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Introduction to the Belgian healthcare system

Introduction to the Belgian healthcare system. Belgium in a nutshell. Belgium is one of the most densely populated countries in Europe. Its 10 807 396 inhabitants (1/1/2010 - Federaal Planbureau) live in a total land area of 30 528 km². Brussels is the capital and the largest city.

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Introduction to the Belgian healthcare system

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  1. Introduction to the Belgian healthcare system

  2. Belgium in a nutshell • Belgium is one of the most densely populated countries in Europe. • Its 10 807 396 inhabitants (1/1/2010 - Federaal Planbureau) live in a total land area of 30 528 km². Brussels is the capital and the largest city. • Belgium has three official languages, namely Dutch, French and German (59,2% = Dutch speaking; 40,2% French speaking; < 1% German speaking). Approximately 8.2% of the population are foreigners, mostly from Italy, Morocco, Turkey, France and the Netherlands. Gerits Pol - PhD - Adjoint DG1

  3. Belgium in a nutshell • The living standard is among the highest in Europe. • In 2007 the Gross domestic product per capita PPP was 35 380 $ (OECD 2009). • From an economic point of view, Belgium has in 2007 a low employment rate (62%) and a still significant public debt (94,3% of GDP - OECD 2005). Gerits Pol - PhD - Adjoint DG1

  4. A short introduction to the constitutional structure of Belgium. • Belgium is a federal state with a parliamentary form of government. • Three levels of goverment: • federal • regional (3 regions and 3 communities) • local (provinces and municipalities). Gerits Pol - PhD - Adjoint DG1

  5. The three communities Gerits Pol - PhD - Adjoint DG1

  6. The three regions Gerits Pol - PhD - Adjoint DG1

  7. A short introduction to the constitutional structure Since the Institutional Reform Act of 1980, part of the responsibility for health care policy has been devolved from the federal government to the regional governments Ambulatory services and health care in institutions were transfered to the communities. Health education, promotion and prevention have also been delegated to the communities. The health care responsibilities of the provinces and the municipalities are limited.

  8. A short introduction to the constitutional structure Important exceptions Organic act – lines of force – basic regulation Financing of operational costs of health care institutions when covered by the organic act Compulsory health insurance Rules concerning the planning of health services

  9. A short introduction to the constitutional structure • Important exceptions • national accreditation criteria on condition that they can have repercussions on planning, financing of operational costs or compulsory health insurance • establishment of criteria for the accreditation of academic hospitals Gerits Pol - PhD - Adjoint DG1

  10. A short introduction to the constitutional structure • To keep the cost of curative care under control the federal level makes use of three instruments: • determining the basic rules for planning of medical infrastructure • financing of hospital running costs • reimbursement of medical activities • It is based on the principles of equal access and freedom of choice, with a Bismarckian-type of compulsory national health insurance, which covers the whole population. Gerits Pol - PhD - Adjoint DG1

  11. An introduction to the Belgian health system • Even specialists who work full-time in hospitals generate their incomes from individual patient fees rather than from salaries (with exception of the specialists working in university hospitals). • Methods of payment to hospital specialists are often a mixture of different compensation forms. By pooling the patient fees they receive a lump sum and a variable amount per service, after deduction of hospital costs that cover the hiring of equipment and facilities. • Furthermore there is no privilege of private or public initiative. Gerits Pol - PhD - Adjoint DG1

  12. An introduction to the Belgian health system • The vast majority of GPs work as independent self-employed health professionals. • Primary care is not yet structured and private group practices are still rare but the number of partnerships among GPs in which each practitioner serves his own patients individually and receives a fee for that service is growing. There are a number of group practices where the fees are pooled. • Patients do not often have to wait long, if at all, for access to either GPs, specialists or hospitals. Also, GPs make many visits to patients at their homes (37% of total number of GP visits in 2005). • There is no clearly defined gatekeeper function. The free choice of physician is an important right granted to patients. This is one of the reasons why the average number of physician contacts per person in Belgium is high (2004: 7.1 outpatient contacts per person). Gerits Pol - PhD - Adjoint DG1

