Healthcare in Belgium

University Hospital of Antwerp

Healthcare in Belgium is best depicted as a 3 legged table-like structure standing over the patient. The table-top is a primarily publicly funded healthcare and social security service, run by the federal government, which organizes and regulates healthcare. The first leg provides healthcare in the form of independent private practitioners and public, university and semi-private hospitals and care institutions, there are a few (commercially run for profit) private hospitals.[1] The second leg is the insurance cover provided to patients and the third leg is formed by the industry which covers production and distribution of healthcare products, and research and development, although an important part of the research effort is done in universities and hospitals.

Organization

Healthcare in Belgium is mainly the responsibility of the federal minister and the "FOD Volksgezondheid en Sociale Zekerheid / SPF Santé Publique et Securité Sociale" ("Public Administration for Public Health and Social Security"). For some matters responsibility is delegated to the authorities of the communities, but in practise these responsibilities are exercised by the governments of the Flemish and Walloon (French) regions and the German-speaking community. Both the Belgian federal government and the Regional governments have ministers for public health and a supportive administrative civil service.

Political and regulatory

Territorial Competence Administrative service
Federal
Legislative Federal Parliament
Executive Federal Minister of Public Health and Social Security [2][3] Maggie De Block (2014-2019)
Judiciary Administrative court: Council of State (Raad van State / Conseil d'État)

Appeals: Court of Labour (Arbeidshof / Cour du travail)
First Instance: Labour Court (Arbeidsrechtbank / Tribunal du travail)

Public Administration for Public Health, Food Chain Safety and the environment [4] (FOD Volksgezondheid, Veiligheid van de Voedselketen en Leefmilieu / SPF Santé publique, Sécurité de la Chaîne alimentaire et Environnement)

