BELGIUM

Health policy is both a responsibility of the federal authorities and federated entities (regions and communities). The federal authorities are responsible for the regulation and financing of the compulsory health insurance; the determination of accreditation criteria (i.e. minimum standards for the running of hospital services); the financing of hospital budgets and heavy medical care units; legislation covering different professional qualifications; and the registration of pharmaceuticals and their price control. Federated entities are responsible for health promotion and prevention; maternity and child health care and social services; different aspects of community care; coordination and collaboration in primary health care and palliative care; the implementation of accreditation standards and the determination of additional accreditation criteria; and the financing of hospital investment. To facilitate cooperation between the federal authorities and the federated entities, interministerial conferences are regularly organized.

The organization of health services is characterized by the principles of therapeutic freedom for physicians, freedom of choice for patients, and remuneration based on fee-for-service payments.The compulsory health insurance is managed by the National Institute for Health and Disability Insurance (NIHDI-RIZIV-INAMI), which allocates a prospective budget to the sickness funds to finance the health care costs of their members. All individuals entitled to health insurance must join or register with a sickness fund: either one of the six national associations of sickness funds, including the Health Insurance Fund of the Belgian railway company, or a regional service of the public Auxiliary Fund for Sickness and Disability Insurance. Private profit-making health insurance companies account for only a small part of the non-compulsory health insurance market. In the past, sickness funds received the budget they needed to reimburse their members but since 1995, they have been held financially accountable for a proportion (25%) of any discrepancy between their actual spending and their budget, for which 30% is determined according to a normative risk-adjusted allocation.
Decision-making in the Belgian health system mainly relies on negotiations between several stakeholders. General policy matters concerning health insurance and its budget are decided by representatives of the government and the sickness funds but also by representatives of employers, salaried employees and self-employed workers. The health insurance system is also regulated by national conventions and agreements between representatives of health care providers and sickness funds (e.g. fees determination).
The Belgian health system is based on the principle of social insurance characterized by horizontal solidarity (between healthy and sick people) and vertical solidarity (based to a large extent on the labour incomes) and without risk selection. Financing is based mostly on proportional social security contributions related to taxable income and, to a lesser extent, on progressive direct taxation, and a growing area of alternative financing related to the consumption of goods and services (mainly value added tax).
The budget for public health expenditure is fixed by a legal real growth norm (4.5% since 2004). In 2007, Belgian total health expenditure was 10.2% of gross
domestic product (GDP). Health expenditure expressed in US$ PPP (purchasing power parity) per capita was 3595 in 2007, which was the sixth highest health expenditure per capita among the EU27 countries.
Patients in Belgium participate in health care financing through official co-payments and diverse supplements. The main payment mechanism is the fee-for-service payment. There are two systems of payments: (1) a direct payment (mainly for ambulatory care), where the patient pays for the full cost of the service and then obtains a reimbursement from the sickness fund for part of the expense; and (2) a third-party payer system (mainly for ambulatory drugs and hospitals), where the sickness fund pays the provider directly and the patient is only responsible for paying any co-payments, supplements or non-reimbursed services. However, the third-party payer system can be applied under specific conditions for ambulatory care to ameliorate the financial access for vulnerable population groups.
The reimbursement of services depends on the type of service provided, the income and social status of the patient (preferential reimbursement or not), as well as the accumulated amount of co-payments already paid for that year. For more vulnerable population groups, several measures were taken to ensure their access to high-quality care (OMNIO, maximum billing (MAB) system, etc.)

A significant proportion of health care providers are paid on a fee-for-service basis. For salaried employees in the health sector, salaries and career evolution are negotiated through a series of collective agreements. The number of health care professionals has been quite stable since 2000. Planning for physicians, dentists and other health care personnel is undertaken by the Committee for Medical Supply Planning. This committee is responsible for formulating proposals for the federal Minister of Public Health on the annual number of candidates per community that are eligible to be granted the professional title of physician, dentist or physiotherapist, after obtaining the relevant diploma.
Based on the committee’s work, a proposal was made to establish a quota mechanism. The quota mechanism is applied immediately after the completion of basic training, at the moment of application for recognition as a dentist or physiotherapist, and at the time of application for specialization for a physician (general practitioner (GP) or specialist). In order to achieve the quotas, the communities, which are responsible for education policy, were requested to take measures to limit the number of students. Some measures to increase the attractiveness of the GP and nursing professions, to make health care providers more accountable, to strengthen primary care and to promote the integration of health services and multidisciplinarity have also been undertaken.

In Belgium, hospitals can be classified into two categories: general and psychiatric. In 2008, there were 207 hospitals, of which 139 were general and 68 psychiatric. The general hospital sector consists of acute (112), specialized (19) and geriatric hospitals (8). The basic feature of Belgian hospital financing is its dual remuneration structure according to the type of services provided: accommodation costs, nursing activities in the nursing units, operating room, and
sterilization are financed via a fixed prospective budget system; while medical services, polyclinics and medico-technical services (laboratories, medical imaging and technical procedures) and paramedical activities (physiotherapy) are mainly paid via a fee-for-service system to the service provider. As an alternative to hospitalization, intermediary structures and services have been developed. These alternatives include day hospitalizations and long-term care centres. For specific groups, such as the elderly and persons suffering from mental illnesses, a wide range of community services are available as an alternative to residential long-term care.
Pharmaceuticals are exclusively distributed through community and hospital pharmacies. Only physicians and (to the extent that their profession requires) dentists and midwives can prescribe pharmaceuticals. About 2500 pharmaceutical products are on a positive list and therefore are partly or fully reimbursable. The percentage of the cost that is reimbursable varies, depending on the therapeutic importance of the pharmaceutical. To reduce expenditure on pharmaceuticals several measures have been undertaken. These include a further reduction in prices for products within the reference price system and establishment of prescription quotas for low-cost drugs, among others. Overall, the health system was recently assessed as having good accessibility and an appropriate level of safety. However, further improvements in effectiveness of preventive care, appropriateness of care, efficiency and sustainability could further enhance the performance of the overall system.
Recent reforms to the health system essentially aim to provide a high quality of care to the whole population and, at the same time, protect the sustainability of the system. The reforms that will be carried out in the coming years will likely continue to promote the objectives of accessibility, quality and sustainability. Further changes will also aim at simplifying the system in order to make it more homogeneous. ( HSiT )