Access to Health Services for Poor and

Access to Health Services
for the Poor and Underserved in France
Enquête sur l’accès aux soins des défavorisés (1996-1997)
Thérèse Lecomte,
Nathalie Meunier,
Andrée Mizrahi,
Arié Mizrahi,
Valérie Paris,
Marie-Jo Sourty-Le Guellec
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Access to health services
for the poor and underserved in France
France: 551,000 km²; population: 58 million.
26% are under 20 years old; 15% are 60
years and over.
Life expectancy: men: 74 years; women: 82
years.
GDP per person: 131,990 FF in 1995.
Unemployment rate: 11.6% of active
population.
Long-term unemployed: 1-1.2 million.
An estimated 300,000 persons are homeless,
marginalized and unable to claim their right of
access to social security.
French health insurance covers 70% of health expenditure
The French health care system is based on universal compulsory health insurance, significant patient
cost-sharing, and supplementary insurance. About 99% of the population are covered by the statutory
insurance scheme. Coverage is employment based. Contributions to insurance are income related
and are shared by employers and employees or paid directly by non salaried individuals. Patients
may be required to make copayments. Some employers provide supplementary insurance for their
employees through mutual fund organizations to cover patient copayments. Individuals may also
subscribe to private supplementary insurance. Out-of-pocket payments currently account for around
14% of national health expenditure. An estimated 87% of the French population are covered by both
compulsory and supplementary health insurance.
Deteriorating social context
The current high unemployment rate (12%) is worrying as it implies further social deterioration.
Theoretically, unemployed people are still covered by the insurance scheme. However,
marginalization and homelessness often render them unable to claim their right of access.
Furthermore, an increasing proportion of those on low incomes, while receiving mandatory coverage,
cannot afford to advance payment for care which will be reimbursed later. They can neither afford
copayments nor supplementary insurance. As a result, a growing number of persons cannot afford to
use the normal care system. Faced with this deteriorating situation, parallel care delivery systems
have been introduced at a local level, facilities have been created, with health care providers
volunteering to deliver health care to the underserved.
Thérèse Lecomte, Nathalie Meunier, Andrée Mizrahi,
Arié Mizrahi, Valérie Paris, Marie-Jo Sourty-Le Guellec
Enquête sur l’accès aux soins des défavorisés
CREDES - 1996-97
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CREDES has carried out a national survey specifically to estimate the extent of
the phenomenon
In 1996-97, CREDES carried out a two-step specific survey to study the impact of poverty on access
to health care. The fringe population usually slips through the net of traditional surveys and they must
be approached indirectly.
We began by identifying health care providers and facilities actually accessible to the underserved.
These include traditional providers or facilities, such as physicians and hospitals, which agree to
provide ‘charity care’. There are also new facilities created specifically to provide the underserved
with health care.
The second part of the survey covered the human resources, equipment and services offered at
these specific facilities.
Survey design
First step: hostels and day-centers for the homeless and information offices were
targeted
• aim: to assess the health care facilities made available for the uninsured and those unable to
pay.
• data collected: health care resources used when residents or visitors need care.
• participation in survey: 661 valid questionnaire returns (representing a 37% response rate).
• result: an inventory of health care centers specifically for the disadvantaged.
Second step: health care centers specifically for the disadvantaged were targeted
•
•
•
•
aim: to assess human and material resources existing outside the traditional system.
data collected: quantitative data on medical and paramedical staff, facilities and patients.
participation in survey: 171 specific centers responded.
findings: extensive participation by physicians and nursing staff generally on a voluntary basis.
Attention given to reintegrating them into the standard health care system through assistance
with the necessary administrative procedures.
