France: Health System Summary, 2024

This Health system summary is based on the France Health System Review published in 2023 in the Health Systems in Transition (HiT) series. Health system summaries use a concise format to communicate central features of country health systems and analyse available evidence on the organization, financing and delivery of health care. They also provide insights into key reforms and the varied challenges testing the performance of the health system.

Challenges facing mental health systems arising from the COVID-19 pandemic: Evidence from 14 European and North American countries.

We assessed challenges that the COVID-19 pandemic presented for mental health systems and the responses to these challenges in 14 countries in Europe and North America. Experts from each country filled out a structured questionnaire with closed- and open-ended questions between January and June 2021. We conducted thematic analysis to investigate the qualitative responses to open-ended questions, and we summarized the responses to closed-ended survey items on changes in telemental health policies and regulations. Findings revealed that many countries grappled with the rising demand for mental health services against a backdrop of mental health provider shortages and challenges responding to workforce stress and burnout. All countries in our sample implemented new policies or initiatives to strengthen mental health service delivery - with more than two-thirds investing to bolster their specialized mental health care sector. There was a universal shift to telehealth to deliver a larger portion of mental health services in all 14 countries, which was facilitated by changes in national regulations and policies; 11 of the 14 participating countries relaxed regulations and 10 of 14 countries made changes to reimbursement policies to facilitate telemental health care. These findings provide a first step to assess the long-term challenges and re-organizational effect of the COVID-19 pandemic on mental health systems in Europe and North America.

France: Health System Review.

This review of the French health system analyses recent developments in health organisation and governance, financing, healthcare provision, recent reforms and health system performance. Overall health status continues to improve in France, although geographic and socioeconomic inequalities in life expectancy persist. The health system combines a social health insurance (SHI) model with an important role for tax-based revenues to finance healthcare. The health system provides universal coverage, with a broad benefits basket, but cost-sharing is required for all essential services. Private complementary insurance to cover these costs results in very low average out-of-pocket (OOP) payments, although there are concerns regarding solidarity, financial redistribution and efficiency in the health system. The macroeconomic context in the last couple of years in the country has been affected by the Covid-19 pandemic, which resulted in subsequent increases of total health expenditure in France in 2020 (3.7%) and 2021 (9.8%). Healthcare provision continues to be highly fragmented in France, with a segmented approach to care organization and funding across primary, secondary and long-term care. Recent reforms aim to strengthen primary care by encouraging multidisciplinary group practices, while public health efforts over the last decade have focused on boosting prevention strategies and tackling lifestyle risk factors, such as smoking and obesity with limited success. Continued challenges include ensuring the sustainability of the health workforce, particularly to secure adequate numbers of health professionals in medically underserved areas, such as rural and less affluent communities, and improving working conditions, remuneration and career prospects, especially for nurses, to support retention. The Covid-19 pandemic has brought to light some structural weaknesses within the French health system, but it has also provided opportunities for improving its sustainability. There has been a notable shift in the will to give more room to decision-making at the local level, involving healthcare professionals, and to find new ways of funding healthcare providers to encourage care coordination and integration.

France: health system review

This review of the French health system analyses recent developments in health organization and governance, financing, healthcare provision, recent reforms and health system performance.Overall health status continues to improve in France, although geographic and socioeconomic inequalities in life expectancy persist. The health system combines a social health insurance model with an important role fortax-based revenues to finance healthcare. The health system provides universal coverage, with a broad benefits basket, but cost-sharing is required for all essential services. Private complementary insurance to cover these costs results in very low average out-of-pocket payments, although there are concerns regarding solidarity, financial redistribution and efficiency in the health system. The macroeconomic context in the last couple of years in the country has been affected by the COVID-19 pandemic, which resulted in subsequent increases of total health expenditure in France in 2020 (3.7%) and 2021 (9.8%).Healthcare provision continues to be highly fragmented in France, with a segmented approach to care organization and funding across primary, secondary and long-term care. Recent reforms aim to strengthen primarycare by encouraging multidisciplinary group practices, while public health efforts over the last decade have focused on boosting prevention strategies and tackling lifestyle risk factors, such as smoking and obesity with limited success. Continued challenges include ensuring the sustainability of the health workforce, particularly to secure adequate numbers of health professionals in medically underserved areas, such as rural and less affluent communities, and improving working conditions, remuneration and career prospects, especially for nurses, to support retention. The COVID-19 pandemic has brought to light some structural weaknesses within the French health system, but it has also provided opportunities for improving its sustainability. There has been a notable shift in the will to give more room to decision-making at the local level, involving healthcare professionals, and to find new ways of funding healthcare providers to encourage care coordination and integration.

