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Belgium: Health system review
Abstract and Figures
The Health Systems in Transition (HiT) profiles are country-based reports that provide a detailed description of a health system and of policy initiatives in progress or under development. HiTs examine different approaches to the organization, financing and delivery of health services and the role of the main actors in health systems; describe the institutional framework, process, content and implementation of health and health care policies; and highlight challenges and areas that require more in-depth analysis. The Belgian population continues to enjoy good health and long life expectancy. This is partly due to good access to health services of high quality. Financing is based mostly on proportional social security contributions and progressive direct taxation. The compulsory health insurance is combined with a mostly private system of health care delivery, based on independent medical practice, free choice of physician and predominantly fee-for-service payment. This Belgian HiT profile (2010) presents the evolution of the health system since 2007, including detailed information on new policies. While no drastic reforms were undertaken during this period, policy-makers have pursued the goals of improving access to good quality of care while making the system sustainable. Reforms to increase the accessibility of the health system include measures to reduce the out-of-pocket payments of more vulnerable populations (low-income families and individuals as well as the chronically ill). Quality of care related reforms have included incentives to better integrate different levels of care and the establishment of information systems, among others. Additionally, several measures on pharmaceutical products have aimed to reduce costs for both the National Institute for Health and Disability Insurance (NIHDI) and patients, while maintaining the quality of care.
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... 6 In België zijn de gefedereerde entiteiten bevoegd voor gezondheidspromotie en ziektepreventie. 7 Momenteel ondersteunen ze rookstop door een begeleiding met erkende tabacologen gedeelteltijk terug te betalen. 8 • Een literatuurstudie naar ethische aspecten bij longkankerscreening (Hoofdstuk 7); ...
Er gaan steeds meer stemmen op om personen met een hoog risico op longkanker, zoals bv. zware (ex-)rokers, regelmatig te screenen met een CT-scan met lage stralingsdosis. Wanneer de kanker in een vroeg stadium wordt ontdekt, zijn de behandelingsmogelijkheden en overlevingskansen immers beduidend beter. Aan het Federaal Kenniscentrum voor de Gezondheidszorg (KCE) werd gevraagd om de doeltreffendheid, veiligheid en kosteneffectiviteit van een dergelijke screening te onderzoeken. Longkankerscreening blijkt aanzienlijke voor- en nadelen te hebben, die de overheid en vervolgens de hoogrisicopersonen goed tegenover elkaar moeten afwegen. Longkankerscreening kan kosteneffectief zijn als de bereidheid van de overheid om te betalen zich bevindt boven de €20 000 per gewonnen levensjaar in goede gezondheid.
... 6 En Belgique, les entités fédérées sont responsables de la promotion de la santé et de la prévention des maladies. 7 Elles soutiennent actuellement le sevrage tabagique en remboursant partiellement l'accompagnement assuré par un tabacologue reconnu. [8][9][10] 1.2. ...
De plus en plus de voix s’élèvent pour proposer régulièrement aux personnes à haut risque de cancer du poumon, comme les gros (ex-)fumeurs, un dépistage au moyen d’un CT-scan à faible dose. Les possibilités de traitement et les chances de survie sont en effet nettement meilleures lorsque ce cancer est identifié à un stade précoce. Le Centre Fédéral d’Expertise des soins de santé (KCE) a été chargé de se pencher sur l’efficacité, la sécurité et le rapport coût-efficacité d’un tel dépistage. Il ressort de ses recherches que le dépistage du cancer du poumon présente des avantages et des inconvénients considérables, qui doivent être mûrement pesés par les autorités puis par les personnes à haut risque elles-mêmes. Le dépistage du cancer du poumon peut être coût-efficace si les autorités sont prêtes à débourser un montant de plus de €20 000 pour le gain d’une année de vie en bonne santé.
... 6 In Belgium, the federal states are responsible for health promotion and disease prevention. 7 They currently support smoking cessation by partially reimbursing counselling with recognised tobacologists. [8][9][10] 1.2. ...
