Sustainability of the health system

Sustainability of a system can be defined as the system’s capacity to stay durably financed by public sources, to provide and maintain infrastructure and workforce (e.g. through education and training), facilities and equipment, to be innovative and to be responsive to emerging needs.

Sustainability is a broad and heterogeneous concept. We have chosen to divide it into 4 sub-dimensions:

• Financial sustainability (economic and fiscal) 
• Sustainability in terms of human resources 
• Sustainability in terms of available infrastructure and equipment
• Sustainability in terms of innovating capacity

Some indicators in this dimension are called 'future evolution' indicators (S-18, S-19 and S-20). Unlike the others, they assess the sustainability of the health system based on projection models and not only on past data. The relevance of this approach and the selection of the indicators concerned were the subject of a separate report (KCE report 341).

Most of these indicators are contextual, i.e. they are neither ‘good’ nor ‘bad’, but they provide an overall picture of the situation.

Summmary of the indicators on sustainability of the health system

(ID) indicator		Score	BEL	Year	Fla	Wal	Bru	Source	EU-15 (mean)
Healthcare expenditures and financing
S-1	Current expenditure on health (% GDP)	→	10.0	2016	-	-	-	SHA,OECD	9.5
S-2	Current expenditure on health per capita (in PPP US$)	↗	4660	2016	-	-	-	SHA, OECD	4539
S-3	Current expenditure on health (% financed by public sector)	→	78.8	2016	-	-	-	SHA, OECD	76.6
S-20 NEW 2021	Projection of public expenditure on health (% GDP), evolution in percentage points		+0,79	2019-2024	-	-	-	Study Committee on Ageing	-
Health workforce in the future (inflow, outflow)
S-4	Medical graduates (/100 000 population)	↗	12.1 (14.8)	2015 (2017)	-	-	-	SPF-FOD cadastre, OECD 2018	14.2 (EU-13)
S-14 NEW 2019	Foreign-trained physicians (% of those licensed to practice)	↗	11.5	2015	-	-	-	SPF-FOD, OECD 2018	13.9 (EU-10)
S-5	Medical graduates becoming GP (% of those with medical specialisation)		31.1	2016	34.9*	27.3*	-	INAMI-RIZIV	-
S-6	Mean age of practising GPs (in FTE, years)		52.7	2016	52.0*	53.8*	-	INAMI-RIZIV	-
S-7	Physicians aged 55+ (% of those practising)		44.4	2015	41.3*	47.8*	-	INAMI-RIZIV, OECD 2018	-
S-15 NEW 2019	GP aged 55+ (% of those practising)		54.5	2015	51.1*	58.6*	-	INAMI-RIZIV	-
S-8	Nursing graduates (/100 000 population)	↗	49.7	-	-	-	-	SPF-FOD cadastre, OECD 2018	42.3 (EU-13)
S-9	Nursing students following the bachelor route (% of new graduates)	→	55.7	2017	48.8*	64.8*	-	SPF-FOD cadastre	-
S-10	Nurses aged 50+ (% of those professionally active)	C	33.4	2016	34.1	31.3	35.2	SPF-FOD	-
S-16 NEW 2019	Foreign-trained nurse (% of those licensed to practice)	↗	3.2	2015	-	-	-	SPF-FOD cadastre, OECD 2018	3.2 (EU-8)
S-18  NEW 2021	Projection of the number of contacts with GPs (Demand), evolution in %		+7.1	2020-2025	+7.4	+7.0	+5.5	Federal Planning Bureau	-
S-19  NEW 2021	Projection of the number of GPs active in the healthcare sector (Supply), evolution in %		+2.6	2021-2026	+4.1*	+0.4*		FPS, Planning Unit	-
Maintenance of facilities
S-11	Curative care bed-days (number/capita)		1.1	2016	1.06	1.17	1.04	RHM-MZG, OECD	1.0
Innovation
S-13	Percentage of GPs using electronic global medical record (eGMR);  through MyCareNet		58	2018 (q3)	-	-	-	eHealth	-
S-17	Electronic global medical;  record (% of all global medical record)		65	2016	67	59	62	AIM-IMA, INAMI-RIZIV	-

* Based on the linguistic role of the physician (and not regional level) 

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

• Among care for the elderly indicators: Long-term care in residential facility (% pop aged 65+) (ELD-1); Long-term home nursing care (% pop aged 65+) (ELD-2); Number of long-term care beds in institutions (per 1 000 pop 65+) (ELD-4); Low care-dependent persons in residential/nursing facility for elderly (% of residents) (ELD-5); Number of practising geriatricians (per 10 000 population) (ELD-6).