Defining the Characteristics of an e-Health Tool for Suicide Primary Prevention in the General Population: The StopBlues Case in France.

With over one million deaths per year in the world, suicide is a major public health problem that could be significantly reduced by effective prevention programs. E-health tools are of particular interest for primary prevention as they can address a broad population including people unaware of their own risk and provide information and help without the fear of stigma. Our main objective was to define the overall characteristics of an e-health tool for suicide primary prevention in the French general population by defining the characteristics of the IT features; the content of the information delivered; the best way to structure it; and how it should be relayed and by whom. The research was carried out through a literature review and a co-construction phase with stakeholders. Four types of strategies may guide the construction of e-health tools for suicide primary prevention: education and awareness, (self-)screening, accessing support, and mental health coping. They should be accessible on different devices to reach the most users, and language and content should be adapted to the target population and to the issue being addressed. Finally, the tool should be consistent with ethical and quality best practices. The e-health tool StopBlues was developed following those recommendations.

Breast Cancer Care Pathways for Women with Preexisting Severe Mental Disorders: Evidence of Disparities in France?

The excess cancer mortality in persons with severe mental illness (SMI) has been well documented, and research suggests that it may be influenced by care-related factors. Our objective was to assess breast cancer care pathways in women with SMI in France, using an exhaustive population-based data-linkage study with a matched case-control design. The cases were 1346 women with incident breast cancer in 2013/2014 and preexisting SMI who were matched with three controls without SMI presenting similar demographics, initial breast cancer type, and year of incidence. We compared cancer care pathways and their quality for cases and controls, using a consensual set of indicators covering diagnosis, treatment, follow-up, and mortality (until 2017). After adjusting for covariates, cases had lower odds to undergo the main diagnostic tests, lumpectomy, adjuvant chemotherapy, and radiotherapy, as well as hormone therapy, but higher odds for mastectomy. Suboptimal quality in cancer pathways was observed for both groups, but to a higher extent for cases, especially for not receiving timely care after diagnosis and post-treatment follow-up. Breast cancer mortality, considering competing risks of deaths, was significantly elevated in women with SMI. These findings highlight disparities in cancer care pathways for individuals with SMI, as well as specific aspects of the care continuum which could benefit from targeted actions to reach equity of outcomes.

Excess mortality of people living with a mental disorder: lessons from literature and perspectives / Surmortalité des personnes vivant avec un trouble psychique : enseignements de la littérature et perspectives

AIM: Considering the persistent excess mortality of people living with a mental disorder, this article provides an overview of potential causes to identify relevant research perspectives and to support the development of short-term measures in the French context. METHODS: We rely on a narrative review of the literature, both quantitative and qualitative, to define a conceptual framework of the different factors which could contribute to this excess mortality. Particular attention is given to research carried out in France to identify possible measures to implement in line with the specificities of the national context. RESULTS: The excess mortality of people living with a mental disorder represents a health inequality resulting from a combination of factors, which are not only linked to individual behaviors and living conditions detrimental to health but also to the health system – both in terms of its organization and of the health professionals involved. Questions relating to the extent of the role played by the different factors and to the way they interact (specific social processes, combination of inequalities or a particular convergence at the crossing of all these factors…) remain. CONCLUSION: These findings support the development of complementary research, relying on mixed methodologies, as well as of measures promoting access to somatic care for people living with a mental disorder throughout their care pathways (stronger development of prevention and patient education, better integration of somatic and psychiatric care teams, alternative modes of funding supporting a holistic approach to health…).

