The Healthcare System of Saint-Pierre and Miquelon: Local Scheme, Hospital, Emergencies and Medical Evacuations

Saint-Pierre and Miquelon depends neither on the mainland Assurance Maladie (French public health insurance) nor on an overseas fund: according to the CLEISS (the French centre for international social security links) and the IEDOM (the overseas issuing institute), it has a local scheme covering all risks. The Caisse de prévoyance sociale (CPS), a multi-branch private-law body created by the ordinance of 26 September 1977, runs the public social security service. It carries out the missions of a CPAM (local health insurance office), a CAF (family allowance fund), a CARSAT (pension fund), a regional medical service department and a URSSAF (contributions collector), and validates, organises and compensates scheduled medical evacuations.

The architecture follows that of the general scheme: local affiliation has been aligned with universal health protection since 1 January 2023 (Article 93 of the Social Security Financing Act for 2023), while the solidarity supplementary health scheme does not apply to the archipelago. The scheme runs a deficit: a balancing grant from the national health insurance fund, of more than €50 million a year, tops it up under national solidarity. The whole of social protection is explained in the guide to health and social protection in Saint-Pierre and Miquelon.

According to the CPS, affiliation is open to anyone who lives in the archipelago in a stable and regular way, who carries out a salaried or non-salaried professional activity there, or who is a child under 18, a dependant of their parents. An adult is affiliated individually. For family benefits, permanent residence is required and foreigners show the regularity of their stay. Daily allowances require 150 hours worked in the three months before the leave (or contributions on a salary of at least 1,015 times the hourly SMIC over six months); maternity requires 10 months of registration.

An insured person from mainland France who arrives with a certificate from their former fund (CPAM or CGSS) and their carte Vitale registers with the CPS with the documents listed on its website. An employee posted by their employer can stay attached to the French scheme for up to two years. A State civil servant assigned there is affiliated, with their dependants, from the day they take up their duties. Each situation is presented in the page on healthcare reimbursement.

The coordinated care pathway applies, with the declaration of a referring doctor. The territorial health administration counted six GPs (one of them in Miquelon) and one medical adviser, one private pharmacist, five dentists, two psychologists, fifteen nurses, eight physiotherapists and two podiatrists. The IEDOM judges the density of professionals high given the size of the territory, while noting that not all specialities are present permanently.

The CPS multi-purpose health centre, created in 2005 to make up for the low number of private-practice professionals, employs nearly 35 full-time equivalents: general medicine (four GPs, third-party payment possible, walk-in consultations Monday to Saturday), nursing care, physiotherapy, speech therapy, dental surgery, orthodontics, dietetics and psychology. General medicine there is open Monday to Friday from 8 a.m. to 12 noon and from 1.30 p.m. to 6 p.m., and Saturday from 9 a.m. to 12 noon. In Miquelon, the medical centre attached to the hospital brings together the commune’s only GP, two nurses, two care assistants and an ambulance driver; an infirmary operates in Langlade in July and August.

The archipelago’s hospital is a public facility created by the ordinance of 26 September 1977. Its capacity is 35 beds, 18 of them general medicine, 13 general surgery and 4 maternity, with an emergency department, a 4-station dialysis unit, a medical biology laboratory, an operating theatre with a delivery room, a CT scanner, two radiology tables, a mammography unit and a pharmacy authorised to prepare chemotherapy. A 25-place home care service, a 35-place long-term care unit and a 25-place EHPAD complete the offer; the facility has 401.6 full-time equivalents, 23.5 of them medical staff.

The hospital carries out more than 21,000 consultations a year (about 43% of them by visiting external practitioners) and shows an occupancy rate of about 70%. Its maternity ward, the smallest in France, received the “Baby-Friendly Hospital Initiative” label in 2023. An MRI is planned, and the demolition of the former town-centre hospital, abandoned since 2013, continues for €5 million. Since 2023, the hospital has hosted third-year general medicine trainees from Rennes.

The IEDOM mentions no private healthcare facility in the archipelago: private-practice professionals work in surgeries and the CPS health centre acts as the first-line care provider. The hospital organises outreach specialist consultations (ophthalmology, endocrinology, oral surgery, cardiology, pain medicine, urology, gastroenterology, allergology for the September-October calendar) and, for several years, collective telemedicine with specialists in mainland France.

When no alternative exists locally, the CPS organises a medical evacuation (EVASAN) to Canada or mainland France. The nearest Canadian hospital centre, in St. John’s (Newfoundland), is 45 minutes away by air. The number of evacuations exceeds 1,000 a year: about 75% to Canada (St. John’s and Halifax) and the rest to France. Since 2018, the CPS has relied on a tripartite service agreement with the local hospital and the Newfoundland and Labrador health authority to ensure continuity of care all year round. The fall in evacuations to St. John’s is explained by more teleconsultations.

• Absolute emergency: decided by authorised hospital doctors; the file is examined afterwards by the medical adviser and the medical evacuation committee.
• Scheduled evacuation: the doctor files a request with the CPS medical department; the committee, which meets every week, replies with an agreement, a refusal or a stay of decision and decides on the destination and any companion.
• Cover: transport, care and a flat-rate residence allowance depending on hospitalisation, age and the presence of a companion. Choosing another facility remains possible, but the extra cost is borne by the insured person (CLEISS). The allowances are revalued periodically.

The decree of 10 May 2011 provides that care received during an emergency evacuation to a third State is covered by the CPS and then reimbursed by the mainland scheme. An assistance and repatriation contract steps in for uncovered costs, for example family accompaniment or a private stay outside the archipelago.

The emergency numbers displayed by the hospital centre are 15 (emergencies), 17 (police) and 18 (fire brigade). The hospital centre switchboard is 05 08 41 14 00, the Miquelon medical centre 05 08 41 04 00. The emergency department records an average of nearly 13 visits a day; it handles 818 visits per 1,000 inhabitants against 310 in mainland France.

Medicines are reimbursed at 30%, 65% or 100% depending on the medical benefit (CLEISS). The hospital centre pharmacy is open Monday to Friday from 9 a.m. to 12 noon and from 2 p.m. to 6.30 p.m. with weekend duty rotas, and the archipelago has one town pharmacy. The CPS runs prevention initiatives: an annual dentist appointment programme for insured people aged 3 to 24, school screening, and an annual flu and Covid-19 vaccination campaign (vaccine covered at 100% for people at risk, with a coverage voucher, and injection by a doctor, midwife, pharmacist or nurse).

Vaccinations are discussed with the referring doctor, the CPS annual campaign serving as a benchmark for flu and Covid-19. The prefecture publishes an epidemiological report and a health observatory in its health section. The general guide to healthcare systems around the world helps compare this organisation with other territories.