Financial sustainability (S-1, S-2, S-3)

The financial sustainability of a health system is related to the evolution of expenditure dedicated to healthcare. Financial sustainability involves two aspects: economic sustainability, related to the growth in health expenditure as a proportion of Gross Domestic Product (GDP) and fiscal sustainability, related to the capacity to collect public revenues (taxes and social contributions) to meet the public expenditures.

• Economic sustainability is measured here by two indicators:  the current expenditure on health expressed as a percentage of Gross Domestic Product (GDP) (S-1), and the current expenditure on health expressed in US$ PPP per capita (S-2).
• Fiscal sustainability is measured by the percentage of health expenditure financed by public sources, i.e. a measurement of the system’s ability to continue being financed by public sources (S-3). 

By comparing S-1 (current expenditure on health) against S-3 (public expenditure on health), one can assess both aspects of the system’s financial sustainability.
Indicator S-2 (per capita expenditure) is mostly used for international comparisons. These three indicators are contextual, i.e. they are neither ‘good' nor ‘bad', but they help to define the sustainability context of the health system.

RESULTS

• In 2016, current expenditure on health for Belgium was 42.43 billion € and is increasing.
• This amount of health expenditure represents 10.0% of the Belgian Gross Domestic Product (GDP) (S-1); the percentage remains relatively stable over the years (Figures 1 and 2).
• Per capita, and expressed in Purchasing Power Parity (US $ PPP), an international unit that makes it possible to compare among different countries while taking into account each country’s purchasing power, this represents 4660 US $ PPP, which is very close to the EU-15 average (4539 US $ PPP) (Figures 3 and 4).
• In 2016, 78.8% of current expenditure on health was financed by the public sector (33.44 billion €). This percentage has increased slightly (76.3% in 2006 versus 78.8% in 2016) and is somewhat higher than the European average (76.6% in 2016) (Figures 5 and 6).
• The three sources of public revenue in the health sector are social contributions from employees (17.7%) and from employers (32.6%), and transfers from internal public administration revenue (49.7%).

Figure 2 - Current expenditure on health, as percentage of GDP, international comparison, 2016
Data source: SHA, OECD Health Statistics 2018

Figure 4 - Current expenditure on health per capita, in PPP US$, international comparison, 2016
Data source: SHA, OECD Health Statistics 2018

Figure 6 - Current expenditure on health, percentage financed by public sector, international comparison, 2016
Data source: SHA, OECD Health Statistics 2018

Link to technical datasheet and detailed results

Sustainability in terms of human resources

One important sub-dimension of a health system's sustainability is its ability to generate and maintain a sufficient quota of healthcare professionals.

Below is a suggested series of indicators which can help to determine this key aspect:

• Number of new medical graduates (S-4) and new nursing graduates (S-8), as well as the proportions of foreign-trained (S-14);
• Prospects of renewing general practitioners, according to the number of new graduates selecting this type of speciality (S-5) and the average age of general practitioners (S-6);
• Proportion of healthcare professionals who will retire in the near future (S-7 for physicians, S-15 for general practitioners, and S-10 for nurses);
• The training level of nurses (S-9).

These indicators should be interpreted together with the indicators on accessibility in terms of human resources, which provide information about the current density of practising physicians and nurses. 

Number of new medical graduates (in Belgium and abroad) (S-4)

The number of new medical graduates is a reflection of policy choices made these latest years regarding the number of students admitted to specialisation.

In 1997, the Belgian Federal government decided to establish a system of quotas that aimed at restricting access to specialisation as GPs and medical specialists (‘contingentement’ or quota system). This system came into force in 2004. i.e. after all students who had enrolled before the government decision could complete their training. There are two coexisting types of quotas:
- A maximum federal quota which cannot be exceeded for all specialisations;
- Minimum quotas to be reached for some new specialisations or specialisations requiring special attention: general practitioners, child and adolescent psychiatry specialists, emergency physicians, acute medicine physicians, and geriatricians. These quotas are then distributed between the Flemish ad French communities.
This system of quota only applies to physicians having received basic training in Belgium; some specialisations are also excluded (data management, forensic medicine, occupational medicine).
A system of ‘smoothing numbers’ was also put in place, allowing the universities to dip into the pile of future quotas to provide agreements for current students. In addition, since the 6^th State reform, the Federal State remains responsible for the definition of the maximum quotas, while the Communities are responsible for the sub-quotas.