Objectif: Face au constat d'une surmortalité persistante des personnes vivant avec un trouble psychique, cet article dresse un état des lieux de ses causes potentielles afin d'identifier des perspectives de recherche et d'étayer la mise en place d'actions à court terme dans le contexte français. Méthodes: Nous nous appuyons sur une revue narrative de la littérature, quantitative et qualitative, mobilisée pour proposer un cadre conceptuel des différents facteurs pouvant jouer un rôle dans cette surmortalité. Une attention particulière est portée aux recherches françaises afin d'identifier des pistes d'actions adaptées aux spécificités de ce contexte national. Résultats: La surmortalité des personnes vivant avec un trouble psychique constitue une inégalité de santé résultant d'une combinaison de facteurs qui ne sont pas uniquement liés à des comportements individuels et des conditions de vie défavorables à la santé, mais également au système de santé ­ tant du point de vue de son organisation que des professionnels y intervenant. Des interrogations, relatives à l'ampleur du rôle joué par les différents facteurs et à la façon dont ils interagissent (traitement social spécifique, cumul d'inégalités ou conjonction singulière au croisement de ces facteurs…), demeurent. Conclusions: Ces résultats appellent la mise en œuvre de recherches complémentaires, mobilisant des schémas d'études mixtes, ainsi que de mesures favorisant l'accès aux soins somatiques des personnes vivant avec un trouble psychique, tout au long des parcours de soins (prévention, éducation thérapeutique, meilleure intégration des services somatiques et psychiatriques, modes de financement des soins encourageant une prise en charge globale de la santé…).

Exploring variation of coverage and access to dental care for adults in 11 European countries: a vignette approach.

BACKGROUND: Oral health, coupled with rising awareness on the impact that limited dental care coverage has on oral health and general health and well-being, has received increased attention over the past few years. The purpose of the study was to compare the statutory coverage and access to dental care for adult services in 11 European countries using a vignette approach. METHODS: We used three patient vignettes to highlight the differences of the dimensions of coverage and access to dental care (coverage, cost-sharing and accessibility). The three vignettes describe typical care pathways for patients with the most common oral health conditions (caries, periodontal disease, edentulism). The vignettes were completed by health services researchers knowledgeable on dental care, dentists, or teams consisting of a health systems expert working together with dental specialists. RESULTS: Completed vignettes were received from 11 countries: Bulgaria, Estonia, France, Germany, Republic of Ireland (Ireland), Lithuania, the Netherlands, Poland, Portugal, Slovakia and Sweden. While emergency dental care, tooth extraction and restorative care for acute pain due to carious lesions are covered in most responding countries, root canal treatment, periodontal care and prosthetic restoration often require cost-sharing or are entirely excluded from the benefit basket. Regular dental visits are also limited to one visit per year in many countries. Beyond financial barriers due to out-of-pocket payments, patients may experience very different physical barriers to accessing dental care. The limited availability of contracted dentists (especially in rural areas) and the unequal distribution and lack of specialised dentists are major access barriers to public dental care. CONCLUSIONS: According to the results, statutory coverage of dental care varies across European countries, while access barriers are largely similar. Many dental services require substantial cost-sharing in most countries, leading to high out-of-pocket spending. Socioeconomic status is thus a main determinant for access to dental care, but other factors such as geography, age and comorbidities can also inhibit access and affect outcomes. Moreover, coverage in most oral health systems is targeted at treatment and less at preventative oral health care.

France's response to the Covid-19 pandemic: between a rock and a hard place.

France is one of the European countries hardest hit by the Covid-19 pandemic. The pandemic brought into light structural weaknesses of the health system, including its governance and decision-making process, but also provoked changes that helped to improve its resilience. We analyse the French experience of Covid-19 in 2020 by critically reviewing major policy measures implemented during the first two waves of the pandemic. France has struggled to find the right balance between the rock of economic and social damage caused by containment measures and the hard alternative of a rapidly spreading pandemic. The response to the first wave, including a full lock-down, was an emergency response that revealed the low level of preparedness for pandemics and the overly hospital-centred provision of health care in France. During the second wave, this response evolved into a more level strategy trying to reconcile health needs in a broader perspective integrating socio-economic considerations, but without fully managing to put in place an effective health strategy. We conclude that to achieve the right balance, France will have to strengthen health system capacity and improve the cooperation between actors at central and local levels with greater participatory decision-making that takes into account local-level realities and the diversity of needs.