... Het Belgische gezondheidszorgsysteem wordt grotendeels gefinancierd met overheidsmiddelen. Maar ook privégelden van profit en non-profit actoren spelen een belangrijke rol in de bestaande zorgverlening 95 . Succesvolle hervormingen vereisen dan ook gedeeld eigenaarschap van zowel zorgverleners als de overheid. ...
POSITION PAPER 2 -- 1. CHRONISCHE ZIEKTEN: EEN UITDAGING VOOR DE BELGISCHE GEZONDHEIDSZORG 5 -- 1.1. CHRONISCHE ZIEKTEN BLIJVEN EEN PRIORITEIT VOOR DE BELGISCHE OVERHEDEN 5 -- 1.2. CHRONISCHE ZIEKTEN: EEN UITDAGING VOOR ALLE GEZONDHEIDSZORGSYSTEMEN 6 -- 1.2.1. Internationale consensus over plan van aanpak 6 -- 1.2.2. Prevalentie van chronische ziekten in Europa 6 -- 1.3. PREVALENTIE VAN CHRONISCHE ZIEKTEN IN BELGIË 7 -- 1.4. HET BELANG VAN MULTIMORBIDITEIT 7 -- 1.5. EEN BELASTING VAN DE MEEST KWETSBARE PATIËNTEN 7 -- 1.6. STIJGENDE KOSTEN 7 -- 2. WAT IS EEN CHRONISCHE ZIEKTE? VAN EEN PATHOLOGIEGERICHT NAAR EEN BEHOEFTEN-GESTUURD CONCEPT 8 -- 2.1. EEN BREDE WAAIER VAN PATIËNTENBEHOEFTEN 9 -- 2.2. KIEZEN VOOR EEN BEHOEFTEN GESTUURDE BENADERING 9 -- 3. HET BELANG VAN PATIENT- EMPOWERMENT 10 -- 4. SCOPE EN METHODEN 11 -- 4.1. SCOPE: FOCUS OP CHRONISCHE ZORG EN GEZONDHEIDSZORG 11 -- 4.1.1. Belang van Health in all Policies 11 -- 4.1.2. Scope: focus op chronische zorg en gezondheidszorg 11 -- 4.2. METHODEN 11 -- 5. EEN VISIE OP DE TOEKOMSTIGE ORGANISATIE VAN CHRONISCHE ZORG IN BELGIË 12 -- 5.1. VISIE OP CHRONISCHE ZORG IN DE BELGISCHE GEZONDHEIDSZORG 12 -- 5.1.1. Bronnen 12 -- 5.1.2. Kernvisie 13 -- 5.1.3. Bijkomende kwalificaties 13 -- 5.1.4. Visie op chronische zorg binnen de gezondheidszorg 14 -- 5.2. CONCEPTUEEL MODEL: ACTIVITEITEN OM DE VISIE OP CHRONISCHE ZORG TE REALISEREN 15 -- 5.2.1. Module 1: routinezorg plannen, verlenen en coördineren 15 -- 5.2.2. Module 2: respons op acute episodes en het verlenen van gespecialiseerde diensten 15 -- 5.2.3. Module 3: uitvoeren van activiteiten rond vroegtijdige opsporing 15 -- 5.2.4. Module 4: ondersteunen van empowerment van patiënt en mantelzorger 16 -- 5.2.5. Module 5: activiteiten voor gezondheidspromotie en acties gericht op primaire preventie 16 -- 5.2.6. Module 6: een dynamisch zorgmodel implementeren en opvolgen 16 -- 5.2.7. Noodzakelijke voorwaarden voor bovenvermelde activiteiten 17 -- 5.2.8. Overzicht van het conceptuele model voorgesteld voor een gezondheidszorgsysteem aangepast aan zorg voor chronisch zieken 17 -- 5.3. VAN ACTIVITEITENMODEL TOT BELEIDSAANBEVELINGEN 18 -- 6. BELEIDSAANBEVELINGEN 18 -- 6.1. ROUTINEZORG PLANNEN, VERLENEN EN COÖRDINEREN 18 -- 6.1.1. Geïndividualiseerd zorgplan 18 -- 6.1.2. Routinezorg en ondersteuning bieden aan de chronisch zieke 21 -- 6.1.3. Het controleren en evalueren van de zorgkwaliteit 27 -- 6.1.4. Instaan voor zorgcoördinatie 