  13. An introduction to the Belgian health system • The legislation is roughly the same for public and private hospitals. In Belgium the label public / private refers to its ownership. • There are binding planning criteria: no hospital may be built, replaced or expanded if it does not meet these criteria. • Each department in a hospital must be accredited by the competent health minister. Accreditation is based upon norms of an architectural, organisational and functional nature (the hospital act). Gerits Pol - PhD - Adjoint DG1

  14. An introduction to the Belgian health system • The system of accreditation is primarily concerned with safety, hygiene, quality and continuity of care. The aim is to guarantee that hospital care meets requisite standards. • In principle, a hospital should have at least 150 acute beds, three basic departments (surgery, internal medicine plus a third one) and a number of basic functions such as anaesthesia, clinical pathology, radiology, rehabilitation, hospital pharmacy and palliative care. • Hospitals that had not met these conditions by 1 July 1998 were required to either close or merge. For the new mergers there is no maximum capacity. Gerits Pol - PhD - Adjoint DG1

  15. An introduction to the Belgian health system • In addition to the minimum hospital capacity the minimum bed capacity depending on hospital type is also fixed. When implementing the bed occupancy standards, account is automatically being taken of the performance in respect of length of stay. • Hospitals showing a structural undercapacity are required to close a number of beds. • A bed as a basic element of accreditation is a normally occupied bed that achieves a normal length of stay in relation to the disease and marks a normal shift towards day hospitalisation as compared to the national average. Gerits Pol - PhD - Adjoint DG1

  16. An introduction to the Belgian health system • In 1994, the competent advisory wrote a note entitled ‘A Note of Principle: from Structure to Activity programme’. The note contains elements for a new accreditation concept for hospitals. • Hospitals will be subject to tremendous upheaval as a result of both external and internal factors, such as the ageing of the population, changing attitudes towards hospitalisation and changes in medical technology. • Accreditations should no longer be primarily based on infrastructure (number of beds, types of beds, ets..) but rather on the nature of medical and nursing care that the hospital provides or intends to provide. Gerits Pol - PhD - Adjoint DG1

  17. An introduction to the Belgian health system • The basis for accreditation has to shift from the static hospital facilities data towards the activities which the hospital engages in, expressed as activity programmes intended for well-defined patient groups. • One can distinguish 2 types of programmes: the basic and the specialised programmes. • The basic programmes, with a mostly medico-surgical content, that may be differentiated on the basis of the age group of the patient • Specialised programmes that are directed towards groups of patients with identifiable and clear-cut conditions. They may be either problem/pathology-oriented or rather functional/organizational. Gerits Pol - PhD - Adjoint DG1

  18. An introduction to the Belgian health system • Meanwhile, the concept of ‘care programme’ has been included in the Hospital Act. • A Royal Decree has to specify the accreditation characteristics of each programme, such as the target group; the nature and content of the care; the minimum level of activity; the required infrastructure; the required medical and non-medical staffing and expertise; quality and quality assurance standards; business economics criteria; and finally geographical accessibility criteria. Gerits Pol - PhD - Adjoint DG1

  19. An introduction to the Belgian health system • At present there are care programmes for reproductive medicine; cardiac pathology; oncology, paediatric, oncology (general and breast cancer) and finally geriatric. • A medical council has to be established in every hospital. This council gives advice to the general manager on five issues: (1) general regulations; (2) medical activities; (3) relations with other staff functions; (4) financial means and finally (5) techniques necessary for medical activity. Gerits Pol - PhD - Adjoint DG1

  20. Some key data (vragen aan Anja Baelen) • The total number of acute hospitals is 146 (July 2008). The total number of acute beds is 55 053. The number of admissions in 2008 was 1 809 457 in acute beds and the average length of stay was 7,81 days. • The total number of specialized hospitals is 23. The total number of specialized beds is 1867. • The total number of geriatric hospitals is 8. The total number of beds in this type of hospitals is 1181. • The number of psychiatric hospitals is 69 and the total number of beds in psychiatric hospitals is 15 746. Gerits Pol - PhD - Adjoint DG1

