1. News and updates
The description of the Belgian health system is regularly updated on the platform of the European Observatory on Health Systems and Policies: HSPM platform - News and updates.
The Belgian health system covers almost the entire population for a large range of services. The main source of financing is social contributions, proportional to income. The provision of care is based on the principles of independent medical practice, free choice of physician and care facility, and predominantly fee-for-service payment.
The Belgian population enjoys good health and long life expectancy. This is partly due to the population’s good access to many high-quality health services. However, some challenges remain in terms of appropriateness of pharmaceutical care (overuse of antibiotics and psychotropic drugs), reduced accessibility for mental health and dental care due to higher user charges, socioeconomic inequalities in health status and the need for further strengthening of prevention policies. The system must also continue to evolve to cope with an ageing population, an increase of chronic diseases and the development of new technologies.
This Belgian HiT profile (2020) presents the evolution of the health system since 2014, including detailed information on new policies. The most important reforms concern the transfer of additional health competences from the Federal State to the Federated entities and the plan to redesign the landscape of hospital care. Policy-makers have also pursued the goals of further improving access to high-quality services, while maintaining the financial sustainability and efficiency of the system, resulting in the implementation of several measures promoting multidisciplinary and integrated care, the concentration of medical expertise, patient care trajectories, patient empowerment, evidence-based medicine, outcome-based care and the so-called one health approach. Cooperation with neighbouring countries on pricing and reimbursement policies to improve access to (very high price) innovative medicines are also underway. Looking ahead, because additional challenges will be highlighted by the COVID-19 crisis, a focus on the resilience of the system is expected.
3. Executive summary
The Belgian population enjoys good health and long life expectancy
Living standards are considered high in Belgium, which was relatively less affected by the 2008 financial crisis compared with other European countries. Efforts to reduce the public debt and the at-risk-of-poverty or social exclusion rate, and efforts to increase the employment rate will nevertheless continue.
The Belgian population is growing at a rate of about 0.5% each year as the result of positive net migration (more immigrations than emigrations) and a positive "natural balance" (more births than deaths). The ageing population is expected to increase in the future, at least until 2070. The proportion of the population aged 67 years and over (a new cut-off based on the increased retirement age) is estimated to increase from 16.5% in 2018 to 22.9% in 2070.
The health status of the Belgian population is generally good, with an increasing life expectancy situated just above the EU-28 (European Union Member States at 1 July 2013) average [but below the EU-15 (EU Member States before May 2004) average]. Nevertheless, obesity as well as alcohol and tobacco consumption are high and have a significant impact on population health. Reducing socioeconomic inequalities also remains a challenge and prevention policies could be further strengthened with a focus on risks factors and diseases that cause most of the disease burden. Cerebrovascular and ischaemic heart diseases are the leading causes of death; followed by dementia (including Alzheimer’s diseases), lung cancer and chronic obstructive pulmonary disease.
Health care competences are shared between the Federal State and the Federated entities
Belgium has three official languages (Dutch, French and German) and three levels of power, i.e. Federal authorities, Federated entities (three regions based on territory and three communities based on language) and local authorities (provinces and municipalities).
Belgium is a Federal state with a parliamentary democracy. The political system is based on proportional representation and there are many different political parties (Dutch-speaking, French-speaking or German-speaking). Jurisdiction over health policy and regulation of the health care system – based on a compulsory health insurance requiring social contributions – is divided among the Federal State and the Federated entities. The Federal State (Federal authorities) is competent for matters in the general interest of all Belgians, such as the national compulsory health insurance, the setting of the hospital budget and of general organisation rules, the regulation of health products and activities, the regulation of health care professionals, and patients’ rights. The National Institute for Health and Disability Insurance (NIHDI) manages the compulsory health insurance while the Ministry of Health (MoH, Federal Public Service Health, Food Chain Safety and Environment – Health Directorate) is responsible for the general organisation and planning rules of the health system.
Federated entities are the main competent authorities in the fields of care for older people, disabled care (including the granting of allowances), mental health care, primary and home care and rehabilitation. They are also the main competent authorities for health promotion and disease prevention. To facilitate cooperation between the Federal authorities and the Federated entities, inter-ministerial conferences are regularly organised.
The health insurance budget and health policy rely on negotiations between representatives of the government, patients (via the sickness funds), employers, salaried employees and self-employed workers. Health care provider representatives are also involved in decisions on the tariffs and reimbursement levels of health care services via national conventions or agreements between health care providers’ and sickness funds’ representatives.
