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The French Health Care System

by Isabelle Durand-Zaleski, AP HP and University Paris–Est, Paris, France

What is the role of government?

The provision of health care in France is a national responsibility. The Ministry of Social Affairs, Health, and Women’s Rights is responsible for defining national strategy (Touraine, M., 2014). The French system has evolved from a labor-based Bismarckian system to a mixed public–private system. Over the past two decades, however, the state has been increasingly involved in controlling health expenditures funded by statutory health insurance (SHI).

Planning and regulation within health care involve negotiations among provider representatives, the state, and SHI. Outcomes of these negotiations are translated into laws passed by parliament.

In addition to setting national strategy, the responsibilities of the central government include allocating budgeted expenditures among different sectors (hospitals, ambulatory care, mental health, and services for disabled residents) and, with respect to hospitals, among regions.

The Administration of Health and Social Affairs is represented by Regional Health Agencies, which are responsible for population health and health care, including prevention and care delivery, public health, and social care. Health and social care for elderly and disabled people come under the jurisdiction of the General Council, which is the governing body at the local level.

Who is covered and how is insurance financed?

Publicly financed health insurance: Total health expenditures constituted 11 percent of GDP in 2013, of which 76 percent was publicly financed (DREES, 2015).

SHI is financed by employer and employee payroll taxes (64%); a national earmarked income tax (16%); taxes levied on tobacco and alcohol, the pharmaceutical industry, and voluntary health insurance companies (12%); state subsidies (2%); and transfers from other branches of Social Security (6%) (Assurance Maladie, 2015).

Coverage is universal and compulsory, provided to all residents by noncompetitive SHI. SHI eligibility is either gained through employment or granted, as a benefit, to students, to retired persons, and to unemployed adults who were formerly employed (and their families). Citizens can opt out of SHI only in rare cases (e.g., individuals working for foreign companies). The state covers the insurance costs of residents who are not eligible for SHI, such as the long-term unemployed, and finances health services for undocumented immigrants who have applied for residence. Visitors from elsewhere in the European Union (EU) are covered by an EU insurance card. Non-EU visitors are covered for emergency care only.

Private health insurance: Most voluntary health insurance (VHI) is complementary, covering mainly the copayments for usual care, balance billing, and vision and dental care (minimally covered by SHI). Complementary insurance is provided mainly by not-for-profit, employment-based mutual associations or provident institutions, which are allowed to cover only copayments for care provided under SHI; 95 percent of the population is covered either through employers or via means-tested vouchers. Private for-profit companies offer both supplementary and complementary health insurance, but only for a limited list of services.

VHI finances 13.8 percent of total health expenditure. The extent of VHI coverage varies widely, but all VHI contracts cover the difference between the SHI reimbursement rate and the service fee according to the official fee schedule. Coverage of balance billing is also commonly offered, and most contracts cover the balance for services billed at up to 300 percent of the official fee.

To reduce inequities in coverage stemming from variations in access and quality, standards for employer-sponsored VHI were established by law in 2013. By 2016, all employees will benefit from employer-sponsored insurance (for which they pay 50% of the cost), which would cover at least 125 percent of SHI fees for dental care and EUR100 (USD121) for vision care per year. (All figures in USD were converted from EUR at a rate of about 0.83 EUR per USD, the purchasing power parity conversion rate for GDP in 2014 reported by OECD, 2015 for France.) The population of beneficiaries without supplementary insurance is estimated at 4 million. Choice among insurance plans is determined by the industry in which the employer operates (DREES, 2015).

What is covered?

Services: Lists of covered procedures, drugs, and medical devices are defined at the national level and apply to all regions of the country. The Ministry of Health, a pricing committee within the ministry, and SHI funds all play roles in setting these lists, rates of coverage, and prices.

SHI covers the following: hospital care and treatment in public or private rehabilitation or physiotherapy institutions; outpatient care provided by general practitioners, specialists, dentists, and midwives; diagnostic services prescribed by doctors and carried out by laboratories and paramedical professionals; prescription drugs, medical appliances, and prostheses that have been approved for reimbursement; and prescribed health care–related transportation and home care. It also partially covers long-term hospice and mental health care, and provides only minimal coverage of outpatient vision and dental care.

While preventive services in general receive limited coverage, there is full reimbursement for targeted services and populations, e.g., immunization, mammography, and colorectal cancer screening.