Public Health

MEDEX:[5] Department for Medical Expertise
  • Civil service staff, absences, accidents at work, work related diseases
  • Medical certification of Pilots & air traffic controllers
  • Medical certification of professional drivers
  • Medical certification of ship officers
  • Warvictims & Military victims in peacetime
  • Victims of violent crime
  • Ombudsservice
  • Medical evaluation centres
Superior Health Council:[6] Scientific advisory board
  • Psychiatric health care: behaviour issues, addiction, education in psychiatric healthcare, best practise in therapy
  • Environmental issues: Ionising radiation, sound & dustpollution
  • Chemical environmental issues: chemical agents, pollution agents, biocides and pesticides
  • Health and safety in nutrition and in the foodchain
  • Biohazards: (human) blood products, tissues and organs, infectious diseases, epidemiological control
  • Cosmetology
  • Public Health Genomics
Consultative bodies:[7] Commissions and consultations between public administration and healthcare institutions and organisations
National Council for Hospitals and Care institutions Nationale Raad voor Ziekenhuisvoorzieningen (N.R.Z.V.) Coordination advisory council between government and hospitals & care institutions
Multipart structure Consultation advisory council constituted of:
  • professional organisations of:
    • physicians, Gp's and specialists,
    • nurses
    • other medical practitioners
    • hospitals and care institutions
    • medical insurers
  • the Government
  • Experts from
    • Public health, food chain safety and Environement
    • Institute for public sickness insurance and handicaps Rijksinstituut voor Ziekte- en Invaliditeitsverzekering (RIZIV)
    • Institute for knowledge about health care Federaal Kenniscentrum voor de Gezondheidszorg (KCE)
    • National Council for Hospitals and Care institutions Nationale Raad voor Ziekenhuisvoorzieningen (N.R.Z.V.)
    • Commission for control of the Healthcare budget and RIZIV
  • Inspectorate of Finance (From Treasury dept., public spending).
Joint Commission (De Nationale Paritaire Commissie Geneesheren-Ziekenhuizen"') Consultation and advisory commission Physicians - Hospitals
Commissions Working groups (Special Interest Commissions) on:
  • Telematica (application of digital technology)
    • Hospital digitisation
    • Health networks
    • Communication 1st & 2nd-line care
    • Digital data communication of care practitioners
    • Personal health data management
    • Remote healthcare
  • Embryo in vitro
  • Antibiotics
  • Patient rights
  • Euthanasia
  • Abortion
Federal Platforms Advisory boards for:
  • Palliative care
  • Psychiatric care
  • Coma patients
  • Hospital hygiene
  • Blood transfusion (BeQuinT)
Board of physicians: Medical practise, quality and evaluation advisory:
  • Cardiac Pathologies
  • Geriatrics
  • Specialised Emergency response and care
  • Intensive care
  • Chronic Renal Insufficiency
  • Mother and newborn infants
  • Medical imaging and Radiation therapy
  • Reproductive Health
  • Oncology
  • Paediatrics
Inter-ministerial and intergovernmental conferences Consultative and coordination between Ministerial Depts. of Federal and Regional governments
  • Agriculture
  • Food safety
  • Scientific R&D Policy
  • Public health
    • General policy
    • Epidemic control
  • Drug spolicy
Committees Consultative committees
  • Belgian counselling Committee for Bio-ethics
  • Medical - pharmaceutical committee
  • Federal breastfeeding committee
  • Committee for medical utensils an machinery
Planning Commission Investigates th Demand for Care practitioners and plans the offer
  • Working group on physicians (GP) and specialists
  • Working group on physiotherapists
  • Working group on dentists
  • Working group on nurses
  • Scientific working group
Scientific Institute of Public health:[8] Scientific expertise in public healthcare
Directorate Communicable and infectious diseases: plays an important role within the Belgian, European and international networks of surveillance and response to infectious diseases and food safety hazards.
  • detection
  • early and rapid identification
  • microbiological monitoring of communicable and infectious agents,
  • preventing and treating such diseases.
  • Food borne pathogens
  • Bacterial diseases
  • Viral diseases
  • Mycology and aerobiology
  • Immunology
Directorate Expertise, service provision and customer relations: providing the logistical, technical and scientific support.
  • Biological standardisation: Assessment and checking of the quality of biological medicines for human use (vaccines and blood products) before market
  • Quality of medical laboratories: Assessment and checking of the quality of clinical biology laboratories and in vitro diagnostic medical devices
  • Biosafety and biotechnology & platform Molecular biology and biotechnology: Assessment of the risks linked to the use of genetically modified organisms (GMOs)
Directorate Food, medicines and consumer safety analytical chemical research to promote public health: to detect the presence of chemical substances in food, consumer non-durables and the environment; scientific research in the following domains:
  • Medicines
  • Consumer safety
  • Chemical residues and contaminants
Directorate Public Health and surveillance epidemiology and toxicology centre to provide reliable, practical and impartial information on the health of the Belgian population, inform the policy makers and population on factors that influence public health and public health policy.
  • risk factors that affect health and well-being
  • monitoring health problems illnesses that constitute a risk to public health
  • assess the impact of lifestyle on public health a
  • improve the quality of care
  • assess the risks of exposure to chemical substances and radiation
  • coordinating sharing an transmission of health information in Belgium
Belgian GLP Monitoring Programme Quality Assurance Bureau (QAB) of IPH has been the official GLP (Good Laboratory Practice) Monitoring Authority for Belgium since 1988
Federal Agency for medicines and health products.[9] is the competent authority for medicines and health products in Belgium

Safety of the food chain

Federal Agency for the Safety of the Food Chain (FASFC).[10] is the competent authority for safety of the food chain in Belgium

Environment

Federal agency for nuclear control [11] FANC monitors and controls the general public, workers, and the environment against the dangers of radiation

