although healthcare is not only medical - care , the part played by medical services is an essential determinant of overall health of a population .
all public systems look for an organizational structure on how to channel 710% of the national income into healthcare services .
however , most healthcare systems fall under one of two broad categories ( table 1 ) . despite the expansion of medical knowledge and the use of increasingly sophisticated technology and training , healthcare systems in most countries of the world
are considered to be in crisis as most of them are underperforming systems [ 24 ] . 
 
broad categories of current healthcare systems in spite of the apparent public health well - being in libya , the libyan health system is a low responsive , inefficient and underperforming system which lacks goals and/or smart ( specific , measurable , achievable , realistic , time specific ) objectives .
many of the improvements that occurred in the last few decades were due to public actions from outside the health sector rather than clear vision from within the healthcare system .
these public measures include education particularly of females , food subsidy policies , and increasing purchasing power .
lessons from better performing healthcare systems around the world are needed in our efforts to reorganize and improve our healthcare services . in
a who report evaluating healthcare systems of different nations ( 2000 ) , the french health care system ( fhcs ) ranked first among 191 member countries surveyed .
france was described as having a technically efficient and generous healthcare system that provides the best overall health care .
aspects examined in this evaluation included universal coverage , equity , distribution of costs , responsiveness of healthcare providers , patient satisfaction , patient and provider freedoms , and the health and longevity of the population . according to the same report ,
the best health system in the near and middle - east region was oman ( 8 position ) , while saudi arabia , united arab emirates , and morocco were in the 26 , 27 and 29 positions respectively .
another credit to the fhcs came from the european health consumer powerhouse . in their 2006 report
, the fhcs ranked first among the eu member states according to the euro health consumer index ( ehci ) .
these include aspects as patient rights , information , waiting times for treatment , outcomes , generosity and pharmaceuticals . in different ehci reports ,
top performing countries are those which have a long tradition of plurality in healthcare financing and provisions , i.e. with a consumer choice between different insurance providers , who in turn do not discriminate between providers who are private for - profit , non - profit or public . these countries have adopted a bismarckian healthcare system . there is relatively a large gap of points of these countries to the first beveridge country , which is in sixth place .
although france performed relatively less well ( third and fifth position ) in later reports , very subtle changes in single scores modify the internal order of the five top countries .
canada , libya and most of the healthcare systems in our part of the world follow the british system which has been a notoriously mediocre performer since the start of the ehci .
libya ranked 87th in the who report , canada places 23rd out of 30 in the latest edition of the ehci .
canada spends more money to achieve worse results than any other country in the lowest quartile of the ehci .
these achievements make the fhcs an interesting case and a practical model on how to organize many of the essential aspects of modern national health services that we have discussed in our previous works [ 5 , 8 ] .
it plays a direct role in the funding and provision of health care and regulates the relations between funding institutions , health professionals and patients ( table 2 ) .
responsibility of the state in the french national health system the population in france is considered to be in good health .
they consult their doctors more often , are admitted to hospital more often , and purchase more prescription drugs .
the french had structured their system to be an ideal synthesis of solidarity and liberalism .
although the state imposes strong price control policies on the entire health sector , there is no public perception in france that health services are  rationed  to patients .
the system lies between britain 's  nationalized  health service , where there is too much rationing , and the united states  competitive 
the fhcs is planned and organized in relation to the needs and expectations of the population .
it has a strong commitment to a universal , obligatory , and solidarity method of health care delivery .
there are many protective mechanisms built in so that cost sharing does not prevent people from receiving necessary care .
it ensures equitable geographical coverage and an efficient interaction between the different players , i.e. hospitals ( public and private ) , private practitioners , medical auxiliaries , the pharmaceutical industry , etc .
there are no waiting lists for elective procedures and patients need not seek pre - authorizations . in line with the principle of social  solidarity 
both citizens and non - citizen residents contribute according to their means and obtain services according to their needs . each person with social insurance benefits from a protection that he finances according to his resources against the risk and consequences of illness independently of his age or state of health .
in some instances , the statutory health insurance system provides 100% coverage , as in the case of perinatal care and costs related to industrial injury and long - term illnesses , where social security pays the whole cost of life - long essential medications as insulin .
some pharmacists use digital information systems to deduct sums reimbursed by social security . in the same manner , many are also linked to certain complementary insurance schemes . to insure equity ,
patients are exempt from payment when ( 1 ) expenditures exceed approximately $ 100 , ( 2 ) hospital stays exceed 30 days , ( 3 ) patients suffer from serious , debilitating , or chronic illness , or ( 4 ) if income falls below a certain threshold , thereby qualifying them for free supplementary coverage or a complementary state - funded healthcare .