Cost-sharing and out-of-pocket spending: Cost-sharing takes three forms: coinsurance; copayments (the portion of fees not covered by SHI); and balance billing in primary and specialist care. In 2013, total out-of-pocket spending made up 8.8 percent of total health expenditures (excluding the portion covered by supplementary insurance), a lower percentage than in previous years, possibly because of the agreement signed between physicians’ unions and government to limit extra billing (DREES, 2015). In exchange for a voluntary restriction on extra billing to no more than twice the official fee, this contract offers patients partial reimbursement of extra billing by SHI and reduced social charges for physicians.

Most out-of-pocket spending is for dental and optical services, for which official fees are very low, not more than a few euros for glasses or hearing aids and a maximum of EUR200 (USD241) for dentures, but all of these are commonly balance-billed at amounts over 10 times the official fee. The share of out-of-pocket spending on dental and optical services is decreasing, however, while that on drugs is increasing, owing to increased VHI coverage of dental and optical care and increasing numbers of delisted drugs, as well as a rise in self-medication (DREES, 2015).

Coinsurance rates are applied to all health services and drugs listed in the benefit package, and vary by:

  • type of care (inpatient, 20%; doctor visits, 30%; and dental, 30%)
  • effectiveness of prescription drugs (highly effective drugs, like insulin, carry no coinsurance; rates for all other drugs are 40%–100%, based on therapeutic value)
  • compliance with the recently implemented gatekeeping system

The table below lists nonreimbursable copayments for various services. These apply up to an annual ceiling of EUR50 (USD60). There are no deductibles.

ServiceCopayment
EurosU.S. Dollars
Inpatient hospital day1822
Doctor visit1.001.20
Prescription drug0.500.60
Ambulance2.002.40
Hospital treatment above EUR1201822

Safety net: People with low incomes are entitled to free or state-sponsored VHI, free vision care, and free dental care, with the total number of such beneficiaries estimated at around 10 percent of the population (DREES, 2015). Exemptions from coinsurance apply to individuals with any of 32 specified chronic illnesses (13% of the population, with exemption limited to the treatments for those conditions); individuals who benefit from either complete state-sponsored medical coverage (3% of the population) or means-tested vouchers for complementary health insurance (6% of the population); and individuals receiving invalidity and work-injury benefits (Fonds CMU 2014). Hospital coinsurance applies only to the first 31 days in hospital, and some surgical interventions are exempt. Children and people with low incomes are exempt from paying nonreimbursable copayments.

How is the delivery system organized and financed?

Collective agreements between representatives of the health professions and SHI, signed at the national level, apply to all but those professionals who expressly opt out.

Primary care: There are roughly 102,000 primary care physicians (GPs) and 118,000 specialists in France. About 46 percent of physicians are self-employed, more GPs (59%) than specialists (36%) (INSEE 2015; CISS 2014). Forty-two percent of GPs, mostly younger doctors, are in group practices. An average practice is made up of two to three physicians. Seventy-five percent of practices are made up exclusively of physicians; the remaining practices comprise a range of allied health professionals, typically paid fee-for-service.

There is a voluntary gatekeeping system for adults age 16 and over, with financial incentives offered for registering with a GP or specialist (Cour des Comptes, 2013).

Self-employed GPs are paid mostly fee-for-service and can receive a yearly capitated per-person payment of EUR40 (USD48) to coordinate care for patients with a chronic condition (Assurance Maladie, 2015). In addition, up to EUR5,000 (USD 6,031) annually is provided for achieving targets related to the use of computerized medical charts, electronic claims transmission, delivery of preventive services such as immunization, compliance with guidelines for diabetic and hypertensive patients, generic prescribing, and limited use of psychoactive drugs for elderly patients.

Since 2013, GPs can also enter into a contractual agreement under which they are guaranteed a monthly income of EUR6,900 (USD8,322) if they set up their practice in a region with insufficient physician supply (Ministry of Health, 2014). Moreover, they can work part-time in multidisciplinary medical centers and receive a salary or capitated payment. For those who elect to work full-time in medical centers, the guaranteed salary is around EUR50,000 (USD60,300) (Quotidien du Médecin, 2015).