Plants and animals

CODA-CERVA (Veterinary and Agrochemical Research Centre [12] proactive policy in terms of food production safety, animal health and public health, at both the Federal and international levels:
  • Scientific research
  • Expert advice
  • provision of services
    • Veterinary activities
      • Epidemic, endemic and emerging transmittable diseases in animals
      • Zoonotic and emerging infectious diseases threatening public health
      • Epidemiology: surveillance, risk analysis, and molecular epidemiology
    • Agrochemical activities
      • Contaminants and the quality of the environment in the framework of safe food production
Flemish Community
Legislative the Flemish parliament
Executive the Flemish Government, competent minister for welfare and social affairs, as of 2015 Jo Van Deurzen [13]
Judiciary none competent at this level
The competent administration is the Flemish Public service for Family-matters, Wellbeing and Health [14]
  • Health strategic competences
    • Public smoking ban, regulation an control, Assistance giving up smoking
    • Regulations on sale of alcohol
    • Drug and alcohol abuse and addiction
    • Health risks in construction
    • Radiation of wireless antennae
  • Subsidizing
    • School milk and fruit
    • Controls on food quality and industrial kitchens
    • Sexual health
    • prevention Hearing damage
  • Help and assistance for
    • Psychological help
    • Violence and Abuse
    • Addiction
  • Healthcare
    • Prevention
    • Vaccination programs
    • Prevention in Hospital and care environments
    • Patient rights
    • Care insurance
  • care situations
    • Home care
    • Psychiatric care
    • Care for the elderly
    • Palliative care
  • Handicap
    • Basic support budget (Basisondersteuningsbudget - BOB) and Personal assistance budget (Persoonsvolgende budget - PVB) financial support programs for the handicapped
    • Elderly support benefit
    • Assistance for people with limited mobility
    • Recognition as handicapped person / carer
    • Assistance with living for handicapped
    • Learning an working for the handicapped
    • Mobility issuers for the handicapped
French Speaking Community
Legislative the Parliament of the French-speaking Community
Executive [15] the Walloon government Competent minister, as of 2015 Joelle Milquet.
Judiciary none competent at this level
The competent administration is the "Direction de la Santé Publique de la federation Wallonie- Bruxelles" [16]
  • Health strategic competences: Public anti- Addiction programs smoking ban, Drug and alcohol abuse and addiction support
  • School health and kitchens
  • Healthcare Prevention, Vaccination programs
  • care situations: Home care, Psychiatric care, Care for the elderly, care for the handicapped
German-speaking Community
Legislative the Parliament of the German-speaking community
Executive the government of the German-speaking community [17]

Competent minister for welfare and social affairs, as of 2015 Herr Antonios Antoniadis,[18] Minister für Familie, Gesundheit und Soziales

Judiciary none competent at this level
The competent administration is the "Ministerium der DG" [19]
  • Health for Children: School health and kitchens, Health care, Prevention, Vaccination programs
  • Health for the Elderly: Home care, Care for the elderly, Psychiatric care, industrial Kitchens
  • Care for the handicapped
Provincial authorities
Legislative the Provincial Council: which is the elected body
Executive the Deputation or Provincial College and the Governor, who is appointed by the regional government, are the executive body, within that college one deputy has the responsibility for welfare and social affairs.
Judiciary none competent at this level
The Provincial authority for welfare is competent for matters that transcend the local level or local competences.
  • Assistance of people with disabilities and special needs
  • Assistance with chronic care
  • Assistance with psychological care
  • Assistance for palliative care
  • Care for the elderly
  • Care for children taken into public care by the juvenile judge
  • Hygienic control of industrial kitchens
  • Monitoring and registering of genetic birth defects

The provincial authority is also competent for catastrophe planning and management of the emergency services,

  • Ambulance services
  • Fire-fighting services, including the Civil protection service
  • private subcontractors (towing services, salvage, lifting and transport services) in case of emergencies or catastrophes
  • Coordination of all emergency services (police, highway services, army) during catastrophes
Local authorities
Legislative City or Communal Council
Executive College of Mayor and Aldermen ; dedicated alderman for Social affairs
Judiciary none competent at this level
The Public Centre for Social Welfare is a local authority public service
  • in Dutch: Openbaar centrum voor maatschappelijk welzijn (OCMW),
  • in French Centre public d'action sociale (CPAS)
  • in German Öffentliches Sozialhilfezentrum (ÖSHZ).

