Health inequalities and France's national health strategy.

Around the world, rising health-care costs are claiming an increasing share of national budgets. In September, 2013, the French Government launched a comprehensive national health strategy to address fi nancial issues under national health insurance, health-care reform, public health issues, and social aspects of health inequalities. This strategy will inform preparations for a new health law to be presented to parliament before the summer. This will be the fi rst time that a French law will address both issues related to public health and to health insurance and reimbursement. To prepare the content of the law, I initiated public forums throughout the country, and from November, 2013, to March, 2014, there have been 150 public forums involving 23 000 participants. A key goal of the new strategy is to tackle health inequalities that are rooted in social determinants. The French health-care system is often seen as one of the best: it ranked fi rst of 191 states in WHO’s World Health Report in 2000. Indeed, compared with the regional average in Europe, France has higher life expectancy (82 years vs 79 years), lower maternal mortality ratio (8 per 100 000 livebirths vs 20), and spent about twice as much of per capita total expenditure on health. However, as in other countries, there is evidence of substantial and increasing health inequalities in France, and so far there has been no comprehensive policy to reduce them. There are more inequalities in death rates in France than in many other European countries, particularly for men, and these inequalities have increased in recent years. Inequalities in quality of life as a result of diverse disabilities are another cause for concern. The inequalities in death rates and quality of life concern virtually all diseases, risk factors, and states of health. In its report on health inequalities, the French High Council for Public Health highlighted how this issue has been addressed from the sole perspective of personal care in the context of patient–doctor relations. Hitherto, the French debate on health inequalities has largely focused on access to health care under the health insurance and social protection schemes. The French health-care system combines universal coverage with a public–private mix of hospital and outpatient care. Although indicators of health status and consumer satisfaction are high, reform is needed to tackle the chronic fi nancial defi cits incurred by French national health insurance. Several recent policy developments have improved fi nancial accessibility to health care for the poor. Under the national health strategy, universal coverage is to be strengthened with a particular focus on universal access to supplementary insurance. Nevertheless, achieving universal coverage has not prevented geographical disparities in the distribution of health resources and unacceptable variation in health outcomes according to socioeconomic status. There is a broad consensus that these issues extend beyond fi nancial and organisational aspects of the health-care system and require stronger public health interventions and a multisectoral approach. One of my core commitments under the national health strategy is to promote a new social contract across the whole of government to foster the development, sustainability, and equity of the health-care system with the aim of not only improving performance indices but also reducing health inequalities. Under this social contract, every government department will be accountable for the impact of their policies on public health and health inequalities. The social contract will ensure a strong focus on the social determinants of health inequalities. Redesigning the organisation and delivery of health services is the second main goal of the national health