The average income of primary care doctors in 2011 was EUR82,020 (USD98,925), 94 percent of which came from fees (INSEE 2015) and the remainder from financial incentives and salary. Fees, set by the Ministry of Health and SHI, have been frozen since 2011 (Cour des Comptes 2013).

Experimental GP networks providing chronic care coordination, psychological services, dietician services, and other care not covered by SHI are financed by earmarked funds from the Regional Health Agencies (Nolte, E., 2008).

Outpatient specialist care: About 36 percent of outpatient specialist care providers are exclusively self-employed and paid on a fee-for-service basis; the rest are either fully salaried by hospitals or have a mix of income. In October 2014, participation in pay-for-performance programs was extended to all self-employed physicians, including specialists, who must meet disease-specific quality targets in addition to those targets that apply to GPs. The average income derived from pay-for-performance is EUR5,480 (USD6,609) per physician (Cour des Comptes 2014); such income constitutes less than 2 percent of total funding for outpatient services.

Patients can choose among specialists upon referral by a GP, with the exception of gynecology, ophthalmology, psychiatry, and stomatology (Assurance Maladie, 2015). Bypassing referral results in reduced SHI coverage.

The specialist fee, set by SHI, is EUR28 (USD34), but specialists can balance-bill. Half of specialists are in group practices, which are increasing among specialties that require major investments, such as nuclear medicine, radiotherapy, pathology, and digestive surgery (Sénat 2014).

Specialist doctors working in public hospitals may see private-pay patients, on an out-patient or an in-patient basis, but they must pay a percentage of their fees to the hospital. A 2013 report to the Ministry of Health estimated that 10 percent of the 46,000 hospital specialists in surgery, radiology, cardiology, and obstetrics had treated private patients. The mounting discontent over excessive balance billing revealed in the press, together with the claim of unfair competition made by private clinics, has prompted several public inquiries—the latest of which resulted in recommendations to increase public control over this activity (Ministère de la Santé 2013).

Administrative mechanisms for paying primary care doctors and specialists: Patients pay the full fee (reimbursable portion and balance billing, if any) and claim reimbursement covering the full sum or less, depending on coverage, minus EUR1.00 (USD1.20), capped at a maximum of EUR50 (USD60) per patient per year. The 2015 Health Law included a contentious item stipulating that by 2017 patients will pay directly only for balance billing, and the reimbursable fee will be paid directly by SHI.

After-hours care: After-hours care is delivered by the emergency departments of public hospitals, private hospitals that have signed an agreement with their Regional Health Agency, self-employed physicians who work for emergency services, and, more recently, public facilities financed by SHI and staffed by health professionals on a voluntary basis. Primary care physicians are not mandated to provide after-hours care.

Physicians are paid an hourly rate, regardless of the number of patients seen. Emergency services can be accessed via the national emergency phone number, which is staffed by trained professionals who determine the type of response needed. Feasibility of telephone or telemedicine advice is currently under assessment; it would include sharing information from the patient’s electronic medical record with the patient’s primary care doctor. Publicly funded multidisciplinary health centers with self-employed health professionals (physicians and nonphysicians) allow better after-hours access to care in addition to more comprehensive care; fee-for-service payment is the rule for these centers (IRDES, 2014).

Hospitals: Public institutions account for about two-thirds of hospital capacity and activity, private for-profit facilities account for another 25 percent, and private nonprofit facilities, the main providers of cancer treatment, make up the remainder (DREES, 2015). Since 2008, all hospitals and clinics are reimbursed via the diagnosis-related group (DRG) system, which applies to all inpatient and outpatient admissions and covers physicians’ salaries. Bundled payment by episode of care does not exist.

Public hospitals are funded mainly by statutory health insurance (80%), with voluntary insurance and direct patient payment accounting for their remaining income. Public and private nonprofit hospitals also benefit from grants that compensate research and teaching (up to an additional 13% of the budget) as well as the provision of emergency services and organ harvesting and transplantation (on average, an additional 10%–11% of a hospital’s budget). Private, for-profit clinics owned either by individuals or, increasingly, by large corporations have the same funding mechanism as public hospitals, but the share of respective payers differs. Doctors’ fees are billed in addition to the DRG in private clinics, and DRG payment rates are lower there than they are in public or nonprofit hospitals. This disparity is justified by differences in the size of facilities, the DRG mix, and the patients’ characteristics (age, comorbid conditions, and socioeconomic status) (IRDES 2013). Rehabilitative hospitals also have a prospective payment system based on length of stay and care intensity.

