Healthcare accessibility can also be considered from the angle of the number of qualified practising healthcare providers in the country and the number of available beds in some healthcare sectors.
This information is also essential in order to plan the healthcare offer for the years to come.

In this section, you can find indicators on physician and nurse availability in general:

• Number of practising physicians (A-5)
• Number of practising nurses (A-6)
• Number of nursing staff vacancies in hospitals (A-7)
• Number of patients per nurse (A-8) 

Some of the indicators analysed in other sections of this report may also be interpreted in terms of human resources accessibility:

• Among mental healthcare indicators: Number of psychiatrists (MH-2);
• Among care for the elderly indicators: Number of geriatricians (ELD-6), Number of available spaces in long-term care beds (ELD-4), Percentage of elderly people receiving long-term care at home (ELD-2)
• Among end-of-life care indicators: Number of patients receiving palliative care (EOL-1)

Lastly, future projections about the expected number of healthcare professionals (S-4 to S-10) are discussed in the ‘Sustainability’ section.

Number of practising physicians (A-5)

This indicator measures the number of practising physicians per 1000 population.

It is considered that a physician is ‘practising’ if he/she has provided more than one clinical service (i.e. at least two consultations, visits or technical procedures – prescriptions are not counted here) during a given year. Physicians in training are not counted.

Until 2009, the calculation of physician density took into account all physicians licensed to practice (rather than practising physicians, defined as physicians having had more than 1 patient contact per year), which explains why, for a long time, Belgium showed one of the highest levels of physician density in Europe. These data have now been retrospectively corrected.

In addition, for 2016, the OECD data (reproduced in this datasheet) relate to the number of physicians who provided at least one clinical service (instead of more than one clinical service). Details about the number of physicians having provided more than one clinical service (34 502 instead of 34 834) are available on the RIZIV-INAMI  website.

RESULTS

• There were 34 834 practising physicians in Belgium in 2016, which translates into a density of 3.07/1000 population. Between 2000 and 2016, this density level has remained fairly stable. However, increasingly widespread ageing among physicians can be observed (see the indicators about physician age in the Sustainability section)
• The density of practising physicians in Belgium is lower than the EU average (3.54/1000 population). The different OECD countries do not, however, all use identical methods to calculate the same indicator (e.g. to define practising activity levels). The comparisons may, therefore, be incorrect.
• This indicator poorly reflects the actual number of practising physicians, since it includes all physicians who performed at least one clinical procedure, which is an extremely broad definition. To overcome this problem, INAMI also estimated the number of practising physicians in Full-Time Equivalents (FTEs), based on the amounts of reimbursed services. According to these estimates, the number of practising general practitioners (GPs) was 8 988 FTEs in 2016 (12 929 in absolute numbers), including 7 719 conventioned GPs in FTEs. Expressed in terms of density, this corresponds to 0.79 GPs per 1000 population, including 0.68 conventioned GPs. Details per medical specialty is shown in Table 1.
• When expressed in FTEs, the density of conventioned gynaecologists is fairly low (see also the indicator for conventioned physicians).
• However, it should be noted that this analysis is based on physicians’ residential addresses and not on their workplaces. A recent study based on general practitioners’ workplaces showed that in 2017, there were 1.23 general practitioners per 1000 population in Brussels (versus 1.17 per 1000 population in 2016 based on the GPs’ places of residence; RIZIV-INAMI data for 2017 are not yet available).

Link toward the technical sheet and detailled results

Number of practising nurses (A-6)

Nurses play a key role in delivering healthcare, whether in hospitals and other healthcare institutions or as part of first-line and home care services.
In most countries, nurses represent the largest professional group among all healthcare professions; a lack of nurses can therefore lead to accessibility issues (e.g. making waiting lists longer), or have consequences on quality of care (e.g. high patient-to-nurse ratio).
The PlanCAD Project, resulting from a combination of several administrative databases, helps to make a distinction between practising nurses in the healthcare sector and those who are professionally active on the Belgian labour market, also in other sectors than healthcare.

