The impact of the crisis on the health system and health in Belgium
4. Implications for health system performance and health
5.4 Resilience in response to the crisis
Rapid change was not felt to be an urgent requirement in the wake of the crisis in Belgium because of the reforms introduced at the beginning of the 1990s and because there was no government for much of 2010 and 2011. Between 2008 and 2012, there was time to formulate policies that met stricter budgetary limits and at the same time could guarantee accessibility to services and more efficiency. When it became clear that the surplus in the health care budget had to be used for other social security sectors, all stakeholders became aware that greater efficiency measures were needed in the health care sector. This mentality change may have long-term consequences, both for the responsible and appropriate use of resources and for the acceptance of efficiency measures.
Technical measures have been taken to improve communication between different official data sources, such as the data from the sickness funds, (clinical) data registered at hospitals to allow them to obtain their annual budget, and fiscal data. This offers efficient instruments for generating data that are directly useful for policy-makers.
Belgium has invested in the monitoring of the health care budget since 1994, and in 2010 investments were made to prepare an assessment of health system performance (Vanthomme et al., 2010). A core set of 55 indicators was identified, of which 40 would eventually be measured. After the publication of the preparatory report in 2010, additional indicators were added that related to health promotion, mental health care, general medicine, long-term care, end-of-life care, continuity of care, patient centredness and equity. In 2012, the first Health System Performance Assessment report was published (Vrijens et al., 2012).
The report highlighted that the strengths of the Belgian health system are related to the vaccination rate in children, survival rates five years after a breast cancer or colorectal cancer diagnosis, relational continuity with GPs and increases in the prescription of low-cost drugs. Room for improvement was found in very high suicide rates, the growing number of people who are overweight or obese, the coverage rate of breast and cervical cancer screening in target groups, the high rate of caesarean sections and the social inequalities in many indicators.
6. Conclusions
The financial and economic crisis did not have a huge immediate impact on the Belgian health care system, mainly because of the measures to protect the health care budget installed before the crisis. Because of the real growth cap applied to the health care budget since 1995 and budget surpluses built up in previous years, the Belgian health system was well prepared to buffer the effects of the economic crisis. Budgetary margins were often used to improve accessibility to health care. Accessibility and quality of care are, and have long since been, the major objectives of health care policy, with respect for therapeutic freedom and freedom of choice. Therefore, when it became necessary to start taking economic measures, the focus was first on measures that would not be felt immediately by patients. Misuse of the system and outliers in terms of volumes of health care service provision were tackled first. Efficiency measures were then taken. Measures taken in the pharmaceutical sector were very effective. Future plans for efficiency measures will focus on evidence-based reimbursement (e.g.
fee-related real costs); appropriate use and financing of medical imaging, dialysis and DMPs; efforts to promote primary care; and the further development of integrated care for chronic diseases.
Resistance may be expected from stakeholders when efficiency measures reduce therapeutic freedom and perhaps freedom of choice. In addition, changes in financing, envisaged, for example, for the national fee schedule used in FFS reimbursement, will be challenging, as it currently determines the income of health care providers.
Moving towards more integrated care will require a mentality shift among stakeholders. The Sixth State Reform will make this shift even more challenging, as some health responsibilities are moved to the communities while others remain a central government responsibility. Goodwill and communication between the different levels will be indispensable.
Data technical measures have been helpful in the process of implementing evidence-based policy changes. Several measures have been taken in the past to facilitate communication between data sources. Involved stakeholders are
increasingly aware of the benefit of collaborating and are increasingly setting up formal collaborations to develop policy-preparing documents.
It is expected that the consequences of the economic recession will continue to be felt during the years ahead. The Belgian stability programme established in 2010 aims to reduce government debt to end the EU excessive debt procedure that was to be achieved by 2012 and to restore budgetary balance by 2015. The objective is to maintain a socially secure society with accessible and efficient health care.
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