In Belgium, basic medical training lasts six years (3 Bachelor years + 3 Master years), at the end of which students receive a Medical Doctor’s diploma and are granted a ‘visa’ (Licence to Practise) delivered by the Federal Public Service for Public Health, authorising them to practice in Belgium, as well as an INAMI number through which their services can be reimbursed by the health insurance system. They must also register with their provincial Board of Physicians.
The new graduates can then follow a specialisation (post graduate training) of three to seven years, depending on the area of specialisation (see also above the box about quotas).
Belgium also welcomes , i.e. physicians who have obtained their Medical Doctor's diploma in another country and who have then received a visa authorising them to practise medicine in Belgium. These physicians are nevertheless not all practising physicians.
This (contextual) indicator therefore helps to determine , which is made up, on one hand, by , and on the other hand, by receiving a visa to practise in Belgium. 

RESULTS

• In 2017, 1 685 students obtained their basic Medical Doctor’s diploma in Belgian universities, representing a rate of 14.8 new graduates per 100 000 population. There were 845 in the Flemish Community and 840 in the French community (Table 1).
• Among them, 59.7% were women and 40.3% were men (Table 1).
• Among them, 12.6% had not the Belgian nationality. Their distribution differs strongly depending on the community: 7% for the Flemish Community (a stable rate) and 18% for the French community (strong increase since 2013). A large part of these foreigner are French citizens who have come to study in Belgium, but they also include a growing proportion of students of other European and non-European nationalities (Figure 7).
• In 2017, 436 medical graduates with a foreign diploma received a visa (licence) to practise in Belgium, representing 20.6% of the total number of licences issued that year. This number of new arrivals seems to have decreased (there were 566 in 2015). Among these foreign medical graduates, 6.7% were Belgians (Table 2).
• International comparison (2015 figures): the density of new medical graduates in 2015 (12.1 per 100 000 population) places Belgium slightly below the average density of other European countries (14.2 per 100 000 population). This figure is increasing, as it can be observed in the 2017 results (14.8 per 100 000 population), but it is too early to tell how this will affects Belgium’s international ranking (2017 European data not yet available) (Figures 8 and 9).

Figure 9 - Number of medical graduates (in a Belgian university), per 100 000 population, international comparison, 2015Data source: OECD Health Statistics 2018; EU average= based on 13 of the EU-15 countries for which data were available

Link to technical datasheet and detailed results

Proportion of Foreign-trained physicians (% of those licensed to practice) (S-14)    

Recruiting physicians trained abroad can also help to maintain a sufficient number of physicians in a country. However, in its ‘Global Code of Practice on the International Recruitment of Health Personnel’ (WHO), the World Health Organisation encourages countries to become more ‘autonomous’ in the training of their own healthcare professionals.

RESULTS

• In 2017, out of a total of 63 381 physicians licensed to practise in Belgium, 7,606 (12%) had a foreign diploma. This proportion of foreign-trained physicians is increasing (Figure 10).
• One half of these physicians come from three countries: France (18%), Romania (17%) and the Netherlands (16%) (see Figure 11).
• International comparison (2015): the proportion of foreign-trained physicians compared to the total number of physicians licensed to practice varies from less than 5% in Italy and the Netherlands to more than 35% in Ireland. The Belgian average is slightly below the EU-10 average (13.9%). (Figure 12)

Figure 12 - Foreign-trained physicians, in percentage of those licensed to practice, 2015Data source: OECD Health Statistics 2018; EU average= based on 10 of the EU-15 countries for which data were available

Link to technical datasheet and detailed results

The renewal of general practitioners (S5-S6)

Among the general practitioners who are currently practising, many are approaching the age of retirement. It is therefore vital to attract young graduates towards general medicine in order to maintain the overall balance of the health system.