  21. Payment mechanisms for hospitals • The structure of Belgian hospital financing consists of four parts: • the hospital budget; • the fees; • the pharmaceutical budget; • And finally the patient co-payment budget. Gerits Pol - PhD - Adjoint DG1

  22. Payment mechanisms for hospitals • The budget for hospitals’ running costs or the hospital budget is set each year and is composed of three major sections (A, B, and C) which are set separately and which are further divided into subsections. • Part A consists of three subsections: A1- investment charges; A2 - short-term credit burdens; and finally A3- investment charges for specific medical technical services which are exclusively financed by the hospital budget. Gerits Pol - PhD - Adjoint DG1

  23. Payment mechanisms for hospitals • Section B consists of 9 subsections: • B1- operating expenses of communal services; • B2 - personal expenses of clinical services; • B3 - running costs of specific medical technical services such as radiation therapy, MRI and PET; • B4 - cost relating to re-education and fixed prices; • B5- running costs of hospital dispensary; • B6 - social agreement - non patient-day personnel; • B7- costs related to the academic function (since 1.7.02); • B8 - costs related to the social function (since 1.7.02); and finally • B9 – costs related to social agreements (since 1.1.06) Gerits Pol - PhD - Adjoint DG1

  24. Payment mechanisms for hospitals • Section C consists of four subsections: • C1 - initial costs; • C2 - compensating amounts for previous years; • C3 - supplements and finally C4 - estimated compensating amount. Gerits Pol - PhD - Adjoint DG1

  25. Payment mechanisms for hospitals • Acute %Sp %Psy %Bra + G + Pal %Total % • A1 6,62 5,08 6,81 3,54 6,50 • A2 1,04 0,97 0,61 0,98 0,97 • A3 0,41 0,00 0,00 0,00 0,32 • B1 24,96 30,79 32,90 22,11 26,35 • B2 46,06 52,93 44,90 61,73 46,58 • B3 0,88 0,00 0,00 0,00 0,69 • B4 10,36 8,04 12,16 8,89 10,44 • B5 1,89 1,39 0,75 1,00 1,69 • B6 1,70 0,18 0,02 0,07 1,35 • B7 3,08 0,00 0,00 0,00 2,42 • B8 0,45 0,00 0,03 0,02 0,36 • B9 2,83 0,99 2,01 2,48 2,60 • C1 0,40 0,35 0,61 0,23 0,42 • C2 0,00 -0,24 0,96 -0,49 0,11 • C3 -0,67 -0,46 -0,15 -0,33 -0,58 • C4 0,00 0,00 -1,62 -0,23 -0,23 Gerits Pol - PhD - Adjoint DG1

  26. Payment mechanisms for hospitals • The two most important parts of the hospital budget are • B1 which covers the communal costs and services, more specifically administration, maintenance, heating, catering, laundry and other costs such as depreciation and financing of property investments • and • B2 which covers the costs related to the services of clinical nursing units, emergency admission (accident and emergency services) and nursing activities in the surgical department. • Together the costs of the sum of B1 and B2 represent more than 70% of the • Total budget. Gerits Pol - PhD - Adjoint DG1

  27. Payment mechanisms for hospitals • Section B1 -principles : • 1° Creation of 5 hospital groups • one group of university hospitals • 4 groups of non-university hospitals based on hospital size • 2° Distribution of the national B1 budget among the 5 groups • 3° Distribution of the budget granted to the group between all • elements of B1 based on a fixed percentage • 4° Distribution of the budget granted per element based on distribution codes • 5° Sum of budgets granted for each element Gerits Pol - PhD - Adjoint DG1

  28. Payment mechanisms for hospitals • The national budget B2 is divided among the hospitals on the basis of a scoring system. The scoring system provides basic financing on the one hand and supplementary financing on the other. Each hospital scores a certain number of points • National B2 Budget / Total of Points Country = POINT VALUE • Hospital budget = amount of points x point value • Base : * AP-R-DRG (All Patients Refined Diagnosis Related Groups). • By comparing the length of stay per DRG of the hospital with • the national average, a number of justified beds can be calculated • by unit. • -Activities for : surgical day hospital; improper classical stays and classical stays. Gerits Pol - PhD - Adjoint DG1

