France: #25 in the 2021 World Index of Healthcare Innovation

Introduction

France’s mostly government-run health care system ranked 25th in the World Index of Healthcare Innovation with an overall score of 42.60. France ranked second-to-last in Fiscal Sustainability (#30, 30.34), ahead of only Japan (#31). Both the scale and growth of government health care spending in France has proven difficult for policymakers to address, without sparking a large public backlash.

Though choice of providers is free and open, France’s baseline single-payer system restricts access to the most innovative medicines while also struggling to fully adopt generics as an alternative method to control costs. On a relative basis, France performed best in Quality (#12, 53.25), owing to an efficient hospital system, as well as in Science & Technology (#14, 39.17), thanks to its advances in health care digitization and scientific discoveries.

Background

In 1930, France established a system of mandatory, subsidized health insurance for workers below an income threshold. Private health coverage through mutual benefit associations was widespread; by 1939, two-thirds of French residents had health insurance. After World War II, France began gradually moving away from the German-style model of private insurers and more toward a government-centered system.

In 2016, France enacted a major overhaul of its health care system, consolidating its various occupation-based government-run insurers into a single system, the Protection Universelle Maladie (PUMA). More than 90% of the French population purchases supplemental private insurance, which provides benefits not covered by the government-run system and/or cost-sharing assistance, akin to “Medigap” Medicare supplemental insurance in the U.S.

France is home to one of the world’s largest innovative pharmaceutical companies, Sanofi, which is the product of mergers of several longstanding French and German companies. Other large French companies include Ipsen, Servier, and Pierre Fabre. Drug prices are negotiated by a government agency, the Economic Committee for Health Products (Comité Économique des Produits de Santé, or CEPS); however, generic medicines have fairly low market share in France, which allows pharmaceutical companies to generate considerable revenues from drugs whose patents have expired.

Quality

Lining up with its reputation of longevity and wellness, France does best in the Quality dimension at #12. France’s health care infrastructure (#6) is solid, and the country holds its own in providing patient-centered customer service (#11). Though it ranks #14 in measures of preventable disease, it scores particularly well on preventing hospitalizations and on cardiac and cancer survival rates. Despite these bright spots, France’s overall Quality rating is weighed down by poor performance in handling COVID-19 (#23).

Choice

France ranks #22 overall for Choice. On the plus side, France ranks high in affordability of health insurance (#8). However, it’s overall Choice ranking is weighed down by a low score in freedom to choose health care services (#26), in part because France’s two-tiered health insurance system — which helps eliminate out-of-pocket costs through supplemental insurance — weakens patient choice by making consumers less sensitive to the price of health care. In addition, there is virtually no choice in insurance carrier or plan design, with a single basic insurance choice determined by profession.

Science & Technology

France ranks #14 in Science and Technology. France continues a tradition as a leader in scientific discoveries (#8) with the fourth highest scoring for Nobel laureates as well as a significant body of cited research. However, France lags behind in health digitization (#23).

Fiscal Sustainability

France’s Fiscal Sustainability ranking comes in at #30, better only than Japan. In particular, its public health spending per capita is over 9% (#30), having grown almost a full percentage point in the last 10 years. Without further cost containment measures, the increasing public health spending threatens France’s national solvency — which already ranks #24 among countries in the Index.