The primary indicator is the number of practising nurses in the healthcare sector. This indicator covers nurses employed in the healthcare sector who have provided a certain volume of activity (at least 893 procedures per year, according to the INAMI nomenclature), or who are working for an employer who is practising within the healthcare sector.

The secondary indicators are:

• Number of nurses licensed to practice (holding a Licence to practice), i.e. nurses who have obtained a recognised Nursing Care diploma, including people who hold a Midwifery diploma recorded in the nursing category of the cadastre database.
• Number of professionally active nurses, i.e. nurses who are registered as independent nurses or who are employed with at least 0.1 Full-Time Equivalents (FTEs) per year, but who do not necessarily work within the healthcare sector.

The distinction between practising nurses and professionally active nurses is the sector in which they work. Practising nurses work only within the healthcare sector and not on the rest of the Belgian labour market.

RESULTS

• In 2016, there were 124 196 practising nurses within the healthcare sector (primary indicator), i.e. 105 718 FTEs.
• In 2016, there were 202 402 nurses licensed to practice and 143 470 professionally active nurses on the entire labour market.
• Most professionally active nurses work with an employee status in hospitals (65.5%), followed by nursing and care facilities (13.7%) and home care (7.9%).
• The number of practising nurses within the healthcare sector per 1000 population has increased between 2004 (8.8 per 1000) and 2015 in Belgium (10.8 per 1000). This upward trend can also be observed in other European countries. The number for Belgium is slightly higher than the European EU-11 average (which is 9.4).

 

Note: At the OECD level, inclusion and exclusion criteria differ among countries, which makes international comparisons of these data unreliable.

Link toward the technical sheet and detailled results 

 Number of nurse vacancies in hospitals (A-7)

Since the early 2000s, nurse shortages have been reported in most industrialised countries, including Belgium. This problem could accelerate with population ageing (and the ageing of nurses).

The measurement of the number of vacancies is a contextual indicator which helps monitor this nurse shortage.

RESULTS

• On 31/12/2016, there were 1274 nurse vacancies in Belgian hospitals, most of which were for holders of Bachelor-level degrees (A1):
  • 708 in Flanders
  • 290 in Wallonia
  • 276 in Brussels

 

Link toward the technical sheet and detailled results

Average number of patients per nurse in hospitals (A-8)

The international scientific literature shows that nurse shortages have negative consequences on quality of care and mortality rates among hospitalised patients. It is therefore vital to use wisely the few nursing personnel resources that are currently available in order to limit this negative impact as much as possible. The number of Nursing Hours per Patient Day in Acute Hospitals would therefore be an interesting indicator in this regard.

However, the data that would allow to calculate this indicator are no longer collected due to administrative modifications. This indicator is therefore replaced by an ‘older’ indicator, which is the average patient-to-nurse ratio (average number of patients by one nurse in FTE). This indicator is derived from a European study (RN4CAST, 2009-2010) based on data from 500 hospitals in 12 countries. In 2019, the KCE has performed an update of this study using the same methodology for Belgium only. This indicator can also provide indirect information about quality of care in hospitals.

RESULTS

• Between 2011 and 2015, the number of nursing hours per patient day increased from 4.3 to 6.3 in surgery departments and from 4.8 to 5.5 in medical services.
• The number of nursing hours per patient day varies significantly from one hospital to another. Part of this variability may be explained by differences in care intensiveness, but the variations persist after adjusting for this factor.
• According to the RN4CAST study, the average patient-to-nurse ratio in Belgium was 10.7 in 2010, a high figure compared to other European countries (EU-12 average = 9). Only Germany (13.0) and Spain (12.6) have higher ratios. In Norway, this ratio is lower by one half (5.4). If less qualified nursing staff is also taken into account, the average patient-to-nurse ratio becomes 7.9.
• According to the KCE study, the average patient-to-nurse ratio has slightly improved to 9.4 in 2019 but this is still above what is internationally considered as a safe patient-to-nurse ratio (in England for example, based on the NICE guidance, a patient-to-nurse ratio superior to 8 is considered as manifestly unsafe).