the fhcs provides a high level of resources and a higher volume of service provided which covers prescriptions of homeopathic products , thermal cures , nursing home care , cash benefits , and to a lesser extent , dental and vision care . to assure access to health services , the national health insurance ( nhi ) in the fhcs covers fees for transport of patients to health care facilities .
they cover private taxis for alternative interventions such as physiotherapy . for certain medical treatments such as non - routine dental care , contact lenses , non - standard lenses for glasses , certain laboratory and radiology tests , physiotherapy and speech therapy , and thermal and therapeutic treatments , one must obtain proper approval from social security .
the card contains their social security number and covers all members of their family . through these cards ,
people are linked to a computerized system containing all medical records and vital information such as the card - holder 's blood type and allergies .
the fhcs is based on a single nhi fund , which is part of france 's extensive social security system .
initially modeled after the german sickness fund fostered by chancellor bismarck , the fhcs had evolved into a blend of bismarck and beveridge , public and private , centralization and decentralization [ 10 , 11 ] .
in contrast to germany where numerous sickness funds are regional or tied to professions , all residents in france are automatically enrolled with an insurance fund based on their occupational status .
in addition , all residents can also subscribe to supplementary health insurance to cover other benefits not covered by nhi .
health insurance is funded by contributions based on professional earnings ( 51.1% ) and a tax levied on all income ( including investment income ) known as the general social contribution ( 34.6% ) . for professional earnings ,
remaining sources include special taxes on automobiles , tobacco , alcohol , and a specific tax on the pharmaceutical industry . for several years health expenditure
france 's health expenditure in 2006 was 120.2 milliard euros , while the deficit was 6 milliard euros .
official figures published in july , 2006 , put french health care expenditure at 11.14% of gdp .
this is third worldwide after usa and switzerland ( uk < 8% , canada < 10% , germany < 11% , and us 14.6% ) .
this figure represents a per capita health expenditure of  3,038 . health expenditure in 2008
the health budget in libya during the year 2000 was 500 million libyan dinars ( ld ) .
this represented a per capita health expenditure of 121 ld , among which 45 ld were for medical supplies and drugs .
the payment system is dominated by solo - based , fee - for service private practice for ambulatory care and public hospitals for acute institutional care .
subscribing to health insurance is compulsory ; one may not opt out . for ambulatory care ,
all health insurance plans operate on the traditional indemnity - model reimbursement for services rendered .
the entire population thus has health insurance coverage , generally on a work - related basis .
in fact , patients could choose what physician to see , while physicians had almost unfettered freedom to prescribe tests and treatments .
the fhcs offers a great deal of tolerance for organizational diversity , whether complementary , competitive , or both .
this tolerance justifies the coexistence of public and private hospitals and both office - based private practice and public ambulatory care .
service chiefs in public hospitals have the right to use a small portion of their beds for private patients .
the tolerance justifies also the coexistence of multiple statutory health insurance plans , complementary private health insurance coverage , and significant cost sharing directly by patients .
social security refunds 70% of the cost of an office visit to the treating physician and most specialists .
patients are required to participate in health expenditures , with the aim of fostering consumer responsibility toward the cost of health care .
unlike in the uk , both private and public practices are not free at the point of delivery in france . even if subscribed to social security , when consulting a physician or specialist , one has to first pay the full tariff and would only be reimbursed after - ward in full or in part by the patient 's complementary and /or private insurance company .
the current fhcs is a product of a long history of development of its health establishments .
the maison royale de sant ( currently hpital saint - louis ) was the first hospital in the modern - day sense .
it forms now part of the current assistance public hospitals in paris ( ap - hp ) , an important part of french teaching university hospitals ( chu ) .
these chus are among the best hospitals not only in france but in the world .
french hospitals have significantly contributed to modern medicine as rene laennec 's invention of the stethoscope and louis pasteur whose work has saved millions of lives ( table 3 ) .
major land - marks of contribution by french hospitals in modern medicine 
          france boasts a higher number of hospital beds in proportion to its population than most european and other countries ( 8.7 per 1,000 compared with 7.6 in spain and italy , 6.9 in the uk and 3.7 in libya ) .
these include hospital centers or short - stay hospitals ( hpital de court sjour ) , medium stay centers ( centre de moyen sjour ) and long term treatment centers ( centre et unit de long sjour ) .
