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96 Economic crisis, health systems and health in Europe: country experience
5.4 Resilience in response to the crisis
Midterm impact
Overall, assessment of the system's resilience yields a dual picture. On the one
hand, some elements at the macro and household level (such as household
savings and universal coverage) have resulted in relatively mild effects on health
system outcomes compared with those in other European countries. On the
other hand, long-standing structural trends (outside and within the health
system), in particular social and health inequities, combined with decreasing
coverage scope (what is covered) and depth (how much of a benefit cost is
covered) appear to have had effects, the full extent of which is yet to be seen.
In fact, while in a number of European countries the crisis is nearing the end,
the current situation leads to the presumption that, in France, "the worst may
be to come" (Europe1, 2013). Indeed, a report by the National Institute for
Statistics and Economic Studies (Institut National de la Statistique et des Études
Économiques, 2014) stressed that the recession that France officially entered in
2009 is atypical in two ways compared with previous recessions: first, GDP in
early 2013 remained below any level reached before the crisis and, second, the
trade balance of manufactured goods remained at a negative level owing to the
lack of competitiveness and exterior demand.
For health system users, this protracted crisis seems to be accompanied by a
series of recent phenomena that were perceived as marginal or even unknown
before the onset of the crisis. For example, patients at present increasingly opt
for low-cost VHI contracts, involving reduced coverage for so-called comfort
benefits (e.g. a private room) and the necessity for advance payments at the
point of service. In addition, the Internet has played an increasing role, not
only as a means to obtain health information but also as a tool to save money
when seeking health care (Pianezza, 2012). Further, medical tourism appears
to have undergone a steep increase in popularity, with patients purchasing
or acquiring consultations mainly from Belgium, Spain and Romania. 14 The
number of French patients buying drugs (in person or online) abroad increased
by three percentage points to 8% between 2012 and 2013, and the percentage
of French patients consulting specialists abroad increased by one point to 4%
between 2012 and 2013 (Sofinscope, 2014). Although these developments
should be interpreted in the context of an increasing use of technology and
cross-border services across all sectors of society, the data presented in this study
raise the question of the extent to which the motivation may be financial rather
than an indicator of zeitgeist.
14 Services purchased within the EU are covered by SHI at the amount that would be reimbursed if the service had
been purchased in France, if (1) previous authorization was obtained or (2) it is recognized as emergency treatment.
Otherwise, coverage is decided on a case-by-case basis. VHI generally follows the same mode of operation.