Link towards the technical sheet and detailled results

Link toward the KCE study

A health system that works well should remain financially accessible to the largest number of people. If anyone has to restrict or postpone necessary care or treatments due to (excessively) high costs, or give up other basic needs in order to pay for such care, then the health system is considered to be of poor financial accessibility. In addition, stopping or delaying a treatment because of its cost may have harmful consequences for people’s health in a more or less long-term perspective, which may involve higher health expenditure.

In this report, financial accessibility is measured by the following indicators:

• Share of the population covered by the compulsory health insurance (A-1)
• Share of households’ out-of-pocket payments (A-2, A-3, A-10, A-11)
• Percentage of people who had to postpone medical examinations for financial reasons (A-4)
• Access to agreed tariffs: the density of conventioned GPs and dentists in FTEs (A-12, A-13)
• Percentage of the billed fee supplements to the billed official health insurance fees for hospitalisations (classic and day hospitalisations) (A-14)

The indicator on catastrophic out-of-pocket payments is described in the section on equity and inequalities (EQ-5)

Healthcare insurance status of the population (A-1)

This indicator measures the percentage of population affiliated to a sickness fund that is covered by the compulsory health insurance. Belgium has a compulsory health insurance system which, in principle, covers the entire population: salaried employees, self-employed, public servants, the unemployed, pensioners, people entitled to increased reimbursement (‘BIMs’), the disabled, students, foreign nationals (residents), as well as all their dependents.

RESULTS

• 99% of the population is covered by the health insurance system (2017 figures).
• This percentage is stable since 2009.
• Men are slightly less covered than women (98.7% vs. 99.3%).

Note: Uninsured people are not necessarily excluded from healthcare, as their expenses are most often paid by municipal public social care centres (CPAS).

• The percentage of uninsured people is higher in the Brussels region (1.9%) than in Flanders (0.5%) or Wallonia (0.7%).
• In the 25-40 year-old group, the percentage of uninsured people is more than 2%.
• All countries of the 15-member European Union have coverage rates between 99 and 100%, except Greece (86%), Germany (89.2%) and Luxembourg (95.2%)

Link to technical datasheet and detailed results

Share of households out-of-pocket payments (A-2, A-10, A-3, A-11)

This set of indicators measures the share of healthcare expenditure which is not covered by the compulsory health insurance system and is, therefore, directly charged to patients:

• Out-of-pocket payments (OOPs), expressed as a percentage of current expenditures on health (A-2)
• Out-of-pocket payments (OOPs), expressed as a percentage of final household consumption (A-10)
• Out-of-pocket payments (OOPs) per capita (in US $ PPP) (A-3)
• Out-of-pocket payments (OOPs) for dental care, expressed as a percentage of current expenditure on dental care (A-11)

RESULTS
Out-of-pocket payments (OOPs), expressed as a percentage of current expenditures on health (A-2) :

• When expressed as a % of the current health expenditure, the share OOPs is remained relatively constant between 2004 and 2016, even slightly decreasing (18.2% in 2004 and 15.9% in 2016, Figure 1), while the share of current health expenditure financed by public funds has slightly increased (see also health expenditures in Sustainability section).
• On an international level, OOPs expressed as a percentage of current health expenditure (A-2) have been lower than the EU-15 average since 2013 (Figure 2 and 3).
• The total annual amount of OOPs has increased from 4.93 billion Euros in 2004 to 7.09 billion Euros in 2014, and then slightly decreased to 6.73 billion Euros in 2016. When measured on a per capita basis, OOPs increased from €473.3 in 2004 to €632.9 in 2014 and have slightly decreased since 2014, reaching €593.8 per capita in 2016.
• The amount of official co-payments (‘ticket modérateur’ – ‘remgeld’) paid by patients has been quite stable compared to the change in total OOPs. One possible explanation is that the protection mechanisms established by the Belgian system (maximum billing, increased reimbursements for BIMs) aim to protect patients against excessively high amounts of official co-payments, but not against other costs such as over-the-counter medicines or supplements of physician fees (Figure 1).
• Aside from the costs paid by public funds (compulsory healthcare insurance and other public sources) and those paid by the patients, there are still costs that are paid for by voluntary insurance, which have increased from €132 per capita in 2004 to €189 per capita in 2016 (Figure 1).

