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Other official information and services:  belgium

Efficiency refers to the ability to achieve the best possible result with the smallest possible effort or investment. In the field of health care, an efficient intervention will be one which is effective in achieving a desired result (e.g. preventing or curing a disease, increasing life expectancy, improving general health or quality of life, etc.), but which also has a limited “cost” (financially or in terms of time, complexity, etc.) compared to available alternatives. To put it simply, it is a measure of “return on investment”.

In a context where needs and costs keep increasing and where some resources (like doctors or nurses) are in high demand, improving the efficiency of the health system is crucial to make maximum use of the available budget and other resources.

For this section, we have selected five indicators of efficiency:

  • Four indicators relate to the uptake of newer, more efficient approaches over less efficient conventional ones: one-day surgical admissions (as an alternative to overnight hospital stays) (E-1), the use of low-cost medication (E-3), the use of biosimilar treatments (E-4) and the use of low-care dialysis (E-5).
  • Our last indicator, the length of stay after a normal delivery (E-2), relates to the efficient use of an existing service.

One-day surgical admissions (as a percentage of the total number of surgical operations performed) (E-1)

Until a few decades ago, surgical interventions traditionally required spending one or more nights in hospital. These days, however, simple routine procedures that are planned in advance (like cataract surgery, tonsils removal, circumcision, etc.) can often be carried out in a “one-day surgical unit” where the patient doesn’t need to stay overnight. Such units exist in most Belgian hospitals (97 out of 103 in September 2022).

This approach has a number of advantages for patients (less risk of catching an infection in hospital, less stress particularly for children…), but also for the healthcare system overall, as it allows for more efficient planning and shorter waiting lists, reduces the strain on nursing staff and the need for infrastructure, frees up beds more quickly, etc. This makes it a valuable indicator of the efficiency of the system, but also of its sustainability.

  • The percentage of surgical hospitalisations that were performed during a one-day hospital stay in Belgium increased from 47.7% in 2010 to 49.5% in 2021.
  • This percentage remains slightly higher in Flanders (52% in 2021) than in Brussels (46.7%) and Wallonia (45.1%).
  • There is considerable variation depending on the exact type of surgery (even within the group of operations that can be safely performed without an overnight stay), for reasons that seem linked at least in part to the way those procedures are financed in the one-day clinic setting. For some operations, the percentage of one-day surgery is much higher in neighbouring countries than in Belgium.

Link to the technical sheet and detailed results

Figure E1 - Percentage of surgical day cases amongst all surgical hospitalisations by region (2010-2021)
Data source: RHM - MZG

Average length of hospital stay for a normal delivery (E-2)

The time a new mom and her baby spend in hospital after a normal delivery has become shorter and shorter over the years, partly due to decisions affecting the available budget, and this trend is likely to continue in future. A few years ago, a KCE report also suggested a new model where most of the care for mothers and newborn babies just after delivery would be delivered at home; several experimental “pilot projects” have been launched since to test whether this is indeed feasible.

It also seems that the length of this type of stay is influenced less by the characteristics of the patients (keeping in mind that we are considering only normal, low-risk situations) than by those of the hospital and the healthcare professionals. This makes it a useful indicator of how efficiently health care is organised, which is all the more interesting because figures are available to compare Belgian results with those of other countries.

  • The length of the hospital stay for a normal delivery decreased from 5 days in 2000 to 2.7 days in 2021, with only small differences between regions (2.58 days in Brussels, 2.64 days in Flanders and 2.84 days in Wallonia).
  • In 2021, the average length of stay for a normal delivery was in line with the EU-14 average (2.7 days), while it was still well over the EU-14 and EU-27 averages in 2012.