Thérèse Lecomte, Nathalie Meunier, Andrée Mizrahi,
Arié Mizrahi, Valérie Paris, Marie-Jo Sourty-Le Guellec
Enquête sur l’accès aux soins des défavorisés
CREDES - 1996-97
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Graph 1
Out-of-pocket payments currently account for around 14% of health expenditure
% of persons
covered
100
80
compulsory cover
60
40
supplementary cover
20
0
1960
1970
1980
1990
1995
Source : Enquêtes décennales sur la santé - 1960/1980/1990 - Enquête Santé et protection sociale
Graph 2
Steadily rising unemployment
Unemployment rate and percentage of people receiving the minimum social security allowance
between 1960 and 1995 in France
14%
12%
10%
8%
6%
4%
2%
0%
1960
unemployment
1970
1980
1989
Source : Chômage (INSEE), RMI (CNAF)
Thérèse Lecomte, Nathalie Meunier, Andrée Mizrahi,
Arié Mizrahi, Valérie Paris, Marie-Jo Sourty-Le Guellec
1990
1991
1992
1993
minimum social
security allowance
1994
1995
Enquête sur l’accès aux soins des défavorisés
CREDES - 1996-97
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Graph 3
Inability to pay (even if part of this amount will be reimbursed) prevents some
households from taking advantage of certain types of health care
Percentage of persons renouncing certains types of health care for financial reasons
25
25,3
global
less than 12 months
20
16,3
% of persons
15
13,8
10
8,9
6,8
5
4,9
4,6
4,3
3,4
2,4
0
Dentitry
Glasses
Medical care, tests
Other
Global
CREDES - ESPS 1995
Graph 4
Health care resources used when residents or visitors need care, by type of care
p ha rm ac e u tic als
no s o lu tio n
inte rn al
c e n te r f o r un d e rs e rve d
d is p e n s ary
p s y d ay c e nte r
ho s p ita l
GP
Physicians
in
general
practice
provide
the
disadvantaged with care
free of charge on an ad hoc
basis.
d e ntal c a re
p s yc h iatric c are
Hospitals provide reception
facilities,
where
these
patients can be sent to the
appropriate department for
treatment free of charge.
nu rs e c a re
However, specific centers
are being set up throughout
the country.
m e d ic al c a re
0
10
20
30
40
S o urc e : E nq u ê te s ur l'ac c è s aux s o ins d e s d é f avo ris é s - C R E D E S - 1 9 9 7
Thérèse Lecomte, Nathalie Meunier, Andrée Mizrahi,
Arié Mizrahi, Valérie Paris, Marie-Jo Sourty-Le Guellec
Standard
health
care
facilities are often used.
50
Enquête sur l’accès aux soins des défavorisés
CREDES - 1996-97
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Graph 5
Time needed for complete formalities
100
Help
with
administrative
formalities, to allow
access to the standard
health care system.
Hostels, day-centers
and information offices
provide help with the
administrative
formalities needed for
access to the standard
health system.
% centers helping with formalities
90.88
% of centers providing assistance for formalities
90
83.1
79.57
80
76.32
70
less than 8 days
8-15 days
60
15-30 days
one month and over
50
40
30
20
10
0
hostels
day-centers
others
status unknown
Source : Enquête sur l'accès aux soins des défavorisés - CREDES - 1997
Graph 6
Physicians and paramedics work on behalf of the underserved,
essentially on a voluntary basis
18
other paramedics
462
volunteer paramedics
centers : 158
patients : 3747
patients needing medical care : 2544
patients needing paramedical care : 1850
170
salaried paramedics
16
other physicians
807
volunteer physicians
123
salaried physicians
0
100
200
300
400
500
600
700
800
900
Source : Enquête sur l'accès aux soins des défavorisés - CREDES - 1997
Thérèse Lecomte, Nathalie Meunier, Andrée Mizrahi,
Arié Mizrahi, Valérie Paris, Marie-Jo Sourty-Le Guellec
Enquête sur l’accès aux soins des défavorisés
CREDES - 1996-97
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The survey covered 158 health care centers specifically for the underserved
throughout France : 3747 patients were seen during a 7-day period
Nord:
5 centers
149 patients
21 physicians
14 paramedics
Ile-de-France:
10 centers
433 patients
28 physicians
23 paramedics
Ouest:
21 centers
425 patients
124 physicians
85 paramedics
Bassin Parisien:
25 centers
541 patients
92 physicians
65 paramedics
Est:
18 centers
264 patients
105 physicians
48 paramedics
Centre-Est:
26 centers
465 patients
149 physicians
124 paramedics
Sud-Ouest:
20 centers
403 patients
80 physicians
62 paramedics
Provence-Côte d’Azur-Corse:
33 centers
1067 patients
347 physicians
229 paramedics
Thérèse Lecomte, Nathalie Meunier, Andrée Mizrahi,
Arié Mizrahi, Valérie Paris, Marie-Jo Sourty-Le Guellec
Enquête sur l’accès aux soins des défavorisés
CREDES - 1996-97