Solidarity fund for financing dependency

• Abstract
• Purpose of health policy or idea
• Characteristics of this policy
• Political and economic background
• Purpose and process analysis
• Expected outcome
• References

Abstract

A new fund called National Solidarity Fund for Autonomy (CNSA, Caisse Nationale de Solidarité pour l’Autonomie) is created in 2005 in order to provide co-ordinated and timely care to the elderly people who lost autonomy, or people with acute dependence in general. In order to finance this new fund, the Senate passed a law imposing one extra day of work a year for the employees. The public holiday of Pentecote turned into a working day for all.

Purpose of health policy or idea

The major objective of the reform is to improve the co-ordination of care services for the dependent people and to guarantee an equal access for all on the French territory.

It introduces a new approach to the organisation of services for the dependent people, by creating a new fund which oversees the service needs and financing of both elderly dependent and the handicapped.

This new fund (called CNSA, fifth of the Social security) pools together public funds allocated to elderly (about 5,7 billion Euros) and to handicapped (6,6 billion Euros) by the sickness fund. Moreover an extra day of work installed by law in June 2004 to finance this new fund.

Main points

Main objectives

In 2003, France suffered from the hottest summer of the last 50 years. By the end of the heat wave, more than 15000 deaths estimated to be related to the heat. This high death toll, especially among old people, is mainly attributed to the lack of timely reaction to the situation from the health system.  

As a response to the severe criticisms, the government proposed an action plan with three legs:

First, each department is asked to prepare a specific emergency plan for taking care of the fragile elderly and the handicapped people in the event of exceptional risks. The idea is to identify dependent people who may need assistance at the local level, for prevention purposes.

Second, the government installed an extra unpaid working day with an aim to convert all the tax proceeds from it into a new fund called "National solidarity fund for autonomy" (CNSA).

Third, the CNSA is designed as a public institution which would oversee the co-ordination and financing of services for elderly people who lost autonomy and for the handicapped persons. The institution has three missions:

1.  financing "support services" for dependent elderly and handicapped;
2.  ensuring the equal treatment for all people with problems of autonomy on the French territory;
3.  providing information and analysis concerning the service needs of dependent people.

The CNSA is a public institution controlled directly by the state authorities and the Parliament. It is composed of 48 members bringing together different actors working in the area of dependence: the associations representing the handicapped and the dependent elderly, bodies representing health professionals, public administration and the Parliament. 

The extra day of work is meant to collect two billion Euros, with 800 millions going for retirement places, 800 millions for the handicapped and 400 millions destined to support the elderly in their own residences. Another 385 millions Euro are earmarked for 'future years' - possibly for new constructions for the dependent people.

Type of incentives

Two types of financial assistance is foreseen:

• Direct financial aids for individuals with autonomy problems (elderly and handicapped people);
• Financial supports for the institutions providing nursing care to improve their facilities.

Groups affected

Dependent elderly and handicapped people, All the salaried employees

Degree of Innovation	traditional		innovative
Degree of Controversy	consensual		highly controversial
Structural or Systemic Impact	marginal		fundamental
Public Visibility	very low		very high
Transferability	strongly system-dependent		system-neutral

Good initiative, but too early to judge how will it work.

Political and economic background

The population ageing with the increasing number of dependent elderly and the growing health expenditure linked to ageing are major preoccupations for health policy in France like elsewhere. However, until now there was very little information on the magnitude of the current and future needs of the dependent elderly population or people with problems of autonomy in general.  

The high death toll after the heat wave of the summer 2003, created a collective sense of guilt and a general awareness of the problem of the old people and handicapped persons who need support services for surviving. The government and health officials are severely criticised and accused to be slow in reacting and providing the required actions.

Under the pressure, the government launched in November 2003, its plan for "Ageing and solidarity".

Purpose and process analysis

Current Process Stages

	Idea	Pilot	Policy Paper	Legislation	Implementation	Evaluation	Change
Implemented in this survey?

Origins of health policy idea

The action plan launched by the government in November 2003, "solidarity and fraternity with dependent people" had two major programs:

the first concerned the old people and aimed to facilitate the maintenance of elderly in their own residence, as well as to reinforce the provision of care in institutions (improve the health care supply in nursing homes, creation of new places in heath units);

the second concerned the handicapped people and announced the preparation of a parliament bill to offer a financial compensation for the handicapped.

At that point nobody had an idea how all of these programs will be financed.

The law of June 2004, defined the rules for financing this plan, by installing an extra day of work "for solidarity".

The law of February 2005 defined the role, the missions and the modes of financing of the CNSA and installs the right for compensation of the handicap.

In June 2005, the responsibility for the payment of benefits for the dependent elderly and handicapped people is transferred to the CNSA.

Initiators of idea/main actors

• Government

Approach of idea

The approach of the idea is described as:
new:

Stakeholder positions

There is a general consensus on the need to improve the provision of support/nursing services for dependent elderly and the handicapped. Given the difficulties of defining and separating who is dependent and who is handicapped, it seems justified to have a unique institution which supervise the planning and financing of services for all the people with autonomy problems.  

However, the local authorities are worried about the level of funding they will receive compared with ambitions of the initial plan. If new nursing homes are created at the department level, they might have to contribute from their own budget to their financing.

Moreover, the way the reforms are financed created a lot of controversy: asking only one part of the population "salaried" to subsidy the CNSA while this was probably the group who contributed the most. Initially the public holiday of Pentecote turned into a working day. This has created a lot reactions from all worker trade unions but also from the clergy. There were manifestations in the streets about the first "solidarity day" worked. Government reacted to these by negotiating with various unions the form of "extra time" worked. Now, there seem to be an agreement on a more flexible arrangement where employees can decide which day they will implement the "extra-working". 

Actors and positions

Government
Social security fund	very supportive		strongly opposed
Regional health authorities	very supportive		strongly opposed
Trade unions	very supportive		strongly opposed

Influences in policy making and legislation

See 5.1

Actors and influence

Government
Social security fund	very strong		none
Regional health authorities	very strong		none
Trade unions	very strong		none

Positions and Influences at a glance

Adoption and implementation

Regional authorities will be the major actors in assessing the needs of elderly and the handicapped and developing plans for service provision. They need more financial and logistic support to carry out all the tasks and the investments required.

Monitoring and evaluation

Too early to evaluate. But no mechanism is foreseen to evaluate the impact and efficiency of the measures taken. May be the next heat wave will be the judge.

Expected outcome

A priori, this plan should improve the services provided to the elderly people with autonomy problems and the handicapped, as it proposes a sector wide approach focusing on the needs of dependent people on the whole, instead of fragmented services for different groups in need.

Also, the point is made about regional disparities in the provision of care for the dependent people. Until now there was no real planning for the service needs of handicapped.

Impact of this policy

Quality of Health Care Services	marginal		fundamental
Level of Equity	system less equitable		system more equitable
Cost Efficiency	very low		very high

References

Sources of Information

www.plan.gouv.fr/actualites/fiche.php?id=213

www.reseau-ideal.asso.fr/images/sros.pdf  

www.annuaire-secu.com/html/news139.html  

Author/s and/or contributors to this survey

Thierry Debrand, Zeynep Or

Suggested citation for this online article

Thierry Debrand, Zeynep Or. "Solidarity fund for financing dependency". Health Policy Monitor, October 2005. Available at http://www.hpm.org/survey/fr/a6/5