Mental health care: Services for mentally ill people are provided by the public and private health care sectors, with an emphasis on community-based provision. Public care is provided within geographically determined areas and includes a wide range of preventive, diagnostic, and therapeutic inpatient and outpatient services. Ambulatory centers provide primary ambulatory mental health care, including home visits.

Mental health care is not formally integrated with primary care, but a large number of disorders are also treated on an outpatient basis by GPs or private psychiatrists or psychologists, some of them practicing psychotherapy and, occasionally, psychoanalysis.

Statutory health insurance covers care provided by GPs and psychiatrists in private practice, public mental health care dispensaries, and private psychiatric hospitals. Copayments do not apply to persons with a diagnosed long-term mental illness. Care provided by psychotherapists or psychoanalysts is fully financed by patients or covered by VHI. Copayments and the flat-rate fee for accommodation can also be fully covered by VHI.

Long-term care and social supports: Total expenditure for long-term care in 2013 was estimated to be EUR39 billion (USD47 billion), or 17 percent of total health expenditures (DREES, 2014). Statutory health insurance covers the medical costs of long-term care, while families are reponsible for the housing costs in hospices and other long-term facilities—on average, EUR1,500 (USD1,809) per month (Ministère de la Santé 2013, 2). End-of-life care in hospitals is fully covered. Some funding of care for the elderly and disabled comes from the National Solidarity Fund for Autonomy, which is in turn financed by SHI and the revenues from an unpaid working “solidarity” day. Local authorities, the general councils, and households also participate in financing these categories of care.

Home care for the elderly is provided mainly by self-employed physicians and nurses and, to a lesser extent, by community nursing services. Long-term care in institutions is provided in retirement homes and long-term care units, totaling roughly 10,000 institutions and 720,000 beds. Of these, 54 percent are public, 28 percent private nonprofit, and 18 percent for-profit, although the percentage of for-profit institutions is increasing (DREES, 2014).

In addition, temporary care for dependent patients and respite services for their caregivers are available without restrictions from the states or regions.

Means-tested monetary allowances are provided for the frail elderly. The allowance is adjusted in relation to the individual’s dependence level, living conditions, and needs, as assessed by a joint health and social care team, and may be used for any chosen service and provider. About 1.1 percent of the total population is estimated to be eligible. Informal caregivers also benefit from tax deductions.

What are the key entities for health system governance?

The Ministry of Health sets and implements government policy in the areas of public health and the organization and financing of the health care system, within the framework of the Public Health Act. It regulates roughly 75 percent of health care expenditure on the basis of the overall framework established by parliament, which includes a shared responsibility with statutory health insurers for defining the benefit package, setting prices and provider fees (including diagnosis-related group fees and copayments), and pricing drugs. The parliamentary “Alert” Committee provides a midyear assessment of health care expenditures and proposes corrective measures in case expenditures exceed the target by more than 0.75 percent.

The French Health Products Safety Agency oversees the safety of health products, from manufacturing to marketing. The agency also coordinates vigilance activities relating to all relevant products.

The Agency for Information on Hospital Care manages the information systematically collected from all hospital admissions and used for hospital planning and financing. The remit of the National Agency for the Quality Assessment of Health and Social Care Organizations encompasses the promotion of patient rights and the development of preventive measures to avoid mistreatment, in particular in vulnerable populations such as the elderly and disabled, children, adolescents, and socially marginalized people. It produces practice guidelines for the health and social care sector and evaluates organizations and services.

The National Health Authority (HAS) is the main health technology assessment body, with in-house expertise as well as the authority to commission assessments from external groups. The HAS remit is diverse, ranging from the assessment of drugs, medical devices, and procedures to publication of guidelines, accreditation of health care organizations, and certification of doctors.

Competition is limited to VHI, whose providers are supervised by the Mutual Insurance Funds Control Authority.

What are the major strategies to ensure quality of care?

National plans are developed for a number of chronic conditions (e.g., cancer, Alzheimer’s), rare diseases, prevention, and healthy aging, in addition to the 104 targets set by the 2004 Public Health Act. These plans establish governance (e.g., the cancer plan to coordinate research and treatment in cancer and establish guidelines for medical practice and activity thresholds), develop tools, and coordinate existing organizations. All plans emphasize the importance of supporting caregivers and ensuring patients’ quality of life, in addition to enforcing compliance with guidelines and promoting evidence-based practice.