The following two indicators can help to define prospects for the renewal of general practitioners:

• Proportion of medical graduates becoming GPs 2 years after diploma (S-5)
• Mean age (in Full-Time Equivalent) of practising general practitioners (S-6)

RESULTS

Proportion of medical graduates becoming GPs (S-5)

• The proportion of medical graduates becoming GPs has slightly increased. In 2016, it was at 31%, which remains not enough to replace those who will be retired soon.
• In the 1990s, this proportion was approximately 40% (this is the proportion which, according to the Planning Commission estimates, should ideally be reached again). This number then fell below 25% between 2000 and 2010, when the quota system was introduced. A slight improvement has been observed since 2011, mainly in Flanders, but the number of general practitioners still remains too low: 35% in the Flemish Community and 27% in the French community (2017 figures).

Average age of general practitioners (S-6)

• Over the years, an ageing of general practitioners can be observed. The mean age of general practitioners (in FTE) was 52.7 years in 2016, compared to 46.6 years in 2000.
• The mean age is higher in the French Community than in the Flemish Community (53.8 versus 52.0, respectively, in 2016, based on the language of the diploma)
• By comparison with other specialists, general practitioners are usually older on average, while in 2000, their mean age was similar to that of other physicians.
• This situation can be explained both by the fact that older general practitioners work for longer periods of time, and by the lack of new graduates.

Link to technical datasheet and detailed results

Proportion of practising physicians (general practitioners and specialists) aged 55 years and over  (S-7 and S-15)

Physician ageing is generating a fair amount of concern throughout Europe, as it is feared that not enough new physicians may be available to replace them. This indicator provides an approximate estimate of the proportion of practising physicians (general practitioners and specialists) who will be retiring in the next 10 years (although many physicians still continue to practise after 65 years of age).

RESULTS

Proportion of practising physicians aged 55 years and over (S-7) 

• 44.9% of practising physicians in Belgium were aged over 55 years in 2016, versus 24.1% in 2000.
• These changes can be observed throughout Europe, but Belgium is among the countries with the highest proportion of physicians aged over 55 years (EU-12 average in 2015: 34.5%, compared to 44.4% in Belgium, including 41.3% in the Flemish Community and 47.8% in the French Community).

Proportion of practising general practitioners aged 55 years and over (S-15)

• For general practitioners, this proportion is even greater: 54.5% in 2015, including 51.1% in the Flemish Community and 58.8% in the French Community (distinction based on the language of the diploma).

Figure 17 - Physicians aged 55 and over, in percentage of those practising, 2015Data source: OECD Health Statistics 2018; EU average= based on 12 of the EU-15 countries for which data were available

As a precaution, it should be noted that the definitions of activity levels of practising physicians may vary from one country to another; this should not, however, affect changes over time.

Link to technical datasheet and detailed results

Number of new nursing graduates (S-8)

Maintaining a stable number of nurses requires making investments in this profession’s training as well as in its attractiveness. Many industrialised countries have taken steps towards increasing the number of nursing graduates in response to concerns regarding current or anticipated shortages. In many countries, the nurse workforce is indeed ageing. In Belgium, several measures have been taken to increase the number of nursing graduates, such as Project 600 which offers employees in the health sector the option of studying nursing care while retaining their salary.

RESULTS

• In 2017, 6 357 students obtained their nurse diploma in Belgium (3 538 bachelors (formerly A1) and 2 819 nurses with a diploma level (formerly A2)), representing 50 new graduates per 100 000 population. This figure has been increasing consistently (Figure 19).
• Among these new graduates, 85.5% were women and 14.5% were men, which is a fairly stable proportion over time.
• Among these new graduates, 57.4% come from the Flemish Community and 42.6% from the French Community.
• 15.9% of these new graduates are not Belgian. The proportion of foreign students in Belgian nursing schools differs significantly from one community to the other (Figure 12): in the Flemish Community, the rate is stable at approximately 3-4%, while in the French Community, it is 32% (15.5% if based on the place of residence).
• The density of 49.7 nursing graduates per 100 000 population is higher than the EU-13 average, which is 42 per 100 000 population (Figures 19 and 20). However, these figures are biased by the strong proportion of French students who come to study in the French Community, and who then majoritarily return to their country to practise.

Figure 20 - Number of nursing graduates (with a Belgian degree), per 100 000 population, international comparison, 2015Data source: OECD Health Statistics 2018; EU average= based on 13 of the EU-15 countries for which data were available

Link to technical datasheet and detailed results

Foreign-trained nurses licensed to practise in Belgium (S-16) 

Foreign-trained nurses are defined as nurses having obtained a diploma which is recognised in another country and having received a visa (licence) from the Federal Public Service for Public Health to practice as a nurse in Belgium.

