Belgium Health Profile 2012

The Belgian health system is mainly organized on two levels, i.e. federal and regional. Since 1980, part of the responsibility for health care policy has been devolved from the federal Government to the regional governments.
R

esponsibility for health care policy is shared between the federal Government, exercised by the Federal Public Service Health, Food Chain Safety and Environment (former Ministry), the Federal Public Service Social Security, the National Institute for Sickness and Disability Insurance, and the Dutch-, French- and German-speaking community Ministries of Health. The federal Government is responsible for the regulating and financing of the compulsory health insurance; determining accreditation criteria; financing hospitals and so-called heavy medical care units; legislation covering different professional qualifications; and registration of pharmaceuticals and their price control. The regional governments are responsible for health promotion; maternity and child health services; different aspects of elderly care; the implementation of hospital accreditation standards; and the financing of hospital investment.

According to the European Health for All database, in 2004 total health expenditure as a percentage of gross domestic product (GDP) in Belgium was 9.3%. Health care expenditure expressed in US$ PPP per capita was 2922 in 2004, which was the fifth highest health care expenditure among all 27 European Union (EU27) countries. Health expenditure is expected to increase in the years to come due to low GDP growth and the governments’ policy to increase annual public spending on health care by 4.5% in real terms between 2004 and 2007. The Belgian health system is primarily funded through social security contributions and taxation. Public sector funding as a percentage of total expenditure on health care fluctuates around 70%.
The Belgian health system is based on the principles of equal access and freedom of choice, with a Bismarckian-type of compulsory national health insurance, which covers the whole population and has a very broad benefits package. Compulsory health insurance is combined with a private system of health care delivery, based on independent medical practice, free choice of service provider and predominantly fee-for-service payment.

All individuals entitled to health insurance must join or register with a sickness fund: either  one of the six sickness funds, including the health insurance fund of the Belgian railway company, or a regional service of the public Auxiliary Fund for Sickness and Disability Insurance.

Since 1995, Belgian sickness funds receive a prospective budget from the National Institute for Sickness and Disability Insurance to finance the health care costs of their members. They are held financially accountable for a proportion of any discrepancy between their actual spending and their so-called normative, i.e. risk-adjusted, health care expenditures. The reimbursement of services provided depends on the employment situation of the patient (self-employed or employed, until 2007), the type of service provided, the statute of the person who is socially insured (preferential reimbursement or not) as well as the accumulated amount of user charges already paid. Patients in Belgium participate in health care financing via co-payments, for which the patient pays a certain fixed amount of the cost of a service, with the third-party payer covering the balance of the amount; and via co-insurance, for which the patient pays a certain fixed proportion of the cost of a service and the third-party payer covers the remaining proportion. There are two systems of payment: (i) a reimbursement system, for which the patient pays the full costs of services and then obtains a refund for part of the expense from the sickness fund, which covers ambulatory care; and (ii) a third-party payer system, for which the sickness fund directly pays the provider while the patient only pays the coinsurance or co-payment, which covers inpatient care and pharmaceuticals.

In real terms, the number of all types of health care professionals has increased continuously since the 1970s, due mainly to a lack of control over the supply side of the market. It is generally accepted that currently there is an oversupply of physicians, dentists and physiotherapists in Belgium. In 2004, the density of practising physicians was 4.0 per 1000 population, clearly above the average of the countries belonging to the EU before January 2007 (EU25) of 3.5 physicians per 1000 population. The federal Government  introduced planning for physicians and dentists in 1996, when the Committee for Medical Supply Planning was established to give advice on the numbers of physicians and dentists qualified to practise in Belgium. Later, the remit of this committee was extended to also cover physiotherapists, nurses, midwives and logopaedics. The Committee is responsible for formulating proposals to the Federal Minister of Public Health on the annual number of candidates per community that are eligible to be granted the professional titles of physician, dentist or physiotherapist, after obtaining the relevant diploma. Based on the Committee’s work, a proposal was made for a quota mechanism.

The quota mechanism is applied immediately after the basic training at the moment of application for recognition as a dentist or physiotherapist and at the application for specialization for a physician (GP or specialist). In order to achieve these objectives, the communities, which are responsible for education policy, were requested to take measures to limit the number of medical and dental students. In 1997, the Flemish community introduced entrance examinations to limit the number of students entering medical schools. The French community has chosen to limit the number of medical students after their third year of medical education on the basis of the first three years’ results.

Most physicians – whether GPs or specialists – are paid on a fee-for-service basis. The patient pays the set fee for the consultation directly to the physician, and patients are then directly reimbursed by their sickness funds. Most services are reimbursed at a rate of 75%, so the patient shares 25% of the cost.

In Belgium, hospitals can be classified into two categories: general and psychiatric. In 2005, there were 215 hospitals, of which 146 were general and 69 psychiatric. The general hospital sector consists of acute (116, specialized  and geriatric hospitals .

The basic feature of Belgian hospital financing is its dual remuneration structure according to the type of services provided: services of accommodation (nursing units), emergency admission (accident and emergency services), and nursing activities in the surgical department are financed via a fixed prospective budget system based on diagnosis-related groups (DRGs); while medical and medicotechnical services (consultations, laboratories, medical imaging and technical procedures) and paramedical activities (physiotherapy) are remunerated via a fee-for-service system to the service provider.

Pharmaceuticals are exclusively distributed through community and hospital pharmacies. Only physicians and (to the extent that their profession requires) dentists and midwives can prescribe pharmaceuticals. About 2500 pharmaceutical products are on a positive list and therefore are partly or fully reimbursable. The reimbursable percentage of the cost varies depending on the therapeutic importance of the pharmaceutical.

To advance the use of generic pharmaceuticals, a reference pricing scheme was introduced on 1 June 2001 for products with generic equivalents. A pure reference pricing system sets fixed reimbursement limits for products assigned to the same group of pharmaceuticals that are defined on the basis of chemical, pharmacological or therapeutic equivalence. The Belgian reference pricing scheme is based on the national generic pharmaceutical, i.e. the pharmaceutical with identical active ingredients that has the same form and dosage. The reimbursement level is based on the national generic price, which is fixed at 30% (in 2005) below the price of the original brand.

Although the Belgian health system has not undergone any major structural reforms since the 1980s, various measures have been taken mainly to improve its performance. Reform policy in recent years has included: hospital financing reform; the strengthening of primary care; the restriction of the supply of physicians; the promotion of generic substitution of pharmaceuticals; the increase of accountability of health care providers and sickness funds; tariff cuts; and more emphasis on quality of care, equity, evidence-based medicine, health care technology, benchmarking with financial consequences and economic evaluations.

Future health reforms are likely to build on recent reforms and achievements. Changes in provider payment methods (i.e. DRGs) may improve providers’ accountability and increase efficiency. Primary care could be strengthened by the general application of the Global Medical File and the introduction of financial incentives to enable GPs to play a more central role in the health system and to promote other forms of primary health care, such as home care.

Physicians could be rewarded for improved prescribing. One area could include prescribing targets for generics; this is an example of not only cost savings but also quality improvements in prescribing practices. Finally, an increased and sustained focus on quality is likely to be a significant element in health policy-making.