  29. Payment mechanisms for hospitals • This principle of justified activity is applied to the following units : C, D, I, E, M, G (and H – B – L). • It is not applied to A, K and NIC units. • Neither is it applied to Sp-units and psychiatric hospitals • Granting of justified bed-days of units proportional to bed-days billed. • Hospitals with non officially recognized G-beds: maximum 6 justified beds. • Justified bed-days per bed-index are divided by the normative occupancy rate to obtain the number of justified beds ( for C and D = 80%; E and M = 70% and for G-beds = 90%). Gerits Pol - PhD - Adjoint DG1

  30. Payment mechanisms for hospitals • Basic financing: 1 C-bed = 1 point • Rational: Personnel norms of the C-unit = 12 people per 30 beds with a 80 % occupancy rate = 0,4 person per bed or 0,4 person = 1 point Gerits Pol - PhD - Adjoint DG1

  31. Payment mechanisms for hospitals • Overall budget in billion euros • 2002 4.674.630.000 • 2003 5.093.098.050 • 2004 5.343.074.070 • 5.267.309.407 • 5.483.404.241 • 5.895.618.950 • 6.275.304.870 • 6.573.106.130 • 6.852.485.058 • There is an increase of 47% in the overall budget from 2002 to 2010. Gerits Pol - PhD - Adjoint DG1

  32. Patients’ rights • The general goal is to increase the accessibility and the compliance.It is a separate, straightforward and clear Act, flanking by policies. It is based on individuals’ rights. • The act can be divided in seven sections: • (1) the right to receive high-quality medical care; • (2) the right to freely choose the health care professional; • (3)the right to expect information to assess the health status; • (4) the right to well-informed consent; • (5) the rights relative to medical records; • (6) the right of protection of privacy and finally • (7) the right to lodge a complaint Gerits Pol - PhD - Adjoint DG1

  33. Patient safety • Since July 2007: additional financing for the co-ordination of quality and patient safety in Belgian hospitals • Long-range plan up to 2012 based on the Donabedian’s triad • (3 pillars) • Development of a safety management system (structure) • Analysis of processes (process) • Development of a multidimensional set of indicators (result) • Yearly contracts • Contract year 1 (2007-2008): signed by 80% of the Belgian hospitals • Contract year 2 (2008-2009): signed by 90% of the Belgian hospitals Gerits Pol - PhD - Adjoint DG1

  34. Patient safety • 6 topics with regard to quality and patient safety in contract year 1 (2007-2008) • Most important topic: the assessment of the patient safety culture (Hospital Survey on Patient Safety Culture of the AHRQ) • Benchmark: 132 of 170 participating Belgian hospitals (voluntary basis) Gerits Pol - PhD - Adjoint DG1

  35. Compliance with hand hygiene: increase of 50% before the campaign to 70% after the campaign Gerits Pol - PhD - Adjoint DG1

  36. Internationalcomparison: demographic and economic context • Between 1990 and 2007 the population growth averaged 0.36 % each year. This is only half the rate observed in the other OECD countries (0.84%). • The percentage of the population that is 65 years or older rose from 12 to 17.1% between 1960-2007 (Average of the OECD countries : from 9.0 to 14.7% - OECD 2009). The percentage of 65+ is expected to be 26.5% by the year 2050. • The averagefertility rate decreases between 1960 to 2006 from 2.6 to 1.8 (OECD from 3.2 to 1.7 – OECD 2009) • GDP/capita in USD PPP in Belgium in 2007 = 35.380 $ (Average OECD = 32.798 $ - OECD 2009) • In 2000, the Gini coefficient was 33. This is slighthy higher compared to our neighbouring countries (the Netherlands = 30.9 (1999); France = 32.7 (2004); Germany = 28.3 (2000)) Gerits Pol - PhD - Adjoint DG1