In larger cities these public services manage large budgets, with a substantial administrative burden and run Hospitals, Clinics, Rehab-centers, Old-age pensioners residences and day care centres. The largest PCSW for example is the one in Antwerp it managed in 2013 a budget of 461 million euros and paid benefits to people with no or very small incomes for a total of 125 million, the PCSW employs a workforce of over 1000 people,[20] the Hospitals and other care institutions are grouped into a separate organisation called ZNA [21] (Care Network Antwerp) hat employs another 7000 people, and had a budget of around 568 million euros in 2010.
A recent decision (made public in January 2015) by the Flemish regional government, aims at abolishing this local authority service, which had a substantial measure of independence and authority from the political elected councillors, and bring it under the authority of the communal council over the course of the next 2 year period. This decision is contested by the opposition and by legal impediments at the federal governmental level.

Organisation of Care

Generally speaking health care is organised in 3 layers:

Physicians

The prime care professionals that patients need are their GPs. For your common diseases like cold, flu, injuries and little aches patients contact their GPs.

Physicians in private practise are generally self-employed. Officially they are categorised in the following framework

Most doctors working in hospitals also have a private practise, exceptions are for instance neurosurgeons or radiologists (evidently because they cannot have an OR in their garage or invest in the high tech equipment required to do their job). Doctors are usually paid on a per medical act basis either by the patient at their private practise or by the hospital, however some specialists are employees at a hospitals payroll or for research labs or universities. Assessment consultants are paid a fixed fee for their assessment report by whoever hired them.

Emergency services

For accidents and medical emergencies everybody can call on the emergency services. There are 2 phone numbers to contact the Emergency Services Network, 100 or 112. 100 gives you access to the Ambulance service or Fire department. In larger cities the Fire department operates the Ambulances, elsewhere Ambulances might be allocated to hospitals. 112 gives you access to the Police, Ambulance Services and Fire department. The dispatching centres for the 100 and 112 services despatches an available ambulance from the closest hospital or ambulance centre, the operator is qualified to decide to dispatch a MER-vehicle.

Hospitals and the fire department operate ambulances and some hospitals, also the Red Cross charity operates an number of ambulances, and there are privately owned companies that operate ambulances for the emergency network. The Red Cross charity and a number of other "cross" charities own ambulances and have volunteers that man first-aid posts during events like football matches, cycling races, sports or other mass events, they don participate in the daily Emergency services network, but they do liberate the Emergency Services network from allocating too much assets and resources during those mass events.

Calling an ambulance is not a free service. The ambulance will bring the patient to the nearest hospital. An ambulance is manned by 2 people a driver and a paramedic. Depending on your medical condition a MERV or Medical Emergency Response- vehicle is dispatched. That vehicle is manned by 3 people a driver, an ER-doctor and a senior ER-nurse. The ER-doctor will choose the nearest appropriate hospital that has the necessary facilities based on the patients symptoms and condition, or another hospital in which the patient is under active treatment.

Hospitals

The Federal Service for Public Health describes the hospital sector[22] in the following manner:

General structure:
There are generally speaking 2 distinct types of hospitals: General hospitals and Psychiatric hospitals, on other words psychiatric patients are not mixed with general hospital population. The complete picture looks like this: there a 209 hospitals subdivided in:

The vast majority of hospitals are publicly funded: they are independent units or part of a larger organisation that get funding from the public health service based on the activities they deploy, number of beds operated, specialist knowledge etc... In Belgium there are only a handful of privately owned/operated hospitals that work outside and without the public health service funding, they provide luxury services and luxury accommodation for patient that can afford such exclusive services.