The National Health Authority publishes an evidence-based basic benefit package for 32 chronic conditions. Further guidance on recommended care pathways covers chronic obstructive pulmonary disease, heart failure, Parkinson’s, and end-stage renal disease (Assurance Maladie, 2015).

SHI and the Ministry of Health fund “provider networks” in which participating professionals share guidelines and protocols, agree on best practice, and have access to a common patient record. Regional authorities fund telemedicine pilot programs to improve care coordination and access to care for specific conditions (e.g., stroke) or populations (e.g., newborns, the elderly, prisoners). The PAERPA (Personnes Agées en Risque de Perte d’Autonomie) program, established in 2014 in nine pilot regions, is a nationwide endeavor to improve the quality of life and coordination of interventions for the frail elderly.

For self-employed physicians, certification and revalidation are organized by an independent body approved by the National Health Authority. For hospital physicians, both can be performed as part of the hospital accreditation process.

To ensure the lifelong quality of their practice, doctors, midwives, nurses, and other professionals must undergo continuous learning activities, which are audited every fourth or fifth year. Optional accreditation exists for a number of high-risk medical specialties (e.g., obstetrics and gynecology, surgery, cardiology). Accredited physicians can claim a deduction on their professional insurance premiums.

Hospitals must be accredited every four years; criteria and accreditation reports are publicly available on the National Health Authority website (www.has-sante.fr). CompaqH, a national program of performance indicators, also reports results on selected indicators. Quality assurance and risk management in hospitals are monitored nationally by the Ministry of Health, which publishes online technical information, data on hospital activity, and data on control of hospital-acquired infections. Currently, financial rewards or penalties are not linked to public reporting, although they remain a contested issue.

Information on individual physicians is not available.

What is being done to reduce disparities?

There is a 6.3-year gap in life expectancy between males in the highest and males in the lowest social categories (DREES, 2015) and poorer self-reported health among those with state-sponsored or without any complementary insurance. The reduction of health inequities is a major target of the 2014 National Health Strategy, and the 2004 Public Health Act set targets for reducing inequities in access to care related to geographic availability of services (so far, only nurses have agreed to limit new practices in overserved areas), financial barriers (out-of-pocket payments will be limited by state-sponsored complementary insurance), and inequities in prevention related to obesity, screening, and immunization. A contractual agreement allows for the use of incentives for physicians practicing in underserved areas, the extension of third-party payment, and enforced limitations on denial of care.

National surveys showing regional variations in health and access to health are reported by the Ministry of Health (DREES, 2015).

What is being done to promote delivery system integration and care coordination?

Various quality-related initiatives aim to improve coordination of hospital, out-of-hospital, and social care (see above). At the regional level, telemedicine pilot programs are under way to coordinate health and social care services for target populations identified by the Regional Health Agencies, such as infants, prisoners, and persons with disabilities. Funding streams are pooled and earmarked for these pilots, and assessment is planned for 2016.

What is the status of electronic health records?

A high-level electronic health record (EHR) project is currently being implemented across the entire country. Approximately 551,000 patients, or 0.8 percent of the population, have an EHR, and an estimated 600 hospitals and 6,000 health professionals use them. Hospital-based and office-based professionals and patients have a unique electronic identifier, and any health professional can access the record and enter information subject to patient authorization. Interoperability is ensured via a chip on patients’ health cards. By law, patients have full access to the information in their own records, either directly or through their GP. All “structured information” included in EHRs must be communicated, but handwritten notes are excluded. The sharing of information between health and social care professionals is not currently permitted, but will be tested as part of the PAERPA program for hospice residents.

A national agency for health information systems was created for the purpose of expanding uptake and interoperability of existing systems (ASIP, 2014), and the health records are available on a government website.

How are costs contained?

