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94 Economic crisis, health systems and health in Europe: country experience
important structural aspect of the French health system in this context is the
FFS payment for self-employed professionals based on the national agreements
they establish with the SHI. The newly established pay-for-performance
contracts can be regarded as a first step in reforming the FFS model, although
this remains an extremely challenging policy area. One important issue is the
significant role of the Ministry of Health in the decision-making process and
whether any government would have the required political power to defend
major reform against the interests of professional groups. This difficulty was
illustrated in 2009 by the Ministry of Health and Solidarity's reversal of the
negative financial incentives set in legislation for doctors who refused to sign
a contract to deliver care in underserved areas. Controlling expenditure in the
private practice sector, therefore, remains a major concern.
Third, an integrated and comprehensive policy has been argued to be the
appropriate response for tackling interdependent health determinants (Elbaum,
2007). The 2004 Public Health Act was an attempt to improve coordination and
consistency in public health policies, but this has proven difficult in the French
context. The fact that population health is affected by both income and income
distribution was not systematically recognized by the public health acts and only
2 out of the 100 priorities in the 2004 Public Health Act directly concerned
health inequities (Elbaum, 2007; Chevreul et al., 2010). Acting simultaneously
on several determinants of health requires cooperation between administrations
and payers, both at local and at national levels. Financing public health policies
that deal with health determinants needs to cut across sectors (rather than being
directed only at the health care sector). However, in the French system, the
number of stakeholders (administrative departments) involved at the national
and, more importantly, at the local level is high, potentially making this a
difficult task. Nevertheless, these potential drawbacks may prove an unexpected
political advantage: because of the separation of health care and health promotion
budgets, health care professionals may not identify increases in budgets for health
promotion as a threat to their budgets (Evans & Stoddart, 2003; Chevreul et
al., 2010). Another positive element is the fact that the state and social security
budgets were debated and approved simultaneously by the French Parliament for
the first time in 2007. The justification was that there is little difference to citizens
between taxes and social contributions and that the EU reporting regulations
concern the expenditure of all public administration in total. The 2009 Hospital,
Patients, Health and Territories bill enacted the merger of health care, public
health and SHI funds at the regional level. This can be considered a major step
towards the recognition that health needs should be identified and priorities
established at the local level with the major stakeholders: hospitals, self-employed
health professionals, public health decision-makers, patients' representatives,
representatives of the state and representatives of the SHI (Chevreul et al., 2010).