The compulsory health insurance system is financed by social contributions proportional to income
The Belgian health system is based on compulsory health insurance characterised by solidarity between all Belgian residents. Social contributions, the main financing source, are considered as proportional receipts (the tax rate remains unchanged whatever the income, with some exceptions). Other sources are government subsidies and an alternative financing. Government subsidies come from receipts that are mostly considered as progressive (the tax rate increases with the level of income), such as personal income tax. Alternative financing consists mainly of receipts from value added taxes (VAT), which are regressive (the burden decreases with income) and, to a lesser extent, of receipts from withholding tax, which are progressive. Especially since the 6th State Reform, public financing of the compulsory health insurance has become more progressive, with a ratio of progressive receipts on total receipts of 7.3% in 2007 and 14.1% in 2017. Nonetheless, the shares of both proportional receipts and regressive receipts (52.6% and 26.7%, respectively) exceeded the share of progressive receipts (14.1%) in 2017. Given the decrease in the share of social contributions as a financing source (see section 3.3.2), proportional receipts have shown a downward trend, from 61.5% in 2007 to 52.6% in 2017.
To control expenditure, a real growth cap has been established since 1995 to determine the overall budgetary objective of the compulsory health insurance.
The compulsory health insurance is managed by the NIHDI, which allocates a prospective budget to the sickness funds. Sickness funds are non-profit, private players that operate the reimbursement system of health care services covered by the compulsory health insurance for their members and the payment of a replacement income in case of long-term illness. All Belgian residents must be affiliated to a sickness fund of their choice or to the public auxiliary fund. Since 1995, a mechanism has been introduced to make sickness funds more accountable for the health expenditure of their members. At the end of the year, the NIHDI calculates the difference between the actual health expenditure of their members and their so-called normative (risk-adjusted) expenditures, and sickness funds are held financially responsible for a proportion of this difference.
In addition, Belgian residents can also take out voluntary health insurance (VHI) for services that are only partially covered, or are not covered, by the compulsory health insurance (for example, for extra-billings when patients opt for a single room in hospitals). Voluntary health insurance is provided by both non-profit-making mutual insurance companies and sickness funds, and by private for-profit insurers.
Belgian residents are covered for a wide range of health services
Compulsory health insurance covers 99% of Belgian residents for a large range of services and with no selection based on health risks. The approximately 1% that is not covered comprises people whose administrative and/or financial requirements have not been fulfilled. It should nevertheless be noted that some categories of vulnerable people (for example, irregular migrants) are excluded from this calculation. People covered by another insurance scheme are also not included in this calculation (for example, foreign people working for international organisations). This does not mean that “uninsured people” have no right to necessary medical care. They can be covered through other systems, mainly via the public centre for social assistance (for example, urgent medical aid provided for irregular migrants).
In 2017, current health expenditure was 10.3% of gross domestic product (GDP) and health expenditure, expressed in US$ adjusted for differences in purchasing power per capita, was 5 119.1. More than three quarters of current health expenditure is financed by the public sector (77.25% in 2017). Voluntary health insurance represents a small share (5.12% in 2017) of health expenditure. Patients’ out-of-pocket payments (17.63% in 2017) apply for non-reimbursed services, official co-payments and extra-billings. Official co-payments represented about 22% of patients’ out-of-pocket payments in 2017 (after deduction for the reimbursements related to the system of maximum co-payments). The exact share of extra-billings is not known – in particular in outpatient care. Official co-payments vary from service to service and patients with preferential reimbursement status pay reduced co-payments. A series of protection mechanisms are also in place (for example, a system of maximum co-payments), which mainly depend on a households’ income.
All reimbursed services are described in the nationally established fee schedule (called the nomenclature), which specifies the official fees and cost-sharing mechanisms determined through conventions and agreements negotiated yearly or every 2 years between representatives of sickness funds and health care providers. Reimbursement decisions are based on criteria such as the therapeutic added value of the intervention and the budget impact. Evidence-based practices with a high therapeutic value are preferably reimbursed, whereas comfort or aesthetic services, such as plastic surgery and orthodontics, are only reimbursable under certain conditions (for example, breast reconstruction after cancer). When looking at patients’ out-of-pocket payments, reimbursement is more limited for mental health care and for dental care compared with other care services.
To avoid overconsumption and promote the responsible use of public money, the large majority of patients have to pay in advance the fees for services and then request reimbursement from their sickness fund. Initially, a third-party payment system (where sickness funds directly pay their share) only applied for the purchase of prescribed medicines and hospital/residential care, but this is being gradually extended to primary care (currently for vulnerable social groups and chronic patients). Additionally, in community health centres (wijkgezondheidscentra/maisons medicales) with a capitation-based remuneration system, registered patients who have opted for this system do not have to pay for the services they receive from these centres.
Care is provided based on independent medical practice, freedom of choice and fee-for-service payments
The provision of care is based on the principles of independent medical practice, direct access (no gatekeeping), free choice of physicians and of health care facilities (including hospitals), and predominantly fee-for-service payment (although in recent years, the use of fixed payments has increased).