hospital centers include general hospitals , the ap - hp , specialist hospitals and regional centers ( centre hospitalier rgional / chr or centre hospitalier universitaire / chu when associated with a university ) .
medium stay hospitals contain facilities for convalescence , occupational and physical therapy , and recuperative treatment for drug and alcohol abuse and mental illness .
long - term treatment centers are for those who are unable to care for themselves without assistance and include psychiatric hospitals , nursing homes for the aged and hospitals for children .
private health care institutions include non - profit establishments as the red cross hospitals and for - profit establishments ( private clinics ) .
other health facilities include mother and child welfare services ( pmi , services de protection maternelle et infantile ) that are set up by the departments to provide regular check - ups for pregnant women and infants .
their activities are neither industrial nor commercial and they may be municipal , departmental , interdepartmental or national in status .
france 's private sector is the largest in europe and is accessible to all insured patients .
proprietary hospitals are reimbursed on a negotiated per diem basis ( with supplementary fees for specific services ) and public hospitals ( including private non - profit hospitals working in partnership with them ) are paid on the basis of annual global budgets negotiated every year between hospitals , regional agencies , and the ministry of health .
private hospitals and clinics that are  non - contractual  may also have an agreement with social security .
both public and private hospitals will henceforth be funded through diagnosis - related payments , which are progressively being put in place .
private practitioners are remunerated on a fee - for - service basis and are allowed to combine private practice with salaried work .
many physicians work in private practice and also have the opportunity to work part - time in public hospitals .
a number of agencies are set up to improve health safety and prevention , exercising some of the responsibilities of the state ( table 4 ) .
agence national d'accrditation et dvaluation en sant  has a responsibility to promote health care evaluation , to prepare hospital accreditation procedures , and to establish medical practice guidelines .
it also sets up regional hospital agencies with authority to coordinate public and private hospitals and allocate their budgets .
structures set up to improve health safety and prevention as part of the responsibilities of the state in the french national health system
six percent (  10.5 billion ) of health expenditure was devoted to prevention in 2002 .
half of this was earmarked for disease prevention , one - quarter for screening and testing , and one quarter to cover risk factors .
currently , the main strategic public health priorities include cancer , the environment , some rare diseases such as alzheimer 's , violence , abuse , risky behaviour , addictive behaviour , chronic illnesses , and quality of life .
based on current expertise and resources , these strategic plans are broken down into 100 achievable targets .
the french institute for public health surveillance ( institut de veille sanitaire , invs ) is a national organisation responsible for surveillance and alert in all domains of public health .
this is comparable to centre of disease control in atlanta - usa ( cdc ) .
it prospectively detects sudden and/or gradual changes in risk factors that might modify or alter the health of the population , or certain groups at risk .
it alerts the health ministry of any threat to the health of population whether infectious , environmental , occupational hazards and/or chronic diseases and injuries .
hr include medical professions ( general practitioners , specialists , dental surgeons , pharmacists etc . ) , and the paramedical professions ( nurses , nursing auxiliaries , physiotherapists , laboratory technicians , x - ray operators , etc . ) .
nurses , nursing auxiliaries , clerical and technical staff account for about three - quarters of all health sector staff .
there are around three doctors per 1,000 persons in france ( compared with 1.2 in libya , 1.7 in the u.k .
university hospital doctors have dual status as civil servants due to their teaching and research responsibilities , and state hospital sector employees due to their medical work .
numerous clauses system fixes the number of medical and dental students to be admitted to medical schools each year ( 5,700 medical students in 2004 ) .
a dictate from the code of public health obligates health professionals to attend a minimum number of continuous education hours .
these are mandatory and are paid by the establishment and considered part of the work days .
france is one of the world 's largest consumers of drugs and it is the biggest in europe .
prescription drug purchases account for a larger proportion of outpatient health care consumption than its equivalent in libya .
france is also europe 's largest consumer of sleeping pills , tranquillizers and anti - depressants .
although pharmacies are private undertakings , they must comply with government demographic norms which determine where they may operate .
the fhcs has reasonably good outcomes and/or good quality and is in the top of international health systems in its generosity . in spite of its success ,
it is one of the most costly in europe yet its health professionals are amongst the worst paid .
its real challenge is how to bring costs under control without jeopardizing aspects that make the system so popular , such as quality of care , freedom of choice , and equality of access .
these include how to be more evidence - based , more cost - effective , efficient , and more quality - oriented .