Tackling the COVID-19 pandemic: Initial responses in 2020 in selected social health insurance countries in Europe☆.

Countries with social health insurance (SHI) systems display some common defining characteristics - pluralism of actors and strong medical associations - that, in dealing with crisis times, may allow for common learnings. This paper analyses health system responses during the COVID-19 pandemic in eight countries representative of SHI systems in Europe (Austria, Belgium, France, Germany, Luxembourg, the Netherlands, Slovenia and Switzerland). Data collection and analysis builds on the methodology and content in the COVID-19 Health System Response Monitor (HSRM) up to November 2020. We find that SHI funds were, in general, neither foreseen as major stakeholders in crisis management, nor were they represented in crisis management teams. Further, responsibilities in some countries shifted from SHI funds to federal governments. The overall organisation and governance of SHI systems shaped how countries responded to the challenges of the pandemic. For instance, coordinated ambulatory care often helped avoid overburdening hospitals. Decentralisation among local authorities may however represent challenges with the coordination of policies, i.e. coordination costs. At the same time, bottom-up self-organisation of ambulatory care providers is supported by decentralised structures. Providers also increasingly used teleconsultations, which may remain part of standard practice. It is recommended to involve SHI funds actively in crisis management and in preparing for future crisis to increase health system resilience.

Balancing financial incentives during COVID-19: A comparison of provider payment adjustments across 20 countries.

Provider payment mechanisms were adjusted in many countries in response to the COVID-19 pandemic in 2020. Our objective was to review adjustments for hospitals and healthcare professionals across 20 countries. We developed an analytical framework distinguishing between payment adjustments compensating income loss and those covering extra costs related to COVID-19. Information was extracted from the Covid-19 Health System Response Monitor (HSRM) and classified according to the framework. We found that income loss was not a problem in countries where professionals were paid by salary or capitation and hospitals received global budgets. In countries where payment was based on activity, income loss was compensated through budgets and higher fees. New FFS payments were introduced to incentivize remote services. Payments for COVID-19 related costs included new fees for out- and inpatient services but also new PD and DRG tariffs for hospitals. Budgets covered the costs of adjusting wards, creating new (ICU) beds, and hiring staff. We conclude that public payers assumed most of the COVID-19-related financial risk. In view of future pandemics policymakers should work to increase resilience of payment systems by: (1) having systems in place to rapidly adjust payment systems; (2) being aware of the economic incentives created by these adjustments such as cost-containment or increasing the number of patients or services, that can result in unintended consequences such as risk selection or overprovision of care; and (3) periodically evaluating the effects of payment adjustments on access and quality of care.

Use of electroconvulsive therapy for individuals receiving inpatient psychiatric care on a nationwide scale in France: Variations linked to health care supply.

BACKGROUND: A comprehensive understanding of variations in the use of electroconvulsive therapy (ECT) among health care providers in charge of ECT referrals is lacking. OBJECTIVE: Our objectives were to document ECT use and its variations on a nationwide scale in France and to identify the factors that were significantly associated with these variations. METHODS: Administrative health claims data on hospitalization were used to perform a descriptive analysis of ECT use for adult patients receiving inpatient psychiatric care in mainland France in 2019 and its variations across hospitals in charge of ECT referrals. Based on a conceptual framework drawn from the literature on medical practice variations, a multilevel logistic regression was then conducted to identify patients, hospitals and contextual characteristics that were significantly associated with ECT treatment using non-ECT-treated patients receiving inpatient psychiatric care as the reference population. RESULTS: Patients receiving ECT (n = 3288) were older, more frequently female and had more severe diagnoses than other patients seen in inpatient care (n = 295,678). Significant variations were observed in the rate of ECT use across hospitals (n = 468), with a coefficient of variation largely above one. In the multivariable analysis, ECT treatment was associated with patient characteristics (which accounted for 6% of the variations) but also with characteristics of the hospitals and their environments (44% of the variations), including the type of hospital and its distance to the closest facility providing ECT. CONCLUSIONS: Variations in ECT use were strongly linked to health care supply characteristics, which raises questions about access to quality mental health care.