Out-of-pocket payments (OOPs) per capita (in US $ PPP) (A-3) :

• On an international level, the average OOPs per capita (expressed in Purchasing Power Parity US $, $ PPP) has slightly decreased since 2014 and has become closer to the European average ($739 PPP in Belgium in 2016 versus $732 PPP for the European average).

Out-of-pocket payments (OOPs), expressed as a percentage of final household consumption (A-10) :

• According to OECD figures, the share of household consumption on health was 3.01% in 2016 versus 2.64% for the EU-15 average.
• According to the household budget survey, high-income households spend twice as much on health compared to low-income households (€2 154 for high-income households versus €954 for low-income households in 2016).

Out-of-pocket payments (OOPs) for dental care, expressed as a percentage of current expenditure on dental care (A-11)

• The share of OOPs for dental care is high. Although it is comparable to the European average (57.6% in 2016 versus 59.2% for the European average, based on 10 countries), it is much higher than in neighbouring countries such as Germany (25.5%) and the Netherlands (21.7%).

Link to technical datasheet and detailed results

Postponement of care due to financial reasons (A-4)

This indicator measures the proportion of individuals (households) reporting that they had to postpone care for financial reasons. These figures were reported by the surveyed individuals (households) themselves (self-reported).

Primary indicator:

The primary indicator is derived from the European Statistics on Income and Living Conditions survey (EU-SILC). This survey includes questions about obstacles preventing access to medical or dental examinations (including cost, but also distance, waiting time, etc.) and is done at an individual level.

Secondary indicator:

The secondary indicator is derived from the Belgian Health Interview Survey performed by Sciensano, whose latest edition is dated 2018. This survey is done at a household level rather than per individual. The two indicators cannot, therefore, be combined together.

The question asked to the surveyed households was: “During the past 12 months, did you, or did a member of your household, require any care (medical care, surgery, dental care, prescription medicines, eye glasses or contact lenses, mental healthcare), but had to postpone it because you could not afford it? ”

 

RESULTS
Results of the 2018 Health Interview Survey

• In the 2018 Belgian Health Interview Survey, 9.1% of households reported that they had to postpone care for financial reasons.
• Their geographical distribution is very heterogeneous: 16.1% of households in Brussels reported having to postpone care, versus 12.8% in Wallonia and 5.4% in Flanders.
• There is a clear relationship with the education level of the head of the household: 13.6% of households whose the head had the lowest level of education had to postpone care, versus 5.5% for households’ heads with the highest level of education.
• There is also a relationship with households’ income: 18.4% of households with the lowest income had to postpone care, versus 2.5% of households with the highest income.

EU-SILC Results (2018)

The percentage of households delaying contacts with healthcare services in the Eurostat database (EU-SILC) brings some additional information:

• The proportion of persons (aged 16 years and over) reporting they had to postpone medical examinations for financial reasons has increased from 1.4% in 2011 to 2.2% in 2014. The proportion remained stable around 2.2% during the 2014-2016 period and has then decreased to reach 1.8% in 2018 (Figure 7).
• For dental care, the trends is the same, but with higher proportions: 2.9% in 2011 to 3.8% in 2014, and 3.1% in 2018 (Figure 8).
• Both for medical and dental examinations, these proportions are higher among women than among men.
• Both for medical and dental examinations, this proportion is at its highest between the ages of 35 and 54; among people aged over 65 years, it is lower.
• There are major differences according to individual income. For medicalexaminations, the proportion changes from 0% for the higher-income quintile to 5.4% for the lower-income quintile. For dental examinations, the gap widens, with 0.3% for the higher-income quintile and 8.2% for the lower-income quintile.
• On a European scale, the share of unmet medical needs for financial reasons in Belgium is higher (1.8%) than the EU-15 average, which is 1.1% (2018 figures) (Figure 7). Only Greece and Italy performed worse than Belgium (8.3% in Greece and 2.0% in Italy). This difference is even more noticeable for the lower-income quintile (5.4% compared to a European average of 2.6% for medical needs).
• Regarding unmet dental needs, the proportion is also higher in Belgium (3.1%) compared to the EU-15 average, which is 2.9% (2018 figures) (Figure 8).

