Analysis Looking to Europe

Can France keep its patients happy?

BMJ 2008; 336 doi: (Published 31 January 2008) Cite this as: BMJ 2008;336:254
  1. Laurent Degos, chairman of the board,
  2. François Romaneix, managing director,
  3. Philippe Michel, director, assessment of healthcare strategies,
  4. Jean Bacou, head of international affairs
  1. 1National Authority for Health (HAS), 93218 Saint-Denis La Plaine Cedex, Paris, France
  1. Correspondence to: J Bacou j.bacou{at}
  • Accepted 30 November 2007

The French healthcare system gets high satisfaction ratings but is becoming more difficult to fund. Laurent Degos and colleagues examinethe challenges of keeping citizens content and improving cost effectiveness

Less than a year ago, when Nicolas Sarkozy was running for president, health was not a priority. Indeed Le Monde, a leading French newspaper, carried the headline: “Health, the missing item in Nicolas Sarkozy’s reforms.”1 The reason for this omission may have been that the French health system is largely well perceived by citizens and users. However, the recent debate over the introduction of further non-reimbursable charges of €0.50 (£0.37; $0.75) for each drug packet and paramedical services such as physiotherapy, which came into effect at the beginning of this year, suggests that this satisfaction could become eroded.2 This article outlines the structure of France’s health system, analyses patients’ perceptions of it, and comments on the challenges it faces, not least with containing the high costs.

Overview of French health system

The French health system (box) is financed mainly by employers and employees through social contributions. It is characterised by ease of access to care, which could partly explain the high costs. General practitioners are self employed and get paid through a fee-for-service system. The number of healthcare professionals is fixed nationally by controlling admission to medical schools. This numerus clausus policy has been used to limit primary care expenditure and, as a result, a temporary shortage of doctors is expected in the next few years. Competition in areas with high numbers of general practitioners can sometimes compel doctors to give way to patients’ demands to the detriment of overall provision of health care.

Box 1 French health system3

  • Total health expenditure: 11.14% of gross domestic product in 2005

  • Financing in 2003:

    • Public funds (national social insurance + health allocated taxes): 78%

    • Complementary voluntary health insurance: 14% …

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