RESULTS

• In 2017, out of a total of 202 402 nurses licensed to practise in Belgium, 7 248 (3.6%) had a foreign diploma. This proportion has increased over time, changing from 0.5% in 2005 to 3.2% in 2015 and 3.6% in 2017.
• The proportion of nurses trained abroad is much lower than that of physicians trained abroad (3.5% of nurses in 2017 in Belgium, versus 12.0% for physicians trained abroad), but the figures are quite similar in absolute numbers (7 248 nurses trained abroad and 7 606 physicians trained abroad in 2017).

Figure 22 - Foreign-trained nurses, in percentage of those licensed to practice, 2015Data source: OECD Health Statistics 2018; EU average= based on 8 of the EU-15 countries for which data were available

Link to technical datasheet and detailed results

Proportion of new nursing graduates following the bachelor route (S-9)

In Belgium, there are two levels of training: Bachelor-level (formerly A1) and Diploma-level (formerly A2). It is an established fact that the training level of nursing staff is strongly correlated to the level of patient health: Every 10% increase in the proportion of nursing staff holding an A1-level diploma is associated with a 5% reduction in the mortality rate of hospitalised patients (study conducted by Aiken and al., published in JAMA in 2003). In the United States, the (IOM) recommends reaching nursing staff numbers that include 80% of Bachelors by 2020 (starting from a little over 50% in 2010). In Belgium, policy makers have not (yet) formulated any goals on this subject.

RESULTS

• The percentage of nurses holding a Bachelor’s degree (A1) was 55.7% in 2017.
• This percentage had strongly increased between 2007 (20.1%) and 2011, then seemed to stabilise around 55%.
• The proportions of new graduates having reached a Bachelor level strongly differ between the two Communities: 64.8% in the French Community and 48.8% in the Flemish Community.

Link to technical datasheet and detailed results

Proportion of nurses aged over 50 years (S-10)

Aside from the total number of professionally active nurses in a country, their mean age also has a major impact on the current and future offer of nursing services on the labour market. In industrialised countries, the ageing of this workforce has generated concerns for many years, as it could be an early sign of shortage if insufficient numbers of new recruits are trained to replace them. Another source of concern is that many nurses leave their jobs before the age of retirement.

The proportion of professionally active nurses aged 50 years and over provides an approximate estimate of the number of anticipated retirees in the next 10 years (although a large number leave their jobs before the official retirement age). This indicator should be analysed at the same time as the indicator on the number of practising nurses and the number of new nursing graduates.

RESULTS

• Out of the 143 470 nurses who were professionally active on the Belgian labour market in 2016, 33.4% were aged 50 years and over (34.1% in Flanders, 31.3% in Wallonia and 35.2% in Brussels), and 18.4% were aged 55 years and over (18.3% in Flanders, 17.9% in Wallonia and 20.5% in Brussels).
• In Flanders and in Brussels, the majority of professionally active nurses were aged between 50 and 55 years, while in Wallonia, they were between 40 and 45 years of age.

Link to technical datasheet and detailed results

Sustainability in terms of infrastructure use: Number of curative care bed-days per capita (S-11)

The number of curative care bed-days per capita provides an indication of the population’s needs, and therefore of the infrastructures required in order to meet such needs. This indicator combines the number of admissions in hospitals and the average duration of hospital stays.

The number of curative care bed-days per capita (classic hospitalisations only, excluding day hospitalisations) has remained relatively stable over the past 10 years, with around 1.1 curative care bed-days per capita (S-11) which is also close to the European average, but which remains high compared to some countries such as the Netherlands (0.5). This stability can be explained by the fact that, on one hand, the average duration of stay has strongly diminished during this period, and on the other hand, the number of classic hospitalisations has increased. Assuming that the increase in the number of classic hospitalisations can be explained, for example, by the ageing of the population, and if the shortening of stays has no negative impact on health care quality, then their combined effect could be interpreted as a sign of increased efficiency of the hospital sector at the macro level.