Link to technical datasheet and detailed results

Accessibility to agreed tariffs (A-12, A-13)

Every year (in theory), national agreements are concluded between representative of healthcare providers and sickness funds (mutual medical agreements, mutual dental agreements, etc.) which establish, for a fixed period of time, the official fees that they may claim. This ensures financial security for patients, who can thus plan in advance how much they will need to pay for their visits and care services, with no additional cost. This measure, however, is only valid with healthcare providers that accede to this agreement (i.e. ‘conventioned’ healthcare providers). They may (or may not) also renew this “membership” each time a new agreement is signed. In exchange for this “membership”, these healthcare providers receive certain social benefits.

By calculating the density of conventioned practising health professionals per province and per district, important information can be obtained, both in terms of financial accessibility and geographical accessibility of healthcare. We have chosen to measure this density for general practitioners (as well as, as a sub-indicator, for medical specialists, represented here by gynaecologists) (A-12) and for dentists (A-13). The density is expressed in Full-Time Equivalents (FTEs).

RESULTS
Density of conventioned general practitioners (and gynaecologists) (A-12):

• The distribution of conventioned general practitioners is fairly uniform;
• The density of conventioned gynaecologists is overall low in Belgium, with the exception of the Mons district.

Density of conventioned dentists (A-13):

• The distribution of conventioned dentists is fairly uniform (with small gaps in the Antwerp, Veurne and Charleroi districts)

Link to technical datasheet and detailed results

A-14 Proportion of fee supplements

In the Belgian hospital system, physicians are allowed to charge fee supplements to patients who have chosen to stay in an individual room (except where the individual room stay results from a medical requirement or unavailability of another type of room). This allows these hospitals to attract physicians by offering them better financial conditions. Hospitals can also charge room supplements for occupying these individual rooms, whose amounts are left to the hospitals’ choice. Since 2013 (2015 for day hospitalisations), all supplements have been forbidden in two-bed rooms. Since this change, the number of fee supplements charged to patients has decreased, but their amounts have increased.

Most hospitalisation insurances reimburse – either in part or in full – the fee supplements charged to patients who choose an individual room. However, insurance premiums have been increasing – following the upward trend in fee supplements – and could become unaffordable for some people.

It is observed that some hospitals systematically offer individual rooms to their patients. This trend could lead to a two-tiered health system, with ‘hospitals for the rich’ – offering a higher proportion of individual rooms – and ‘hospitals for the poor’. Therefore, not all patients have equal access to the same quality of care.

RESULTS

• For classic hospitalisations, the total amount of fee supplements represented 20% of the total volume of physician fees officially billed in 2017, which demonstrates a rapid increase, since this percentage was 14% in 2006 and 18% in 2015 (Figure 12).
• For day hospitalisations, the total amount of fee supplements has slightly decreased, from 15% of the total volume of physician fees officially billed in 2015 to 13% in 2017 (Figure 12). This decrease may be explained by the removal of fee supplements in double rooms which, for day hospitalisations, only began in mid-2015.
• Fee supplements were charged for 11% of all healthcare services (12% of classic hospitalisations and 8% of day hospitalisations) (Table 3).
• Since the removal of fee supplements in double rooms, the number of patients who had to pay fee supplements has decreased by 10.8% (classic hospitalisations + day hospitalisations). This reduction, however, only applies to ‘low’ fee supplements (< €1 000). The number of patients facing ‘high’ fee supplements (> €1 000) has increased significantly. This means that less patients have had to pay fee supplements, but that the amounts of fee supplements have increased (Table 4).
• Regional variations are small: fee supplements are charged for 14% of hospital stays in Flanders, 13% in Wallonia and 17% in Brussels. However, their amounts vary significantly from one region to another, with averages of €800 in Flanders, €1 350 in Wallonia and €1 700 in Brussels (see technical datasheet).

Link to technical datasheet and detailed results