29 -- 6.2. RESPONS OP ACUTE EPISODEN EN VERLENEN VAN GESPECIALISEERDE DIENSTEN 32 -- 6.3. HET UITVOEREN VAN ACTIVITEITEN ROND VROEGTIJDIGE OPSPORING 34 -- 6.4. ONDERSTEUNEN VAN EMPOWERMENT VAN PATIËNT EN MANTELZORGER 35 -- 6.4.1. Ontwikkelen van competenties bij zorgverleners en van hulpmiddelen om patient empowerment te ondersteunen 35 -- 6.4.2. Zorgen voor dienstverlening en ondersteuning van patiënt empowerment 37 -- 6.5. HET UITVOEREN VAN GEZONDHEIDSPROMOTIE EN ACTIES GERICHT OP PRIMAIRE PREVENTIE 38 -- 6.6. EEN DYNAMISCH ZORGMODEL IMPLEMENTEREN EN OPVOLGEN 38 -- 7. REFERENTIES 45 -- BIJLAGE VAN DE POSITION PAPER 55 -- OVERZICHT VAN DE BELANGRIJKSTE ACTIEGEBIEDEN EN BETROKKEN ACTOREN 55 -- BIJLAGE 1.1. ONDERWIJS EN OPLEIDING 55 -- BIJLAGE 1.2. ONTWIKKELING VAN PROTOCOLLEN EN COMMUNICATIEHULPMIDDELEN; 56 -- BIJLAGE 1.3. ONTWIKKELING VAN TOEPASSINGEN VOOR INFORMATIE- EN COMMUNICATIETECHNOLOGIE 56 -- BIJLAGE 1.4. INITIATIEVEN VOOR KWALITEITSVERBETERING 57 -- BIJLAGE 1.5. EMPOWERMENT 57 -- BIJLAGE 1.6. PERSONEELSBESTAND 58 -- BIJLAGE 1.7. ORGANISATORISCHE HERVORMINGEN 58
... Patients have free choice of provider, and there is no gatekeeping function, so patients can visit multiple general practitioners (GPs) and have direct access to specialist care. However, financial policies, such as the Global Medical Record (GMR), are used to channel patient behaviour according to the gatekeeper model [33]. Patients who opt in for the GMR allow a GP to manage their medical information and will have lower co-payments. ...
Background
Although the Chronic Care Model (CCM) provides the essential structural components of practice organisation to deliver high-quality type 2 diabetes (T2D) care, little is known about which of its elements are most important, and the extent to which it may reduce social inequities in the quality of T2D care. This study aims to assess the association between the implementation of CCM’s structural elements and the quality of T2D care processes and outcomes in Flanders (Belgium), paying specific attention to differences by patients’ socioeconomic vulnerability.
Methods
We developed a longitudinal database combining information on primary care practices’ CCM implementation, with individual-level health insurance and medical lab data. Our sample included 7,593 T2D patients aged 40 years and above from 58 primary care practices in Flanders, followed up from 2017 to 2019. Medical lab data were available for a subsample of 4,549 patients. By estimating a series of hierarchical mixed-effects models, we assessed the association between primary care practices’ CCM implementation and two process and two outcome indicators of T2D care. In addition, we explored cross-level interactions with patients’ socioeconomic vulnerability.
