The document discusses France's "Quality and Efficiency Programs" which use social and health indicators for performance budgeting and the yearly Social Security law. It provides an overview of the French social protection system and the law. It then focuses on the healthcare objectives and indicators, outlining the 5 themes, 52 indicators across those themes, and organizations involved. Finally, it discusses debates in France around the programs, noting both benefits in evaluating policies but also criticisms around the number of indicators and gaps between the indicators and budgetary choices.

1. « Quality and Efficiency Programs » :
Social and Health Indicators for Social Security
performance budgeting in France
OECD 7th Meeting of the OECD Joint Network of Senior Budget and
Health Officials
Anne-Gisèle Privat, Project manager, Ministry of Health
David Bernstein, Economist, Ministry of Health
February 13th 2019
Ministère des Solidarités et de la Santé
Ministère de l’Action et des Comptes publics

2. 2
Summary
Direction de la sécurité sociale
Social Protection in France and the Yearly Social Security
Law
1
« Quality and Efficiency Programs », indicators tied to the
Social Security Law
2
Focus on the healthcare objectives and indicators3
Discussion and debates in France on the subject
 Need for an overview of OECD countries’ experiences
4

3. Direction de la sécurité sociale 3
1. Social Protection in France and the Yearly Social
Security Law
 Social Security including healthcare is historically a bismarckian system (occupation-
based)
 For healthcare, historical occupational-based funds (agriculture, salaried and
independent workers) still exist but healthcare coverage is now universal and unified
 In 1996, institution of the Yearly Social Security Law presented by the Government to
Parliament in October for the following year
- The law forecasts the financial trajectories for Social Security domains (health, family,
pensions, work injuries) and the policies that enable them
- For healthcare, a particular instrument called “Objectif National des Dépenses
d’Assurance Maladie” (National Objective of Healthcare Expenditures) is voted (200
billion euros for 2019, + 2,5%)
 Final stage of a historical process of increasing regulation and financing of Social
Security (originally private) by the State ?

4. Direction de la sécurité sociale 4
1. Social Protection in France and the Yearly Social
Security Law
Parliament votes on an absolute figure. The sum voted has never been overshot since
2010

5. Direction de la sécurité sociale 5
1. Social Protection in France and the Yearly Social
Security Law

6. Direction de la sécurité sociale 6
2. « Quality and Efficiency Programs », indicators tied to the
Social Security Law
 The Social Security Law and the ONDAM are presented by expenditure category,
not by objectives/programme
 The « Quality and Efficiency Programs », implemented by the law (« loi
organique du 2 août 2005 relative aux lois de financement de la Sécurité sociale »),
in existence since 2008, aim to give a more programmatic view of the Social
Security/healthcare budgets
- They are directly inspired by the similar mecanisms set up, since 2006, for the
State budget (« loi organique relative aux lois de finances »), objectives and
indicators issued in the « Programmes annuels de performance and rapports
annuels de performance »
 Aims of the « Quality and Efficiency Programs »:
- Provide transparent reporting on the quality and outcomes of Social Security
organizations
- Improve clarity of public policies by informing all decision makers and
stakeholders : members of Parliament, workers’ unions, Social Security
funds…
- Contribute to policy evaluations by measuring the performance of social and
healthcare policies

7. Direction de la sécurité sociale 7
 Contributions by 20 different organizations in the process (Social security
organizations, administrations, agencies)
 6 themes: 4 corresponding to the various social risks covered by Social
Security + 1 on disability and long term care+1 separate theme on financing
o Healthcare
o Pensions
o Occupational Risks
o Family support
o Disability and long term care
o Financing issues
 Each section/theme includes the following structure :
o A strategy presentation (6 to 10 pages), that evaluates the previous year’s
achievements and outlines the Government’s main policy objectives to
address existing target gaps
o Context indicators (economic context, demography, social and health)
o Performance indicators, each with targets, comments and methodologies
2. « Quality and Efficiency Programs »: a social and
healthcare dashboard

8. Direction de la sécurité sociale
8
1. Provide equal
access to care
2. Develop
prevention
3. Improve quality
4. Reinforce
efficiency
5. Ensure financial
sustainability of
healthcare
accounts
Health
care
3. Focus on the healthcare objectives and indicators
5 themes

9. Direction de la sécurité sociale
9
 An instrument to monitor the performance of the healthcare social security system
 52 indicators (68, including sub-indicators):
- 17 in the section entitled « context » (21, including sub-indicators)
Context indicators include some international benchmarking
- 35 in the section entitled « objectives » (47, including sub-indicators)
 Available online: http://www.securite-sociale.fr/IMG/pdf/maladie_0310.pdf
 9 organizations contribute to their creation :
3. Focus on the healthcare objectives and indicators

10. Direction de la sécurité sociale
10
3. Focus on the healthcare objectives and indicators
Equal access (example)

11. Direction de la sécurité sociale
11
3. Focus on the healthcare objectives and indicators
Prevention (example)

12. Direction de la sécurité sociale
12
3. Focus on the healthcare objectives and indicators
Quality of care (example)

13. Direction de la sécurité sociale
13
3. Focus on the healthcare objectives and indicators
Efficiency (example)

14. Direction de la sécurité sociale
14
3. Focus on the healthcare objectives and indicators
Efficiency (example)

15. Direction de la sécurité sociale
15
3. Focus on the healthcare objectives and indicators
Financial sustainability (example)

16. Direction de la sécurité sociale
16
4. Discussion and debates in France
 On the + side :
 The instrument is used during debates in Parliament in order to evaluate the success of
policies concerning Social Security healthcare
 Used by Social Security organizations to give context and evaluate impact of the new
Social Security Law
 The preliminary synthesis outlines the Government’s strategy when presenting the
Social Security Law
 A recent online user survey showed that they were read in a variety of professional
circles (journalists, academics, political representatives…)
 On the - side :
 Too many indicators: optimal number of indicators ? Choice of indicators ? Delay in
indicator production ?
 A « gap » between budget-setting and indicators : indicators do not reflect directly
budgetary choices and trade-offs.
 Questions to the floor : Do such systems/instruments exist in your countries, to inform
lawmakers/policymakers ? Are there debates on their usefulness ?

17. Direction de la sécurité sociale 17
Financing issues

18. Direction de la sécurité sociale 18
Financing issues