  37. Internationalcomparison: health status • Life expectancy at birth in Belgium increased from an average of 70.6 years in 1960 to an average of 79.8 years in 2007. (OECD – from 68.5 years to 79.1 years – OECD 2009) • Concerning our neighbouring countries: France, the Netherlands, Germany perform better than Belgium and especially France where the average life expectancy is 1.2 years higher. On the other hand, the life expectancy in Belgium is higher compared to that of the UK and Luxembourg (79.5 and 79.4). • On average, life expectancy at birth for women was 82.6 years in 2007 (OECD countries: 81.9 years) and 77.1 years for men (OECD countries: 76.3) Gerits Pol - PhD - Adjoint DG1

  38. Internationalcomparison: health status • 4. The average life expectancy for women aged 65 was 21 (OECD: 20,2) years in 2007, and 17.3 (OECD: 16,9) years for men. Concerning the neighbouring countries, only France do better than Belgium. • 5. Based on simulations, the average life expectancy at 65 years in OECD countries is expected to be 21.6 years for women and 18.1 years for men by the year 2040. • 6. Mortality: Little or no recent data are available for Belgium in the OECD report. Only the « infant mortality rate » is available. It dropped from 21.1/1000 living births (OECD: 28.7) in 1970 to 4/1000 (OECD: 3.9) in 2007. Our results are higher than the OECD average and worse than Germany (3.9), France (3.8) and Luxembourg (1.8) and better than those from the Netherlands (4.1) and the UK (4.8). Gerits Pol - PhD - Adjoint DG1

  39. Internationalcomparison: health status • The percentage of children with low birth weight in Belgium is 7.9 % in 2007 whereas the average across OECD countries is 6.8 % (OECD 2009). • Aids incidence in Belgium is 7.6 in 2006) (OECD: 16.2) new cases per one million inhabitants (OECD 2009). The Belgium results are worse than those from Germany but better than those in UK, the Netherlands, France and Luxembourg. • Health survey data (2008) show that 23% of the population is not satisfied with their health situation. There are also regional differences: Flanders = 21%; Brussels and Wallonia = 26%. This percentage increases to 48% for 75 +. • In England, Denmark, Norway and Switzerland these percentages are 26%; 22%; 20% and 14% respectively. Gerits Pol - PhD - Adjoint DG1

  40. Internationalcomparison: the relation between the degree of confidence in health care system and health status Gerits Pol - PhD - Adjoint DG1

  41. Internationalcomparison: non-medical determinants of health • 1. Tobacco consumption plummeted in Belgium during the 1982 – 2007 period (Percentage daily smokers: from 40.5% to 22 % ; OECD: 36.4 to 23.6). Our results are better than those in Germany, France and the Netherlands but worse than those in Luxembourg and United Kingdom (OECD 2009). • 2. However, alcohol consumption increased from 8.9 liter/inhabitant > 15 years old in 1960 to 10.7 in 2007 (OECD: 7.7 to 9.7). These results are higher than the OECD average (OECD 2009) • 3. In 2007, 12.7 % of the Belgian population have a BMI > 30 (OECD = 15.4), and this percentage rose by 1,7 % over a period of 7 years. France and the the Netherlands obtained better results (10.5 and 11.2 respectively), but they experienced a faster increase in the past (OECD 2009). In 2008 have 14% of the Belgian population a BMI > 30 (health survey 2008). Gerits Pol - PhD - Adjoint DG1

  42. International comparison: health care resources and utilisation • In 2007 we had an average of 4 active GPs per 1000 inhabitants (3.1). In the ranking we are only preceded by Greece (5.4). • 2. This ratio of GPs rose from 1.6 in 1969 to 4 in 2007. • 3. Our GP/specialist ratio is good (2.0/2.0) compared to the OECD average (0.9/1.8) and we occupy the first position in this ranking. Gerits Pol - PhD - Adjoint DG1

  43. International comparison: health care resources and utilisation • 4. We observe a similar trend in the number of nurses. In 2007 Belgium had 14.8 active nurses per 1000 inhabitants. That is more than the OECD average (9.6) and more than our neighbouring countries. We are in fourth place in this ranking. • 5. The number of acute beds in our country decreased from 5.0/1000 inhabitants in 1995 to 4.3/1000 in 2007. We can observe a similar trend in the OECD countries (4.7/1000 in 1995; 3.8 in 2007). However, the number of beds is much lower in France, the Netherlands and the UK (3.6; 3.0; 2.6). Gerits Pol - PhD - Adjoint DG1