RESULTS

• In 2016, the number of curative care bed-days was 1.1 per capita.
• This number has remained relatively stable over the past 10 years, changing from 1.13 in 2006 to 1.09 in 2016 (Figure 25).
• The results in Belgium are similar to the European average (based on 10 countries) and follow a parallel trend over time. (Figures 25 and 26 )

Figure 26 - Number of curative care bed-days per inhabitant, international comparison, 2016Data source: OECD Health Statistics 2018; EU average= based on 10 of the EU-15 countries for which data were available

Link to technical datasheet and detailed results

Sustainability in terms of innovation: eHealth (S-13 and S-17)

The use of new technologies in the healthcare system is a sign that the system is innovative. In Belgium, the different types of health services based on new information and communication technologies (ICT) can be grouped under the names of e-health (electronic medical records, electronic prescriptions, etc.) and telehealth (tele-medicine and mobile health).

In 2012, an "e-health action plan" was adopted by the various health authorities (9 ministries within federal and federated entities) for a 5-year period (2013-2018). Twenty concrete action points have been defined, with the aim of developing data exchanges between health care providers, increasing patient participation and knowledge, developing a common terminology, simplifying administrative procedures, improving quality of life and efficiency, and evolve towards a transparent governance with all actors involved. By 2018, about 75% of these goals were met.

In 2018, the Interministerial Conference on Public Health decided to launch a new eHealth plan for the 2019-2021 period to extend and strengthen the coordination of ongoing projects. This plan will likely incorporate indicators. In the meantime, only a few process indicators that are difficult to interpret are available.

In this report, we have chosen to measure the degree of computerization of global medical records and of administrative care management procedures, which should ultimately improve coordination, continuity and quality of care; avoid unnecessary or (too often) repeated examinations and conflicting prescriptions; and improve the correct referral of patients to other care providers and the communication between them. Finally, by incorporating reminders and links to good practice guidelines, eGMR can also improve the quality and appropriateness of care.

The two indicators selected are:

• the proportion of global medical records (GMR) that are electronic (S-17)
• the proportion of general practitioners using an electronic global medical record (eGMR) via MyCareNet (S-13)

MyCareNet is a centralised platform that allows all providers and healthcare institutions to exchange information with sickness funds in a simple, reliable and secure way.

RESULTSProportion of global medical records (GMR) that are electronic (S-17)

• In 2017, 65% of GMRs were electronic Global Medical Records (EMRs), but geographical variations can be observed: 67% in Flanders, 62% in Brussels and 59% in Wallonia (2017 data). In some parts of the Hainaut, Limburg or Liege provinces, the proportion of eGMRs was below 50% (Figure 1).

Proportion of general practitioners using an record (eGMR) via MyCareNet (S-13)

• Since the introduction of MyCareNet, a continuous increase has been observed in the number of general practitioners using an eGMR via MyCareNet, from 16% in the first quarter of 2016 to 58% in the third quarter of 2018 (Figure 2).

Figure 27 - Percentage of global medical records that are electronic, per district, 2017Data source: RIZIV-INAMI

Link to technical datasheet and detailed results

Projections on future evolutions (S-18, S-19, S-20)

Most of the indicators used to assess the performance of the health system are based on the data available and their evolution over time until today. This already allows to identify some warning signals.

However, a report on the performance of the health system must also be able to play a predictive role. That is why the so-called 'projection' or 'future evolution' indicators have been added to the sustainability dimension: they assess the sustainability of the healthcare system by using statistical projections (models) for the future evolution of the indicators. This allows to identify the possibility of any future imbalance, for example, between supply and demand.

In 2021, three indicators for future evolution have been added:

• The evolution of sustainability in terms of human resources, measured by two indicators: the projection, by 2025, of the evolution of the demand for general practitioners (measured by the number of contacts) (S-18) and the projection, by 2026, of the evolution of supply (S-19).
• The evolution of financial sustainability measured by the projection of the evolution of health expenditure (% of GDP) by 2024 (S-20).

Evolution of supply and demand in terms of human resources (S-18 and S-19)

As regards the supply of human resources for health, short- and long-term projections are available in Belgium as the Planning Commission of Medical Supply (supported by the Planning Unit for the Supply of Healthcare Professions) quantifies the number of doctors, dentists, physiotherapists, nurses, midwives and speech therapists, as well as their future evolution. Projections are made over a 5, 10, 15 and 20-year period; for doctors, they are calculated by specialty.