Reimbursed health care services are provided by both public and private institutions and individual health care providers who mainly comply with the same set of rules, enjoy the same therapeutic freedoms and offer the same services. Patients are free to choose their health care providers and can access most of the specialised and inpatient care without assessment by a general practitioner (GP).
Physician numbers are regulated by a system of quotas
The density of practising physicians has been quite stable (3.1 per 1 000 inhabitants in 2018) and is below the EU-15 average (3.8 per 1 000 inhabitants in 2018, but the definition of practising physicians varies across countries).
It is also important to highlight that physicians in Belgium are getting older, especially GPs. In 2018, 44.3% of practising physicians were aged 55 years and over, in comparison to 24.1% in 2000. Concerning nurses, the number of practising nurses has increased (from 8.8 to 11.2 per 1 000 inhabitants from 2004 to 2017) but the patient to nurse ratio (the number of patients per nurse) in hospitals remains high.
Access to specialisation for physicians (including GPs) is limited by a quota system, with overall quotas defining the maximum number of physicians as well as minimum quotas for some specialties where a possible shortage has been identified (for example, for GPs). These quotas are determined by the Federal Minister of Social Affairs and Public Health based on the advice of the Planning Commission of Medical Supply of the MoH, which assesses the medical workforce needs. A similar quota system is in place for dentists.
The regulation of health professionals is being modernised
Since 2014, a reform of the regulation of health care professionals has been in progress, articulated around three pillars: competent health care providers, integrated and multidisciplinary health care and patient-centred care. New professional titles and competences have been created (such as advanced practice nurses and oral hygienists) and a new law on the quality of practice in health care has been elaborated.
The hospital landscape is changing
Concerning the hospital sector, mergers have led to larger hospitals, which are spread over different hospital sites. Hospitals can be classified into acute care hospitals, specialised or geriatric hospitals and psychiatric hospitals. In December 2018, there were 174 hospitals (105 acute care hospitals, 9 specialised or geriatric hospitals and 60 psychiatric hospitals) spread over 288 sites. The geographical distribution of hospital care facilities and the number of beds is in line with the population distribution.
The maximum number of beds in acute care hospitals has been fixed since 1982. There is also national planning for heavy medical equipment and some specialised services and care programmes. There has been a gradual decrease in the density of curative beds (from 620 to 497 per 100 000 population between 2000 and 2018), which is expected to continue. In contrast, the capacity for day hospitalisation, geriatric and chronic care beds will need to increase to meet changing population needs. Similar to other neighbouring countries, the average length of stay in curative care beds has decreased due to multiple factors, including incentives to increase efficiency.
Belgian hospital financing features a dual remuneration structure according to the type of services provided. Nursing and non-medical activities are financed by a national close-ended budget that is fixed annually and allocated to hospitals according to a large set of criteria and parameters (with the main subpart of clinical operational costs allocated based on the so-called “justified activities” that focus on pathology-weighted length of stay). Medical and medico-technical acts (consultations, laboratories, medical imaging and technical procedures) and paramedical activities (physiotherapy) are mainly paid through a fee-for-service system.
A redesign of the hospital landscape, including emergency care, is also underway with initiatives on care concentration for complex, expensive and technology-intensive services as well as cooperation and tasks assignment within loco-regional networks and supra-regional networks.
Specific measures were also undertaken to control expenditures and improve the quality of care, such as the introduction of a pay-for-performance programme and a lump sum payment for hospital stays requiring a standard process of low-complexity care, which varies little between patients.
Strengthening of primary care and integrated care
Although GPs do not have a gate-keeping role, measures have been taken to strengthen their position as the preferred entry point for health services. Initiatives have also been developed to improve the continuity and quality of care (for example, care pathways and pilot projects on integrated care for some patients with a chronic condition or the development of a national Evidence-Based Practice Network).
Patients are increasingly involved in their own care
Further attention has been focused on patient empowerment and patients’ involvement in their own care, especially for chronic patients. Efforts are underway to increase information on patients’ rights, to give patients access to their personal health information, and to include them in research and decision-making processes. Patient satisfaction is also increasingly taken into account in the financing of care, in particular through the integration of patient-reported experience measures in the pay-for-performance programme of hospitals.
International collaborations have been fostered to address high pharmaceutical prices
Pharmaceuticals, including over-the-counter medicines, are exclusively distributed through community and hospital pharmacies. To be reimbursed, pharmaceuticals must be included on a positive reimbursement list. The percentage of reimbursement varies according to the therapeutic importance of the pharmaceutical and the socioeconomic status of the patient (whether the patient has access to a preferential reimbursement or not). Different measures were taken to sustain innovation, strengthen the role of the community pharmacist, improve accessibility and promote the cost-effective use of pharmaceuticals. Nevertheless, the exponential increase in the price of innovative treatments and the lack of transparency in confidential price agreements threaten the system and new solutions such as the recent BeNeLuxA initiative are needed. The objective of this initiative is to increase accessibility by building country collaboration on drug policies (horizon scanning, health technology assessment, information sharing and policy exchange, and pricing and reimbursement decisions).