Achieving higher performing primary care through patient registration: A review of twelve high-income countries.

BACKGROUND: Patient registration with a primary care providers supports continuity in the patient-provider relationship. This paper develops a framework for analysing the characteristics of patient registration across countries; applies this framework to a selection of countries; and identifies challenges and ongoing reform efforts. METHODS: 12 jurisdictions (Denmark, France, Germany, Ireland, Israel, Italy, Netherlands, Norway, Ontario [Canada], Sweden, Switzerland, United Kingdom) were selected for analysis. Information was collected by national researchers who reviewed relevant literature and policy documents to report on the establishment and evolution of patient registration, the requirements and benefits for patients, providers and payers, and its connection to primary care reforms. RESULTS: Patient registration emerged as part of major macro-level health reforms linked to the introduction of universal health coverage. Recent reforms introduced registration with the aim of improving quality through better coordination and efficiency through reductions in unnecessary referrals. Patient registration is mandatory only in three countries. Several countries achieve high levels of registration by using strong incentives for patients and physicians (capitation payments). CONCLUSION: Patient registration means different things in different countries and policy-makers and researchers need to take into consideration: the history and characteristics of the registration system; the use of incentives for patients and providers; and the potential for more explicit use of patient-provider agreements as a policy to achieve more timely, appropriate, continuous and integrated care.

Impact of Ed-LinQ: A Public Policy Strategy to Facilitate Engagement between Schools and the Mental Health Care System in Queensland, Australia.

Ed-LinQ is a mental health policy initiative to enhance the early detection and treatment of children with mental illness by improving the liaison between schools and health services in Queensland, Australia. We measured its impact from policy to practice to inform further program developments and public strategies. We followed a mixed quantitative/qualitative approach. The Adoption Impact Ladder (AIL) was used to analyse the adoption of this initiative by end-users (decision makers both in the health and education sectors) and the penetration of the initiative in the school sector. Survey respondents included representatives of schools (n = 186) and mental health providers (n = 78). In total, 63% of the school representative respondents were at least aware of the existence of the Ed-LinQ initiative, 74% were satisfied with the initiative and 28% of the respondent schools adopted the initiative to a significant extent. Adoption was higher in urban districts and in the health sector. The overall level of penetration in the school sector of Queensland was low (3%). The qualitative analysis indicated an improvement in the referral and communication processes between schools and the health sectors and the importance of funding in the implementation of the initiative. Mapping of existing programs is needed to assess the implementation of a new one as well as the design of different implementation strategies for urban and rural areas. Assessing the adoption of health policy strategies and their penetration in a target audience is critical to understand their proportional impacts across a defined ecosystem and constitutes a necessary preliminary step for the evaluation of their quality and efficiency.

The PRINTEMPS study: protocol of a cluster-randomized controlled trial of the local promotion of a smartphone application and associated website for the prevention of suicidal behaviors in the adult general population in France.