On the other hand, the demand for human resources for health is not subject to specific measurements. The demand for general practitioners was therefore assessed on the basis of projections of the number of contacts from a microsimulation model (PROMES) developed by the Federal Planning Bureau in collaboration with NIHDI, the National Institute for Health and Disability Insurance (INAMI - RIZIV). It is based on individual demographic and socio-economic characteristics, morbidity indicators, previous consumption and contextual factors.  

RESULTS

Evolution of the demand for general practitioners (S-18)

• Between 2020 and 2025, the number of contacts with GPs is expected to increase by 7.1%. This increase will be slightly lower in Brussels (5.5%) than in Wallonia (7.0%) and Flanders (7.4%) (Figure 29)

Link to the technical sheet and detailed results

Evolution of the supply of general practitioners (S-19)

• The total number of active GPs in Belgium is expected to increase by 3.5% between 2016 and 2021, by 2.6% between 2021 and 2026, by 3.3% between 2026 and 2031 and by 5.5% between 2031 and 2036 (Figure 30).
• Expressed in FTEs, these figures are expected to decrease between 2021 and 2026 before increasing by 3% between 2026 and 2031, and by 7.8% between 2031 and 2036. (Figure 31)
• Between 2016 and 2036, the increase in the number of GPs will be higher in the Flemish Community: from 6 907 to 8 510, an increase of 23.2% (Figure 30). Expressed in FTEs, however, this increase will be limited to 8.5% (Figure 31).

Link to the technical sheet and detailed results

Relationship between supply and demand

• In the short term (up to 2025), the increase in demand for GPs (S-18) is expected to exceed the increase in supply (S-19), particularly in the French-speaking part of the country. When supply is measured in FTEs, the results are even more worrying, as the number of FTEs is expected to decrease in both language communities. Recent efforts to increase supply therefore seem to fall short of the mark in the immediate future.
• In the longer term, however, the balance could be somewhat restored, as supply is expected to increase further from 2026 onwards (almost +8% FTEs between 2031 and 2036). Although we do not have long-term projections for demand, it seems that efforts to increase the number of young graduates choosing general practice will eventually have a positive impact on supply. 

Evolution of health expenditure (S-20)

In Belgium, as in most OECD countries, population ageing and technological progress are expected to increase the pressure on public health expenditure over the next few decades. Over the same period, the size of the working-age population is expected to remain relatively stable or even decrease. This is of particular concern for fiscal sustainability, as public financing accounts for a large share of total health expenditure (see S-3: 78.8% in 2016).

Indicator S-20 assesses the long-term financial sustainability of the health system using statistical projections of public health expenditure (as a % of GDP), distinguishing between acute and long-term care. 

RESULTS

• In 2019, public expenditure on health was €37.2 billion, which is 7.9% of gross domestic product (GDP); it is expected to reach 8.6% in 2024, and 10.0% in 2040, mainly due to an increase in spending on long-term care (Figure 32).
  • In 2019, most of this expenditure (€30.3 billion or 6.4% of GDP) is related to acute care, compared with €6.8 billion (1.4% of GDP) for long-term care.
  • Public expenditure on acute care is expected to rise from 6.4% of GDP in 2019, to 7.1% in 2024 (+11%), and to 7.8% in 2040 (+22%).
  • Expenditure on long-term care is expected to rise from 1.4% of GDP in 2019 to 1.6% in 2024 (+14%) and to 2.3% in 2040 (+64%).
• Given that public expenditure on health is expected to grow much faster than GDP, it is expected to account for an increasing share of GDP. Between 2019 and 2024, public health expenditure is expected to increase by more than 13% (constant 2019 prices), while GDP growth will only be around 3%. Therefore, an increase of 10% in the share of public health expenditure in GDP is to be expected.
• International comparison: Public expenditure on health in Belgium is expected to follow a similar trend to the EU-28 average in the short and long term. Nevertheless, Belgian public expenditure on long-term care (as a % of GDP) is higher than the EU-28 average, but offset by public expenditure on acute care that is lower than the EU-28 average. These differences are expected to increase slightly in the future (Figure 33).
  • NB: The international comparison is based on the projections of the Ageing Working Group (AWG) of the Economic and Financial Affairs (ECOFIN) Council, which are not directly comparable to the projections of the Study Committee on Ageing. They were made before the COVID-19 crisis and therefore do not take into account the impact of the pandemic.

Link to the technical sheet and detailed results