Financial accessibility

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 ad 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)
  • Catastrophic health expenditure (A-15). This indicator will become available in the course of the year 2019

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 dependants.

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:

RESULTS
Out-of-pocket payments (OOPs), expressed as a percentage of current expenditures on health (A-2) :
Figure 1 - Evolution of patient's out-of-pocket payments and health care expenditure covered by voluntary insurance, expressed in million €, 2004-2016
Data source: SHA, OECD Health Statistics 2018; Assuralia 2018; after MAF = after reimbursement via maximum billing; OOP = Out-of-Pocket payments
Figure 2 - Out-of-pocket payments, as % of current expenditures on health, international comparison, 2004-2016
Data source: SHA, OECD Health Statistics 2018
Figure 3 - Out-of-pocket payments, as % of current expenditures on health, international comparison, 2016
Datasource: SHA, OECD Health Statistics 2018
Out-of-pocket payments, as % of current expenditures on health
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).
Figure 4 - Out-of-pocket payments, per capita (in US $ PPP), international comparison, 2004-2016
Data source: SHA, OECD Health Statistics 2018
Figure 5 - Out-of-pocket payments, per capita (in US $ PPP), international comparison, 2016
Datasource: SHA, OECD Health Statistics 2018
Out-of-pocket payments, per capita (in US $ PPP)
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 Belgian Health Interview Survey performed by Sciensano, whose latest edition is dated 2013. The next edition will be published at the end of 2019 and the indicator will be updated at that time.

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? ”

Secondary Indicator:

More data about unmet healthcare needs can be found in the EUROSTAT database, which is derived from the European Statistics on Income and Living Conditions survey (EU-SILC). This survey also includes questions about obstacles preventing access to medical or dental examinations (including cost, but also distance, waiting time, etc.), but is done at an individual level rather than per household. The two indicators cannot, therefore, be combined together. In addition, the secondary indicator, based on a European survey, is used as a basis for international comparison.     

RESULTS
Results of the 2013 Health Interview Survey
  • In the 2013 Belgian Health Interview Survey, 8% of households reported that they had to postpone care for financial reasons.
  • Their geographical distribution is very heterogeneous: 22% of households in Brussels reported having to postpone care, versus 9% in Wallonia and 5% in Flanders.
  • There is a clear relationship with the education level of the head of the household: 12.5% of households whose the head had the lowest level of education had to postpone care, versus 6.2% for households’ heads with the highest level of education.
  • There is also a relationship with households’ income: 19% of households with the lowest income had to postpone care, versus 3% of households with the highest income.
Figure 6 - Percentage of households that reported to have delayed contacts with health services for financial reasons, by region, 1997-2013
Data source: Sciensano, Health Interview Survey, 1997-2013
EU-SILC Results (2017)

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 over time, changing from 0.5% in 2008 to 2.2% in 2014, then stabilising around 2.0% in 2017 (Figure 7).
  • For dental care, the trends is the same, but with higher proportions: from 1.4% in 2008 to 3.5% in 2017 (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 64; 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 6.7% for the lower-income quintile. For dental examinations, the gap widens, with 0.3% for the higher-income quintile and 10.5% for the lower-income quintile. 
  • On a European scale, the share of unmet medical needs for financial reasons in Belgium is higher (2.0%) than the EU-15 average, which is 1.2% (2017 figures). Only Greece performed worse than Belgium (58% in Greece) (Figure ). This difference is even more noticeable for the lower-income quintile (6.7% compared to a European average of 3.0% for medical needs) (Figure 7).
  • Regarding unmet dental needs, the proportion is also higher in Belgium (3.5%) compared to the EU-15 average, which is 3.2% (2017 figures) (Figure 8).
Figure 7 - Self-reported unmet needs for medical examination due to financial reasons in Belgium (% of individuals included in the survey), international comparison, 2008-2017
Data source: Eurostat 2018; EU average= based on 9 of the EU-15 countries for which data were available
Figure 8 - Self-reported unmet needs for dental examination due to financial reasons in Belgium (% of individuals included in the survey), international comparison, 2008-2017
Data source: Eurostat 2018; EU average= based on 13 of the EU-15 countries for which data were available

  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)
Table 1 : Conventioned practitioners : FTE density per province, per 10 000 population, 2016
Source: INAMI-RIZIV
ProvinceGPs Gynaecologists Dentists 
Antwerp 6.23  0.22 1.84
Brabant wallon 5.70 0.68 3.14
Brussels 4.95 0.52 4.29
Hainaut 6.02 0.51 2.50
Liège 7.47 0.31 4.81
Limburg 8.48 0.28 3.93
Luxembourg 6.85 0.08 3.57
Namur 8.33 0.26 2.84
Oost-Vlaanderen 7.80 0.22 2.99
Vlaams Brabant 7.26 0.48 3.32
West-Vlaanderen  8.03  0.17 3.01 
 
Table 2: Practising physicians : (FTE) density per specialisation, per 10 000 population, 2016
Source: INAMI-RIZIV
  Practising physicians Practising physicians
(in FTEs)
Practising and participating
physicians (in FTEs)
General practitoners  12 929 (1.14)

8 988 (0.79)

7 719 (0.68)
Paediatricians 1 532 (0.14) 952 (0.08)

824 (0.07)

Gynaecologists 1 462 (0.13) 948 (0.08)

369 (0.03)

Psychiatrists 1 958 (0.17) 1 289 (0.11)

1 129 (0.10)

Medical Group 9 753 (0.86) 6 683 (0.59)

5 077 (0.45)

Surgical Group 6 719 (0.59) 4 678 (0.41)

3 202 (0.28)

 
Figure 9 - Conventioned GPs density, in Full-time equivalent (FTE) per 10 000 insured population, per district, 2016
Datasource: RIZIV-INAMI
Conventioned GPs density, in Full-time equivalent (FTE) per 10 000 insured population
Figure 10 - Conventioned gynaecologists density, in Full-time equivalent (FTE) per 10 000 insured population, per district, 2016
Datasource: RIZIV-INAMI
Conventioned gynaecologists density, in Full-time equivalent (FTE) per 10 000 insured population
Figure 11 - Conventioned dentists density, in Full-time equivalent (FTE) per 10 000 insured population, per district, 2016
Datasource: RIZIV-INAMI
Conventioned dentists density, in Full-time equivalent (FTE) per 10 000 insured population

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).  
Figure 12 - Percentage of the total mass of billed fee supplements to the total mass of official health insurance fees – evolution 2006-2015-2017
Data source: IMA-AIM
Table 3: Amount and frequency of fee supplement
Source: IMA-AIM

 

Billed official fees
(million €)

Attested fee
supplements
(million €)

% of attested fee supplements
to billed official fees

% of fee billings 
with supplements

Classic hospitalisation

2 431

476

20%

12%

One day hospitalisation

673

87

13%

8%

Total

3 104

563

18%

11%

Table 4 : Number of patients confronted with fee supplements (2014-2017)
Source: IMA-AIM

 

Number of patients (more than one stay possible per patient)

 

2014

2017

Evolution 2014-2017

All stays

2 072 245

2 146 435

3.6%

Without fee supplements

1 598 822

1 723 799

7.8%

With fee supplements, amongst which

473 423

422 636

-10.7%

0 to 1 000€

308 263

236 639

-23.2%

1 000€ to 3 000€

135 128

148 589

10.0%

3 000€ to 5 000€

19 864

23 535

18.5%

5 000€ to 10 000€

8 270

10 960

32.5%

10 000€ to 30 000€

1 874

2 880

53.7%

30 000€ and more

24

33

37.5%

Link to technical datasheet and detailed results