BACKGROUND: Suicide constitutes a cause of death which could be prevented by e-health programs accessible to the general population. Effective promotion has the potential to maximize the uptake of such programs. However, few e-health programs have been combined with promotion campaigns. The primary objective of this trial is to assess the effectiveness of a tailored promotion, at a local level, of a mobile application and website offering evidence-based content for suicide prevention (the StopBlues program), and to compare the effectiveness of two types of local promotion in terms of their impact on suicidal acts. Secondary objectives focus on the effectiveness of the promotion in terms of the intensity of utilization of the StopBlues program, help-seeking behaviors and the level of psychological impairment of program users. METHODS/DESIGN: This is a three-arm, parallel-group, cluster-randomized controlled trial, with before-and-after observation. Thirty-four clusters, corresponding to geographical areas sharing a common local authority in France, will be included. They will be randomly assigned to one of the following arms with a ratio of 1:1:1: a control group; a basic promotion group in which promotion of the StopBlues program will be done by local authorities; and an intensified promotion group in which basic promotion will be supplemented by an additional one in a general practitioner's waiting room. The primary outcome measure will be the number of suicidal acts within each cluster over a 12-month period following the launch of the intervention. Baseline data will be collected for each cluster over the 12-month period prior to the trial. Secondary outcomes will include length of use of the StopBlues program, measures of help-seeking behaviors and level of psychological distress among users of the program, as well as the cost-effectiveness and budgetary impact of its promotion. A more sustained promotion by local authorities will also be implemented after 12 months in the control group and assessed using the same outcome measures. DISCUSSION: This research should contribute to the sparse evidence base regarding the promotion of e-health programs and will support the wider delivery of the intervention evaluated if proven effective. TRIAL REGISTRATION: ClinicalTrials.gov, ID: NCT03565562. Registered on 11 June 2018.

Care coordination for severe mental health disorders: an analysis of healthcare provider patient-sharing networks and their association with quality of care in a French region.

BACKGROUND: For patients with multiple and complex health needs, such as those suffering from mental health disorders, outcomes are determined by the combined actions of the care providers they visit and their interactions. Care coordination is therefore essential. However, little is known on links between hospitals providing psychiatric care and community-based care providers which could serve as a basis for the creation of formal mental care networks supported by recent policies. In this context, we first aimed to identify and characterize existing types of healthcare provider patient-sharing networks for severe mental health disorders in one French region. Second, we aimed to analyse the association between their characteristics and the quality of the care they provide. METHODS: Patient flows among healthcare providers involved in treating severe mental health disorders in the Provence-Alpes-Côte-d'Azur region were extracted from the French national health data system, which contains all billing records from the social health insurance. Healthcare provider networks that have developed around public and private non-profit hospitals were identified based on shared patients with other providers (hospitals, community-based psychiatrists, general practitioners and nurses). Hierarchical clustering was conducted to create a typology of the networks. Indicators of quality of care, encompassing multiple complementary dimensions, were calculated across these networks and linked to their characteristics using multivariable methods. RESULTS: Three main types of existing healthcare provider networks were identified. They were either networks strongly organized around the main hospital providing psychiatric care; scattered networks involving numerous and diverse healthcare providers; or medically-oriented networks involving mainly physician providers. Few significant associations between the structure and composition of healthcare provider networks and indicators of quality of care were found. CONCLUSIONS: Our findings provide a basis to develop explicit structuring of mental care based on pre-existing working relationships but suggest that healthcare providers' patient-sharing patterns were not the main driver of optimal care provision in the context explored. The shift towards a stronger integration of health and social care in the mental health field might impact these results but is currently not observable in the administrative data available for research purpose which should evolve to include social care.

Disparities in the Use of General Somatic Care among Individuals Treated for Severe Mental Disorders and the General Population in France.

Individuals with severe mental illnesses (SMI) face a striking excess and premature mortality which has been demonstrated in several national contexts. This phenomenon, which constitutes a red-flag indicator of public health inequities, can be hypothesized to result from healthcare access issues which have been insufficiently documented so far. In this context, our objective was to explore patterns of general somatic healthcare use of individuals treated for SMI in comparison to those of the general population in France using national health administrative data and a matched case-control study. Differences in the use of general and specific somatic preventive care services, primary care, routine specialized somatic care and admissions to non-psychiatric hospital departments for somatic causes were described between cases and controls after adjustment on differing clinical needs, socio-economic status, and living environment. Our results show a lower use of general preventive care services and of routine specialized somatic care in the SMI population, despite more frequent comorbidities, and a higher occurrence of avoidable hospitalizations, despite higher contacts with primary care physicians. These findings suggest that the health system fails to address the specific needs of this vulnerable population and support the development of measures aimed at reducing this gap.

Experimenting locally with a stepped-care approach for the treatment of mild to moderate mental disorders in France: Challenges and opportunities.