solutions should be sought as to how to obtain new funds from those able to pay , how to move health insurance financing away from payroll and wage levies since this hampers employers ' willingness to hire ; and how to create a governing council of the health insurance funds with more authority and responsibility .
measures such as shared , computerized medical records for each patient , and instituting care teams for patients with chronic illnesses should lead to better coordination of care with less duplication of services .
other measures that are being implemented are developing and enforcing more practice guidelines , creating a sense of responsibility in both groups of professionals and patients , more attention paid to prevention , decreasing hospitalization rates , decreasing costs of medical prescriptions , using more generic medications and negotiating lower prices for medications and other health products .
other weak points are related to methods for introducing new drugs to the market with regard to reimbursement , and providing more general information to the patients .
a series of measures were taken in the last decade to modernize health care and decrease the ever rising costs in health expenditure .
the  hospital - plan 2007  and its extension  hospital - plan 2012  are other tools that are expected to promote modernization of the hospital sector ( with the introduction of public - private cross subsidies ) and the widespread use of diagnosis - related payments .
this is expected to allow for an increased comparison of volumes of activity and greater transparency of public and private sector costs .
earnings hopefully would be issued based on hospital activities that determine the expenditure and not the inverse .
hospitals are also strongly encouraged to gain more autonomy through local governance that involves establishment of a cluster - based organization in order to foster synergies and economies of scale and ensure a comprehensive continuum of care for patients . the plans were extended to form focus groups and activities that are based on economical reasons .
examples include grouping different medical disciplines such as cardiology , nephrology , oncology , pediatrics , etc together .
these shared interest groups are allotted management departments ( personnel , investment , contracting of objectives ) .
recently , based on a senate report , the french president announced 16 other measures in 2008 to make public hospitals more efficient and better managed .
the plan included measures to further increase the power of hospital directors and gives public hospitals a real chance to compete with private clinics .
currently public hospitals have to wait two years to acquire new equipment while private clinics wait for only six months .
the measures aim to reorganize the geographical map too so that they would be more responsive to the health needs of a certain territory and be able to make rational management and dispensing decisions .
measures promised financial aid for public establishments that agree to form a joint - community of hospitals .
hospitals in a geographic area should coordinate together forming a hospital of reference and essential basic services and cooperation with local hospitals .
private clinics would be invited to accept emergencies , to have continuous services , and accept the most underprivileged patients , in order to also be eligible for financial support from the state .
cutting edge equipment would be used in research for cancer , genetic diseases , geriatric illnesses such as alzheimer 's and parkinsonism . in these hospitals ,
private partners are called to participate in modernization efforts under the principle of ppp which stands for public - private - partnership
. these are contracts where a private operator takes the responsibility of investing in a public establishment in exchange for a lease or franchise of 20 to 30 years .
canada health systems spend a higher portion of gdp , but rank very low in the who report and ehci respectively .
the fhcs , which is a leader in most international evaluations , has been successful in insuring universal coverage while maintaining a sustainable pluralistic delivery system that limits perceptions of health care rationing and restrictions on patient choice , with public - private partnership .
reforms in fhcs were accomplished in incremental stages in 1928 , with big extensions in 1945 , 1961 , 1966 , 1978 , 2000 , 2007 , and lately in 2008 .
the result has been excellent as shown by patient satisfaction scores , high volume output and general wellbeing of the population .
 all public systems look for the best organizational structure to funnel part of their national income into healthcare services . 
 appropriate policies may differ widely across country settings . 
 most healthcare systems fall under one of two broad categories , either bismark or beveridge systems . 
 there is no simple ideal model for the organization of health services , but most healthcare systems that follow the beveridge healthcare model are poor performers . 
 the libyan health system is a low responsive , inefficient and underperforming system that lacks goals and/or smart . 
 ( specific , measurable , achievable , realistic , time specific ) objectives . 
 a look at different organization models in the world would reinforce efforts to reorganize and improve the performance of the libyan national healthcare services . 
 the french health care system ( fhcs ) ranked first according to the who and the european health consumer powerhouse . 
 the fhcs was described to have a technically efficient , generous healthcare system that provides the best overall health care . 
 this makes the fhcs a practical model of organization having many of the essential aspects of a modern national health service . in this review , 
 we describe the main features of the fhcs , current challenges and future trends with particular attention paid to aspects that could be of importance to the libyan healthcare system . 
Introduction
The FHCS
Financing of the FHCS
Health facilities in the FHCS
Public health and surveillance in the FHCS.
Resources in the FHCS
Current challenges for the FHCS
Conclusions