  44. International comparison: health care resources and utilisation • 6. The Belgium’s average occupancy rate for acute care hospital beds is similar to the OECD average for 2007 (75 %). The UK and Germany have a higher occupancy rate than Belgium. • 7. In 2002 Belgium had 1.2/1000 65+ chronic beds in hospitals. This is way below the average within OECD countries (5.7). This is a relatively good result. France, for instance, had 8.1 beds in 2003, the Netherlands 0 beds in 2003 and the UK had 0.4 beds in 2004. Gerits Pol - PhD - Adjoint DG1

  45. International comparison: health care resources and utilisation • 8. Belgium has 152 psychiatric beds/100.000 inhabitants (PHs and General Hospital Psychiatric Wards). In the WHO-Euro region Belgium comes second, preceded only by Malta (185/100.000). • Italy 8/100.000 (min. number of beds in WHO Euro Region) • Germany75/100.000 • France95.2/100.000 • Luxemburg 97/100.000 • Netherlands 114/100.000 • Belgium 152/100.000 • Malta 185/100.000 (max. number of beds in WHO Euro Region) Gerits Pol - PhD - Adjoint DG1

  46. International comparison: health care resources and utilisation • 9. The number of admissions per 100.000 inhabitants in PH and GHPWs in WHO Euro regio) • Romania 1301 (max.) • Germany 1240 • France 1020 • Belgium 900 (eighth place) • Scotland 543 • Netherlands523 • England and Wales 286 • Albania87 (min.) Gerits Pol - PhD - Adjoint DG1

  47. International comparison: health care resources and utilisation • 10. The length of stay (median) in Belgian psychiatric hospitals is 36 days and 18 days in GHPWs. There is no information available for this parameter for our neighbouring countries. • 11. The number of psychiatrists per 100.000 inhabitants in Belgium is 20 in 2007. • Switzerland 42 (highest number) • France22 • Belgium 20 • Germany 19 • UK 18 • Netherlands15 • Turkey 3 (lowest number) (OECD 2009) Gerits Pol - PhD - Adjoint DG1

  48. International comparison: health care resources and utilisation • 12. Heavy medical equipment - 1: • In 2004 Belgium had 21.3 mammography devices per one million inhabitants (21.9). France has the highest number of mammography devices: 42.2 per one million inhabitants in 2002. • The number of units for radiotherapy in Belgium was 7.6 per 100.000 inhabitants in 2005, which is more than the average within OECD countries (6.4); and also more than any of our neighbouring countries. Gerits Pol - PhD - Adjoint DG1

  49. International comparison: health care resources and utilisation • 13. Heavy medical equipment - 2: • We had 7.5 MRI units per million inhabitants in 2007. That is below the average within OECD countries (11), but better than some of our neighbouring countries (NL, FR). • In 2007 we had 41.6 CT scanners, which is above the average within OECD countries (22,8) and more than our neighbouring countries. The number of MRI resp. CT exams per 1000 inhabitants was 48 resp. 168 in Belgium in 2007. Gerits Pol - PhD - Adjoint DG1

  50. International comparison: health care resources and utilisation • 14. The number of GP consultations per inhabitant increased from 7.1 in 1980 to 7.5 in 2005. This score is above average (6.8 in 2005) and higher than in any of our neighbouring countries. Our number of consultations per GP, however, is below average (BEL = 1.863 vs. OECD = 2.511). • 15a. The number of acute care hospital beds per 1000 inhabitants decreased from 5.0 in 1995 to 4.3 in 2007 (OECD: from 4.7 to 3.8). • 15b. The average duration of hospitalization decreased from 9.4 days in 1995 to 7.2 days in 2007. This downward trend can be observed in the other OECD countries as well (8.7 to 6.3). • 15d. The number of hospital discharges was 174/1000 inhabitants in 2007 (OECD: 158/1000 inhabitants). Gerits Pol - PhD - Adjoint DG1

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