In France, publicly funded mental care services are mostly hospital-based and focused on treating severe illnesses. Mild to moderate mental disorders are typically managed by general practitioners (GP) who often lack specific training to treat these conditions. Antidepressant prescribing levels for mild to moderate conditions are inadequately high. Public reimbursement for psychotherapies provided by psychologists is generally not available. This paper presents a local experiment with a stepped-care approach for the treatment of mild to moderate mental disorders in four French départements launched in 2018. The experiment includes the introduction of a standardized assessment protocol for GPs, clear referral guidelines, and full reimbursement of visits to psychologists upon GP referral. Seemingly simple, the policy raises several issues related to the regulation, training and reimbursement of psychologists, and illustrates the need for careful preparation and workforce planning to ensure success and stakeholder support. An independent evaluation of the local experiments is planned, which provides the opportunity to fine-tune the policy before any broader rollout. The issues raised in France and the on-going debate is relevant for other countries preparing similar policies for improving mental care.

Healthcare ecosystems research in mental health: a scoping review of methods to describe the context of local care delivery.

BACKGROUND: Evidence from the context of local health ecosystems is highly relevant for research and policymaking to understand geographical variations in outcomes of health care delivery. In mental health systems, the analysis of context presents particular challenges related to their complexity and to methodological difficulties. Method guidelines and standard recommendations for conducting context analysis of local mental health care are urgently needed. This scoping study reviews current methods of context analysis in mental health systems to establish the parameters of research activity examining availability and capacity of care at the local level, and to identify any gaps in the literature. METHODS: A scoping review based on a systematic search of key databases was conducted for the period 2005-2016. A systems dynamics/complexity approach was adopted, using a modified version of Tansella and Thornicroft's matrix model of mental health care as the conceptual framework for our analysis. RESULTS: The lack of a specific terminology in the area meant that from 10,911 titles identified at the initial search, only 46 papers met inclusion criteria. Of these, 21 had serious methodological limitations. Fifteen papers did not use any kind of formal framework, and five of those did not describe their method. Units of analysis varied widely and across different levels of the system. Six instruments to describe service availability and capacity were identified, of which three had been psychometrically validated. A limitation was the exclusion of grey literature from the review. However, the imprecise nature of the terminology, and high number of initial results, makes the inclusion of grey literature not feasible. CONCLUSION: We identified that, in spite of its relevance, context studies in mental health services is a very limited research area. Few validated instruments are available. Methodological limitations in many papers mean that the particular challenges of mental health systems research such as system complexity, data availability and terminological variability are generally poorly addressed, presenting a barrier to valid system comparison. The modified Thornicroft and Tansella matrix and related ecological production of care model provide the main model for research within the area of health care ecosystems.

Gender and access to professorships in academic medical settings in France.

CONTEXT: Previous studies, mainly originating from North America, suggest that women are less likely than men to obtain professorships in academic medical settings. However, research providing a comprehensive picture of such gender disparities in other national contexts and addressing associated contextual factors is lacking. OBJECTIVES: Our objectives were to assess gender differences in access to professorships in academic medical settings in France, to determine their evolution across regions and medical specialties and over time, and to identify the factors associated with the likelihood of a professor being a woman. METHODS: We carried out a national administrative cohort study of all new professors appointed during 1989-2015 in all medical specialties in the whole of France. We first conducted a descriptive analysis of the percentage of professorships awarded to women and its variations by time, region and specialty. We then ran a logistic regression model to determine factors significantly associated with the likelihood of a professor being a woman. RESULTS: Between 1989 and 2015, 3950 professors were appointed, of whom fewer than one in five were women. Female professors consistently represented a minority in all French regions and specialties over the study period. Although a small increase was observed over the years, women never represented more than 29% of newly appointed professors. After adjustments for other factors, the likelihood of a professor being a woman was significantly higher in specialties with a higher percentage of women among hospital practitioners, in regions with higher numbers of appointed professors and in recent years. CONCLUSIONS: Gender inequalities in career evolution exist in academic medical settings in France and have continued over time despite moderate improvements. Increased awareness based on scientific evidence is a first step towards reducing such inequalities.