quality of the water supply and sanitation. Although among other European countries France has the lowest incidence of obesity and the healthiest dietary practices, there has been a recent rise in obesity (Freeman, 2010). There is also a 0.44% prevalence rate of HIV/AIDS affecting a significant portion of the population. There were an estimated 130,000 persons living with HIV/AIDS in 1999 and an additional 2,000 HIV/AIDS related deaths (CIA, 2001).

Over the years, France has become a transshipment point for, and consumer of, South American cocaine, Southwest Asian heroin, and synthetic drugs made in Europe. As a consequence, the battle against illegal distribution and abuse of illicit drugs has presented a notable problem that threatens the public health of its people (CIA, 2001).

8.7 RESOURCES

In addition to such supportive professional initiatives as PMI focusing on decreasing pre- and postnatal risks and thereby maximizing perinatal maternal child outcomes, the most obvious resources are reflected during care of individuals at, or nearing, the ends of their lives. For example, extraordinary efforts are directed toward providing palliative care that directs attention to affirming the life of the dying individual and relieving pain and other signs and symptoms experienced during death and dying.

8.8 MAJOR HEALTH ISSUES

Despite France achieving relatively overall great health outcomes, and being ranked number one in the world, they do experience major health issues. The top ten leading causes of death and years of life lost in France are listed in Table 8-1 .

8.9 DISPARITIES

The top three causes of death in France, coronary heart disease, stroke, and lung cancer, are identical to the top three causes of death in Germany. Although life expectancy statistics are calculated the same way irrespective of the country, what people die from and why they die can vary tremendously from one country to the next. For example many people die around the world from infections because of the unavailability of antibiotics, whereas in countries where antibiotics are readily available, people may die because of resistance to antibiotics of choice or they lack access to care.

SUMMARY

France is touted as one of the most admired healthcare systems in the world. This is because of its overall good outcomes, its strong emphasis on prevention, and its demonstrated excellence in the care of infants and children. As the government explores new ways to contain costs for health services provided while improving the pay structure of physicians, the outcomes will likely be further improved, and more appreciated by everyone, including those the system serves.

Table 8-1 Top 10 causes of death (all ages) in France, 2002, with the number and percent of years of life lost by disease.

Data From: Death and DALY estimates by cause, 2002. http://www.who.int/entity/healthinfo/statistics/bodgbddeathdalyestimates.xls

Lovett-Scott, M., & Prather, F. (2018). Global health systems: Comparing strategies for delivering health services .

· Chapter 8: The Healthcare System in France

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9.1 INTRODUCTION

Italy, officially known as the Italian Republic, covers an area of 301,225 square km. (116,303 square miles) and is bordered by France, Switzerland, Austria, and Slovenia. Known by its boot-like shape, Italy is equivalent to the size of Georgia and Florida combined. Italy became a democratic republic in 1946 a few years after the fall of the fascist regime in WWII. Italy has OECD status and is a founding member of the European Union (EU). According to the Central Intelligence Agency (CIA), the literacy rate in Italy is high, at 99% (CIA, 2011). In 2011, the population of Italy was estimated at 60.6 million. Italy is an industrialized country and is ranked as the world’s seventh largest market economy (U.S. Department of State Background Note, 2011). However, Italy is struggling with an exceedingly high public debt and fiscal deficit. The proportion of the population under 15 is 14% and the proportion of the population above the age of 60 years is 24% (WHO 2004). The main language used in the country is Italian. The largest ethnic group is Italian. The largest religious group is Roman Catholic.

Indicators for infant mortality and life expectancy suggest that, “Italy has a very healthy population” (Maio & Manzoli, 2002, p. 301). The total estimated infant mortality rate per 1,000 live births is 3:38 deaths; (male: 3.59 deaths/1,000 live births; female: 3.16 deaths/1,000 live births) (CIA, 2011). The estimated life expectancy for men is 79.16 and it is 84.53 for women (CIA, 2011). Adult mortality for men is 91:1,000 and for women, 47:1000 (World Health Organization, 2006). Demographic concerns over the past two decades involve Italy’s persistent low fertility rates. Current estimates indicate Italy’s total fertility rate as 1.39, resulting in birth rates falling below replacement levels of 2.1 children per woman (CIA, 2011; Maio & Manzoli, 2002). Italy’s population challenges include a decline in the younger age groups and a rapidly aging population.

9.1 INTRODUCTION

Italy, officially known as the Italian Republic, covers an area of 301,225 square km. (116,303 square miles) and is bordered by France, Switzerland, Austria, and Slovenia. Known by its boot-like shape, Italy is equivalent to the size of Georgia and Florida combined. Italy became a democratic republic in 1946 a few years after the fall of the fascist regime in WWII. Italy has OECD status and is a founding member of the European Union (EU). According to the Central Intelligence Agency (CIA), the literacy rate in Italy is high, at 99% (CIA, 2011). In 2011, the population of Italy was estimated at 60.6 million. Italy is an industrialized country and is ranked as the world’s seventh largest market economy (U.S. Department of State Background Note, 2011). However, Italy is struggling with an exceedingly high public debt and fiscal deficit. The proportion of the population under 15 is 14% and the proportion of the population above the age of 60 years is 24% (WHO 2004). The main language used in the country is Italian. The largest ethnic group is Italian. The largest religious group is Roman Catholic.

Indicators for infant mortality and life expectancy suggest that, “Italy has a very healthy population” (Maio & Manzoli, 2002, p. 301). The total estimated infant mortality rate per 1,000 live births is 3:38 deaths; (male: 3.59 deaths/1,000 live births; female: 3.16 deaths/1,000 live births) (CIA, 2011). The estimated life expectancy for men is 79.16 and it is 84.53 for women (CIA, 2011). Adult mortality for men is 91:1,000 and for women, 47:1000 (World Health Organization, 2006). Demographic concerns over the past two decades involve Italy’s persistent low fertility rates. Current estimates indicate Italy’s total fertility rate as 1.39, resulting in birth rates falling below replacement levels of 2.1 children per woman (CIA, 2011; Maio & Manzoli, 2002). Italy’s population challenges include a decline in the younger age groups and a rapidly aging population.

9.3 STRUCTURE

Italy’s healthcare system is region-based and highly decentralized. The health service structure encompasses three levels: national (state), regional, and local. The Ministry of Health operates as the central organization of NHS and is responsible for healthcare planning, healthcare financing, and ensuring the uniform delivery of the benefits package. The regions are responsible for ensuring access to the benefits package through their regional health departments, local healthcare agencies (LHAs), and public and private health services providers. Regional governments are aimed at identifying the unique needs of their populations. Due to decentralization, the regions have considerable autonomy in managing their own budgets. This means they are also “required to fund any deficit that might occur from their own resources” (Maio & Manzoli, 2002, p. 302).

At the local level, LHAs are geographically situated throughout the regions and provide service to specific populations. LHAs are in charge of providing a coordinated, comprehensive level of care through their own facilities or through other accredited private providers. Units of care called hospital trusts, as well as university-centered research hospitals provide secondary and tertiary care (Maio & Manzoli, 2002).

Italy has one of the highest numbers of physicians on record worldwide. According to Acti

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