Within the Belgian health system performance assessment framework, governance has been defined as the way in which health decision-makers strive to be accountable for their actions, to empower and involve the public, to be transparent, to provide institutions that fulfil their role and to listen and respond to the needs of the population.
To put it more simply, governance refers to the way in which health policy is conducted, either at the level of the health system as a whole or in specific sectors. This very broad concept encompasses aspects such as:
- using data and evidence to make the right decisions
- having a clear vision and working towards broader goals
- being honest and upfront about what is being done, how and why
- involving citizens in decision-making and giving them the power to act
- implementing decisions as well as possible
- requiring decision-makers to take responsibility for their actions and to give a satisfactory explanation for them
These aspects are crucial to the sustainability of the health system, but are unfortunately difficult to assess through numbers and figures (quantitative indicators).
The four indicators that have been selected for this subdimension relate to the governance of the health system as a whole and cover aspects like accountability, transparency, involvement/empowerment of the public and responsiveness to the needs of the population:
- Satisfaction with the healthcare system (S-29)
- Trust in the healthcare system (S-30)
- Formal participation role of patients in health policy (S-31)
- Availability of data to monitor health-related Sustainable Development Goals (S-32)
Indicators included in other dimensions or domains of the health system performance assessment , e.g. those on equity, on workforce and infrastructure availability, on the adequacy or the continuity of care, on the resilience of the health system, on prevention, etc. – can also provide (sometimes indirect) information on more specific aspects of governance.
Indicators on governance
* No score given as data are old.
Citizen satisfaction with the healthcare system reflects how well the healthcare system lives up to expectations, which tells us something about the way it takes people into account and responds to their needs. The opinions of citizens are important in shaping health policies and providing feedback for reforms or health programs, but they also bring legitimacy to policies and to those who make them. It is important to note that citizen satisfaction is different from patient satisfaction, which is measured at the healthcare provider level.
- Between 2007 and 2022, approximately 90% of the Belgian population reported being satisfied with the healthcare system. This percentage was consistently higher than the EU-14 and EU-27 averages.
- In 2022, Belgium was the EU-27 country with the highest percentage (90%) of the population that reported being satisfied with the healthcare system.
Data source: OECD health data
Data source: OECD health data
Trust is important for a performant health system because it supports cooperation at all levels, which is essential to improve health. The fact that the population trusts its healthcare providers and decision-makers can also have a very real impact on a variety of health-related behaviours. During the COVID-19 pandemic, for instance, it has been a crucial factor in achieving high vaccination rates or ensuring people complied with measures to control the spread of the virus. More largely, patients who trust the system are more likely to make proper use of its services, which, in turn, leads to better health outcomes.
Trust in the healthcare system is stimulated by various aspects of good governance like transparency, accountability, empowerment/involvement of the population and responsiveness to its needs, which makes it a relevant indicator in this context.
• During the COVID-19 pandemic, the mean level of trust in the healthcare system in Belgium increased from 6.7 to 7.0 (on a scale from 1 to 10) between April/May 2020 and June/July 2020, then decreased to 6.3 in February/March 2021.
• The level of trust in Belgium was consistently higher than the EU-27 average (6.3 in April/May 2020, 6.3 in June/July 2020, 5.9 in February/March 2021), and followed a similar trend. The EU-14 average level was higher than the Belgium level in April/May 2020 (7.1) and February/March 2021 (6.5), and equal to the Belgium figure in June/July 2020.
Data source: Eurofound data 2021
Data source: Eurofound data 2021
It is very important that people who use the health system can take part in decision-making and influence the care they receive, because this helps ensure that the health system is centred around them (as it should be!) and to hold governments accountable for their actions. To achieve this, decision-makers have to design strategies to involve various population groups and stakeholders not just once in a while as they see fit, but as a normal part of the decision-making process.
The OECD data we have used for this indicator pinpoint five areas in which citizens can be involved: licensing of medications, insurance coverage/reimbursement, health technology assessment, planning of health services and defining public health objectives
- In 2023, Belgium has a score of 2 (on a scale from 1 to 3) for the way it involves patients in shaping its health policy. Belgian citizens or patient organisations are involved in three areas of health policy making: insurance coverage or reimbursement, health technology assessment and defining public health objectives.
- Over the past ten years, Belgium’s score has remained similar to the EU-14 and EU-27 averages.
The availability of data on health and health care is of course crucial to assess the effects of health interventions and policies, but it also contributes to transparency and accountability by allowing scrutiny of public actors and their decisions. Ideally, health data should be collected over time on a regular basis and make it possible to pinpoint differences by e.g. age, sex, economic status, etc.
The United Nations’ Sustainable Development Goals (SDGs) include 59 health and health-related indicators. Of those, 27 fall under the overarching health goal (“Ensure healthy lives and promote well-being for all at all ages”) and need to be considered and monitored in national health strategies and policies. The remaining 32 relate to other SDGs (e.g. those addressing water and sanitation or nutrition). Each country is responsible for monitoring its progress in implementing the SDGs, which requires high-quality, accessible and timely data collection and analysis to ensure that no one is excluded.
- Belgium had data available for 82% of relevant health-related SDG indicators for at least one year between 2013 and 2017. This is lower than the EU-27 (87%) and EU-14 average (88%).
Data source: WHO data 2013-2017