Maintaining the patients at their home for as long as possible
Regarding mental, palliative, long-term and rehabilitation care, the main focus is now on the deinstitutionalisation of patients and the development of home-based and community-based care so that the patient can remain at home for as long as possible.
Additional efforts needed for preventive care and dental care
Health promotion and disease prevention are under the responsibility of Federated entities but inter-ministerial conferences between Federal State and Federated entities on public health also play an important role. Assessments of the health status of the population and of the performance of the health system nevertheless highlight the need for a strengthening of prevention policies.
Concerning dental care, even though having regular contacts with a dentist is incentivised (for example, with full reimbursement for the majority of preventive and restorative procedures for all children up to 18 years and reimbursement for some dental care made conditional upon a registered dental contact during the previous year), several treatments (for example, fixed prosthodontics, most periodontal treatments, dental implants, orthodontics in adults and fluoride applications) are not reimbursed at all. Overall dental care is the health service with the lowest coverage, with only 38.6% of dental expenditure covered by the compulsory health insurance in 2017.
Reforms focus on improving accessibility, sustainability, efficiency and quality
Ensuring accessibility to health care and the sustainability of the health system have been long-standing policy objectives. Between 2014 and 2019, quality and efficiency have been additional major objectives. This has resulted in the implementation of several measures aimed at improving the structure and quality of health care. Consequently, “multidisciplinary and integrated care”, “expertise concentration”, “patient care trajectories”, “patient empowerment”, “evidence-based medicine”, “outcome-based care” and the “one health” approach were promoted and the regulation of health professionals was restructured. An eHealth plan has also focused on improving information exchange between health care providers and settings, including the digitalisation of medical records, electronic prescribing and patients’ access to their personal health information. The Belgian health care system has also been evolving to cope with an ageing population, an increase of chronic diseases and the development of new technologies.
In terms of governance, the transfer of additional health competences from the Federal State to the Federated entities is in line with the general reorganisation of the Belgian State. Initiatives to increase public accountability and to monitor performance through the Health System Performance Assessment (HSPA) framework have also occurred. A deliberation on the setting of national health targets to guide health policy-makers is also underway.
Over the next few years, major measures are expected to be introduced in Belgium to continue improving the quality of care and efficiency of the health system. Among them are the continuation of the hospital landscape reform, of the mental health care reforms and of the integrated care projects, the development of a national health research system, the reform of the national fee schedule, the implementation of a new law on quality practice in health care, and the possible integration of some vulnerable people currently covered by other systems (such as prisoners) into the compulsory health insurance system.
There is good overall access to health services of high quality, even if some challenges remain
In terms of performance, the health system was recently assessed as having overall good access to health services of high quality (2019 evaluation). The trend is also towards a more efficient use of care services, such as with an increase in the use of low-cost medicines and a decrease in the length of stay for normal delivery of a child. Nevertheless, some challenges remain in terms of appropriateness of pharmaceutical care (overuse of antibiotics and psychotropics), availability of GPs in the future (due to their increasing average age), availability of nurses in hospitals (due to the high number of patients per nurse) and accessibility to some care such as dental care, especially for the lowest income groups. Indeed, the share of individuals reporting unmet needs due to costs, waiting times, or travel distance is 3.7% (EU-15: 3.6) for dental examinations and 2.2% (EU-15: 2.0) for medical examinations. Cost is the main reason in Belgium, with a share of individuals reporting unmet needs because of costs higher than the EU-15 average (3.6% versus 3.1% for dental examinations and 2.0% versus 1.1% for medical examinations in 2017), especially in the lowest income quintile, where these are respectively 8.9% for dental examinations (EU-15: 6.9%) and 5.6% for medical examinations (EU-15: 2.5%). It should also be noted that while the health status of the population is generally good, and avoidable and preventable mortality rates are decreasing, important socioeconomic inequalities are observed through the whole spectrum of health indicators.
In terms of governance, the new division of competences (and budgets) between the Federal State and the Federated entities risks increasing the complexity and fragmentation of the system. Avoiding duplication of efforts and inefficiencies will therefore be a challenge.
In conclusion, what are the next steps?
In the coming years, policy-makers will continue to tackle these challenges and to pursue the goals of improving access to high-quality care while making the system efficient and sustainable. With the current COVID-19 crisis, new challenges will be highlighted and a focus on the resilience of the system is expected.
4. Full report
The full report can be downloaded via the following link: Belgium Health System Review 2020.