Outside these categories there are

In a general hospital any of the following departments may be at the disposal of patients, but not all general hospitals offer all these facilities and departments.

Nursing

Different levels of nursing training are available: basic nurse, midwife, full nurse

Pharmacy

Internet medication: if a patient buys medication in another EU country from a pharmacy for his personal use, by prescription or over the counter, he can import then in Belgium in his luggage or vehicle. Belgian patients may legally buy over the counter painkillers such as paracetamol in Holland where they are cheaper, and take them to Belgium. However attempting to import prescription drugs without prescription, unregistered or forbidden medication, or narcotics purchased on the internet or for recreational drugs illegally on the street is prohibited and customs and police track this business rather strictly. Illegally imported drugs are confiscated, and the carrier might be brought to justice and fined or imprisoned.

Health insurance

History

1894 : The first national law concerning the finance and provision of health care in Belgium was enacted, with social insurance being introduced in 1945.[23]

Working

Health insurance is only one of the pillars of the system of social security provided for every Belgian citizen. Every Belgian citizen has access to the social security system—it is compulsory—but there are gaps in the system where people can drop out: not paying contributions is one such exit, another is homelessness (social security is only available to people with an address).

Financing the system : compulsory social security

Every wage-earning worker or employee: in a factory, an office, working as house personnel (maids, chauffeurs etc) working in Belgium is registered to a central system, also the unemployed. The self-employed, such as shopkeepers, innkeepers, lawyers, and doctors, are also registered.

Workers are paid a daily or monthly wage : their gross salary. From that gross salary their employer has to deduct a certain amount (approx 13%) for social security and another (approx 20%) for taxes. The employer has to pay these amounts directly to the Social Security Services and the Inland Revenue Service (employers are making these payments for the employee and from his wage). On top of the gross salary the employer has to pay an employers contribution for social security of approx 15%-22% to the Social Security Services. Failing to make these payments regularly and on-time is closely monitored and often causes failing businesses to be taken to court for failing to comply with their social security and fiscal obligations for their workers, Reducing the risk for workers the they remain unpaid or that their contributions are not paid for them.
The Self-employed have a system in which they have to declare their earnings and based on that a contribution is calculated which is roughly 20%-22%, but they are not covered like workers. People can opt-in to the system through this self-employed scheme. The government form its tax earnings finances in part the social security system. This is a wealth re-distribution mechanism, because the contributions are incremental : meaning that the more someone earns the more that person will contribute. Moreover for health services the compulsory health insurance the refund system is the same for everybody (corrected for the lowest incomes) : i.e. for a consultation at the GP everybody pays the same and get the same refund (irrespective of their income).

Financing the system: complementary systems

There a complementary system of health insurance offered by the mutualities (extended hospital cover and travel cover), available to all mutuality members, and there is private insurance with commercial insurance companies for extended care (hospital and aftercare) and for travel care.
These systems are pure premium based insurance system.

Covering healthcare costs

1. Consultations with GP's or specialists in their private practise

2. Consultations at hospitals (polyclinic)

3. Hospitalisations and medical interventions

Managing healthcare money streams

the patients key to system

In the 80'ies an "SIS-card" (plastic creditcard-size chipcard like bank card) was introduced, the social security card. With it the Federal Government introduced a "national number", that identifies each individual uniquely based on his/her birthday. Every individual had such an SIS card, and it established their entitlement to social security.
In 2014 that system was superseded by the plastic ID card (Belgium EID card) with social security information on the card chip, readable with a simple card-reader.

Social security

Social security encompasses health, old-age (and other) pensions, unemployment, disability and handicap, both managing the finances (collection of contributions, subsides and payment of refund, allowances etc), but also the management of different kinds of care, regulation of the market of medicines, health and safety at work, health and safety of any public service rendered to the general public, Monitoring and safety of the food chain etc .. just the overview in the regulatory services involved at different government levels in chapter 1 provides an insight in the complexity of the matter of social security.

See also

References