Link to the technical sheet and detailed results

Figure E2 - Average length of stay for a normal delivery by hospital region (2010-2021)
Data source: RHM - MZG

Use of low-cost medication (E-3)

When the patent protection of original drugs expires, low-cost options like generic medicines (“copies”) or original products at substantially reduced prices often become available on the market. Getting the same treatment at a lower price whenever possible is obviously an efficient choice both for the patient and for the health system payer, and governments both in Belgium and abroad have long tried to promote the use of those cheaper alternatives through various measures. In Belgium, those measures include an obligation for all physicians and dentists to prescribe a certain percentage of low-costs medications, but also a financial penalty for the patients, who have to pay more out of pocket for “full-cost” medications if a low-cost alternative exists.

The definition of the low-cost category has changed somewhat over the years, but it currently (as of April 1st, 2021) includes all drugs whose price is within 5% of the cheapest option available for that particular medication.

  • The percentage of low-cost alternatives in the total amount of medication doses delivered outside of hospitals has increased significantly over the last two years, reaching 72.1% in 2022.
  • Regional differences are limited: in 2022, this percentage was 71.6% in Brussels, 71.0% in Wallonia and 72.7% in Flanders.

Link to the technical sheet and detailed results

Use of biosimilar treatments (E-4)

Biologicals, biological therapies or biotherapies are medications that contain a substance produced by or derived from living organisms (bacteria, cultures of animal or human cells, etc.), as opposed to “ordinary” medications created through purely chemical processes (even if they are sometimes copied from substances found in nature).

Although biological therapies are a much more recent invention than their chemical counterparts, the patents for a number of them have already expired, allowing the development of cheaper alternatives known as “biosimilars”. Unlike generic drugs, these biosimilars are not identical copies, because their fabrication process and their sheer complexity make them impossible to replicate exactly – there can even be a little variation between batches of the original product.

Biosimilars will, however, have the same effect as the original biotherapy. Like generic drugs, they are therefore an efficient choice for patients and for the healthcare system, and their use is actively promoted (new measures have been taken in October 2023, with an assessment planned every other year). They have been used in Europe since 2006, and some have been reimbursed in Belgium since 2008. In 2021, they were available on the Belgian market for 12 molecules.

  • The market share of biosimilars has been growing steadily since 2016, reaching 12.6% in 2021. In particular, a sharp increase in biosimilar use has been registered for some biotherapies in recent years.
  • Thanks to the increase in biosimilars market shares, expenses have been reduced while the use of the corresponding drugs has remained stable.
  • However, biosimilar use remains very low in Belgium compared to other European countries (figures are available only for hospitals, not for the ambulatory sector).

Link to the technical sheet and detailed results

Figure E4 - Shares of biosimilars in volume for available Belgian biological pharmaceuticals
Data source: INAMI - RIZIV

Low-care dialysis (E-5)

Dialysis is a type of treatment that helps the body remove extra fluid and waste products from the blood when the kidneys stop working properly and a transplant is not (immediately) possible. As the population gets older and more and more people live with chronic diseases, the number of patients needing this type of treatment is on the rise.

While dialysis can be performed in hospital (high-care dialysis), this is a costly option and not always necessary. As an alternative, a lot of people can be treated at home or in dedicated centres, with part or all of the manipulations required for the treatment being performed by the patient, or benefit from techniques like peritoneal dialysis, which require less equipment (low-care dialysis). Low-care options are also cheaper, and therefore more efficient in cases where they are possible.

Since 2016, a new agreement with INAMI-RIZIV requires general hospitals with a dialysis centre to organise at least 40% of their dialyses in a “low-care” setting. As of 2018, there are financial penalties for those who do not reach this percentage.

  • Overall, Belgium and all three regions currently achieve the required rate of 40% of low-care dialysis treatments. However, a few individual hospitals still miss the mark: in 2021, 4 of the 52 hospitals who had signed the agreement hadn’t reached the target (1 out of 9 in Brussels, 2 out of 24 in Flanders and 1 out of 19 in Wallonia).
  • The number of dialysis treatments has remained stable over the last 5 years, as have the respective shares of the various treatment options.

Link to the technical sheet and detailed results

Figure E5 - Proportion of hospitals having signed the agreement with at least 40% of low-care dialysis
Data source: INAMI - RIZIV