Equity and inequalities in healthcare

Socio-economic inequalities in healthcare use may arise from a variety of causes. In addition to the health status of individuals, and related to this the need for health care use, other factors can also have an impact, such as socio-economic status (education level, income, employment status), availability of services, lifestyle, health insurance coverage (mandatory or supplementary), etc.
In terms of access to healthcare, some inequalities may be considered ‘fair’, for example, receiving more care than the average person when one has a disease. On the other hand, other inequalities in access to care may be considered ‘unfair’, such as those related to differences in income. Unfair inequalities are called ‘inequities’. 

Based on the data that were available for the 2019 report, we were able to conclude that people in more disadvantaged social groups had higher financial barriers to use healthcare services, a lower participation rate in cancer screening programmes, fewer regular dental visits, a higher consumption of medication (antibiotics, antidepressants, polymedication), and a higher probability of not reaching the recommended number of antenatal visits during low risk pregnancies. However, they had a better continuity of care index with their general practitioner. 

We also analysed 3 contextual indicators for equity. These indicators do not directly express the health system’s level of performance, but they can place it within a more or less positive context. These are the Gini coefficient (EQ-1), and the indicators on healthcare financing progressivity and regressivity (EQ-2 and EQ-3).

Additionally, on December 2020, an add-on on equity was published, analysing inequities in access to, use of and financing of care using detailed information on the health status, income, education level, employment status and healthcare utilisation and payments of individuals and households. Results of this report can be downloaded via the following links: Health System Performance Assessment - How equitable is the Belgian health system?

Gini coefficient (EQ-1)

The Gini coefficient illustrates how household income is distributed among the population. As such, it offers a statistical measurement of inequalities in society: the higher the Gini coefficient, the further the income distribution deviates from being perfectly equal among all members of the population. The advantage of this indicator is that it allows for comparisons between countries; its disadvantage is that it is very general.

On an international level, the Gini coefficient is considered as an indicator of the inequality of social and health problems. Indeed, studies have shown that there is an association between the way income is redistributed within the population (income inequality) and some forms of objective health problems and the perceived health situation or status. However, the causality of this relationships remains an open question.

  • Belgium is characterised both by an important middle class (contributing to a limited income inequality) and by a relatively high poverty risk, particularly for people with little or no education.
  • Income inequality is relatively high prior to redistribution through taxes and transfers. However, thanks to its taxation and social security system, Belgium ends up being one of the most egalitarian countries in Europe. This could have a positive impact on population health and healthcare consumption.
  • One-fifth of the population is at risk of poverty and social exclusion; in this respect, Belgium is aligned with the EU-15 average. There are important differences by age and educational level:
    • People aged 65 years and over have a relatively higher poverty risk (although it has been decreasing);
    • People of working age (18 to 64 years old) have the lowest poverty risk (although it has been increasing), but there are substantial differences between low and high educated persons.
    • Children aged 17 years or less have an increased poverty risk, without any clear upward or downward trend in the period 2005-2017.
Figure 1 - Gini index of equivalized income (year 2017)*

 HSPA en Gini

* The figures for Ireland and the United Kingdom refer to the year 2016.

Figure 2 - Gini index before and after taxes and social transfers (year 2015)

 HSPA en Gini before after

Link to technical datasheet and detailed results

Degrees of healthcare financing progressivity and regressivity (EQ-2 and EQ-3)

Universal health care coverage aims to ensure that everyone has access to the healthcare services they need, without experiencing financial difficulties nor worsening their poverty risk. This implies that the burden of financing the healthcare system should not disproportionately rest on those who suffer from illness; in other words, this financial burden should be largely independent of any health risks.
The public health system is funded through a combination of direct and indirect taxes and social insurance contributions. Each individual contributes to the system, at least potentially, through different types of mechanisms:

  • Direct taxes (e.g. the personal income tax), whose average rate increases according to taxable income; these are called progressive taxes.
  • Indirect taxes (e.g. VAT), which are ‘fixed’ since they are the same for everyone. These are called regressive taxes, because low-income people pay proportionally more compared to their disposable income (low-income households spend almost all of their income on consumption, while high-income household use only a smaller part of their income). 
  • Social contributions are a fixed part of gross employment income (with a few exceptions). This type of funding source is called proportional.

The proportion of each of these sources of healthcare funding has implications on redistribution and solidarity through the healthcare system. Healthcare financing is considered progressive when each individual’s relative contribution to healthcare financing increases according to his/her income; in the opposite case, the financing system is considered regressive.

  • Public funding of the health system has become more progressive, particularly since the 6th State reform. However, both the share of proportional receipts and regressive receipts exceed the share of progressive receipts.
  • Proportional receipts have been following a downward trend, because of the decreasing importance of social contributions as a financing source.
Table 1 :Evolution of progressivity indicators of the financing of the public healthcare system (2005-2014)
Sources: SPF – FOD Social Security, Year reports of National Social Security Office, Vade Mecum of financial and statistical data on social protection in Belgium, Year reports of National Institute for the Social Security of the Self-employed, Budget for healthcare by National Institute for Health and Disability Insurance, Book 2018 on Social Security by Court of Audit, National Accounts, KCE calculations

Indicators of progressivity/regressivity





Ratio proportional receipts/
total receipts (in %)





Ratio progressive receipts/
total receipts (in %)




14. 1%

Ratio regressive receipts/
total receipts (in %)





Ratio regressive/progressive





Link to technical datasheet and detailed results


(Further) impoverishing and catastrophic out‑of‑pocket payments (EQ-4 and EQ-5)

Out‑of‑pocket payments are said to be "impoverishing" if the household's financial resources are not sufficient to cover both basic needs and healthcare expenditures. Among poor households, i.e., those with financial resources that are not sufficient to cover their basic needs, these out‑of‑pocket payments are considered "further impoverishing".

Out‑of‑pocket payments for health care are said to be "catastrophic" when they represent more than 40% of total household expenditures (excluding basic needs). This means that (further) impoverishing out‑of‑pocket payments of are always considered catastrophic.

These indicators measure financial hardship when using health care. In an ideal health system, households should pay for health care in function of their capacity to pay (vertical equity principle), and recourse to health care should not plunge them into a situation of (greater) financial insecurity.

  • In 2018, 0.8% of households had to cope with "(further) impoverishing" out‑of‑pocket payments, which is an improvement compared to 2016 and a better result than France (2011: 1.2%) and Germany (2013: 1.2%) for example.
  • In 2018, 3.8% of households faced "catastrophic" out‑of‑pocket payments. This result is in line with the European average, but it is worse than that of Germany (2013: 2.4%) or France (2011: 1.9%).
  • The expenditures of households faced with catastrophic out‑of‑pocket payments differ significantly from those of the general population. For them, spending on medical devices (23%), hospital care (20%) and dental care (16%) accounts for the largest share. Out‑of‑pocket payments for drugs are a smaller share (10%).
Figure 3 - Proportion of households facing (further) impoverishing out-of-pocket payments, latest year available, EU-9

  EQ4 EN

Figure 4 - Proportion of households facing catastrophic out-of-pocket payments, latest year available, EU-9


Figure 5 - Distribution of out-of-pocket payments by health service among the population and households facing catastrophic out-of-pocket payments


Link to technical datasheet and detailed results