SHI has faced large deficits over the past 20 years, but it fell from an annual EUR10–12 billion (USD12.1–14.5 billion) in 2003 to EUR6.2 billion (USD7.5 billion) in 2014. This trend is due to a range of initiatives, including a reduction in the number of acute-care hospital beds; the removal of 600 drugs from public reimbursement; an increase in generic prescribing and the use of over-the-counter drugs; a reduction in the price of generic drugs; and a reduction of the official fees for self-employed radiologists and biology labs. Other cost-containment measures include central purchasing to better negotiate costs, increasing the share of outpatient surgery, and reducing duplicate testing. Competition is not used as a cost-control mechanism. Global budgets are used only in price–volume agreements for drugs or devices. As described above, patient cost-sharing mechanisms include increased copayments for patients who refuse generics or do not use the gatekeeping system (Assemblée Nationale, 2013).

A number of initiatives to reduce “low-value” care, launched by SHI and HAS, include pay-for-performance to reduce prescription of benzodiazepines for elderly persons; reductions in avoidable hospital admissions for patients with heart failure; early discharge after orthopedic surgery and normal childbirth; information on the absence of the benefit of prostate cancer screening; using DRG payments to incentivize shifts to outpatient surgery; establishing guidelines for the number of off-work days according to disease or procedure; strengthening controls for the prescription of expensive statins and new anticoagulants; encouraging the use of Avastin over Lucentis, and other less costly biosimilar drugs; and testing the use of taxi vouchers, instead of ambulances, for chronically ill patients (Assurance Maladie, 2015).

What major innovations and reforms have been introduced?

The new Health Law, based on the 2012 pledge by the newly elected government to reduce health inequities and on the 2014 health strategy (Touraine 2014), was passed in April 2015 to replace the previous law, dating back to 2004. It has 57 articles, the most prominent being the deployment of direct SHI payments to self-employed GPs and a strong commitment to public health and prevention. The direct GP payments have been strongly opposed by physicians’ unions on the grounds that such payments might be delayed by software dysfunction (versus immediate payment at the end of the consultation) and that physicians would become SHI “employees,” and could be pressured into giving cheap care instead of appropriate care. The timetable is to have a full deployment by 2017 (the year of the presidential election).

Prevention and public health measures aim to reduce addictions, eating disorders, and obesity, and include measures to fight binge drinking and anorexia. They support the mandatory neutral cigarette pack, the ban on soda fountains, experimentation with medically supervised IV drug injecting facilities, and mandatory nutrition information on packaged foods (Parlement, 2015).

References

ASIP (2014).

Assemblées Nationale. http://www.assemblee-nationale.fr/14/projets/pl2302.asp.

Assurance Maladie (2015). Rapport charges et produits pour l’année 2016.

Assurance Maladie (2015).

Chevreul, K., I. Durand-Zaleski, S. Bahrami, C. Hernández-Quevedo, and P. Mladovsky (2010). “France: Health System Review,” Health Systems in Transition 12(6):1–291.

CISS (2014). Exercice libéral des médecins.

Cour des Comptes (2013). Le médecin traitant et le parcours de soins coordonnés : une réforme inaboutie.

Cour des Comptes (2014). Les relations conventionnelles entre l’assurance maladie et les professions libérales de santé.

DREES (2014). Ministère de la Santé. Comptes nationaux de la santé 2013.

DREES (2015). Ministère de la Santé. Les dépenses de santé en 2014.

Fonds CMU 2014. Sixieme rapport d’evaluation de la loi du 27 juillet 1999 portant creation d’une couverture maladie universelle.

INSEE 2015. Médecins suivant le statut et la spécialité en 2015.

INSEE 2015;2. Les revenus d’activité des médecins libéraux récemment installés : évolutions récentes et contrastes avec leurs aînés.

IRDES 2013.

IRDES 2014.

Ministère de la Santé 2013(1).

Ministère de la Santé 2013(2).

Nolte, E., C. Knai, and M. McKee (2008). Managing Chronic Conditions: Experience in Eight Countries. European Observatory.

Organisation for Economic Co-operation and Development (OECD) (2015). OECD.Stat. DOI: 10.1787/data-00285-en. Accessed July 2, 2015.

Parlement (2011). Arrêté du 22 septembre 2011 portant approbation de la convention nationale des médecins généralistes et spécialistes.

Parlement (2015). La loi de santé.

Quotidien du Médecin (2015). Rémunération des maisons de santé.

Senat (2014). L'exercice Regroupé, Un Nouveau Mode D'organisation De L'offre De Soins.

Touraine, M. (2014). “Health Inequalities and France’s National Health Strategy.” Lancet, March 29, 2014 383(9923):1101–02.