Results
Patients were more likely to have their HbA1c tested twice a year and LDL cholesterol tested yearly in practices with a higher overall CCM implementation. Regarding the different CCM elements, the clinical information system and linkages to the community were significantly associated with higher odds of being up-to-date with HbA1c testing, whereas stronger community linkages was the only dimension significantly associated with yearly LDL cholesterol testing. While socioeconomic vulnerable patients were less likely to have their HbA1c tested twice yearly, this difference disappeared in the highest-scoring practices. Regarding the outcome indicators, only a negligible proportion of variation in HbA1c and LDL cholesterol levels was due to systematic differences between practices, and hence, no clinically relevant associations with the CCM elements were found.
Conclusion
Our pioneering findings support the social capital pathway, as CCM implementation is associated with a reduction in the healthcare inequity gap in the T2D care process. This suggests that promoting CCM implementation may improve healthcare equity, particularly in regions with significant socioeconomic disparities or high concentrations of deprived individuals.
Purpose
People with substance use disorders (SUD) have multiple associated health and social conditions that may lead to unmet needs, even among those receiving professional support. Furthermore, the fragmented nature of care provision may also contribute to unmet needs. Therefore, we assessed the needs of service users with SUD and identified their need profiles and their determinants. We aimed to identify possible gaps in care that were likely to hamper recovery pathways and to examine whether the care supply was tailored to users’ needs.
Methods
A convenience sample of 562 service users with SUD drawn from diverse mental health services in Belgium, including specialised services for SUD, were assessed using the Camberwell Assessment of Needs– Short Appraisal Schedule (Patient version). Additional indicators, including social integration, substance use behaviours, service utilisation, and well-being, were also collected. A Latent Class Analysis was performed to identify need profiles.
Results
Three classes of need profiles were identified. The largest class comprised 40% of the sample and included individuals with few needs. The second class encompassed 35% of the sample and represented those whose needs were mainly met by professionals. The third class, accounting for 25% of the sample, included individuals with many unmet needs. Across classes, company, intimate relationships, and sexual expression were the most reported unmet needs. Poor social integration and subjective well-being were associated with more needs, either met or unmet. Females (OR = 2.76, p = 0.025), and those using social services (OR = 2.54, p = 0.022), homecare and outreach services (OR = 3.683, p = 0.003) were more likely to report met needs. In contrast, using multiple substances was associated with unmet needs (OR = 3.87, p = 0.008). There was no significant association between need profiles and the use of specialised services for SUD.
Conclusion
Needs of people with SUD go beyond substance use and encompass social relationships. Although no major differences in need profiles were observed based on service utilisation, social integration and interpersonal relationships deserve greater attention from the perspective of the personal recovery of people with SUD.
POSITION PAPER 2 -- TABLE OF CONTENTS 2 -- 1. CHRONIC DISEASES: A CHALLENGE FOR THE HEALTH CARE SYSTEM 5 -- 1.1. CHRONIC DISEASES REMAIN A PRIORITY FOR THE BELGIAN HEALTH AUTHORITIES 5 -- 1.2. CHRONIC DISEASES: A CHALLENGE FOR ALL HEALTH CARE SYSTEMS 5 -- 1.2.1. Strategies proposed by international organisations 5 -- 1.2.2. Prevalence of chronic diseases in Europe 6 -- 1.3. PREVALENCE OF CHRONIC DISEASES IN BELGIUM. 6 -- 1.4. IMPORTANCE OF MULTIMORBIDITY 6 -- 1.5. A BURDEN FOR THE FRAILEST PATIENTS 6 -- 1.6. ESCALATING COSTS OF CHRONIC DISEASES 7 -- 2. WHAT IS A CHRONIC DISEASE? FROM A DISEASE-ORIENTED TO A NEEDS-BASED -- CONCEPT 8 -- 2.1. MULTIPLICITY OF PATIENTS NEEDS 8 -- 2.2. NEEDS-BASED APPROACH FOR CHRONIC CARE 8 -- 3. IMPORTANCE OF PATIENT EMPOWERMENT 9 -- 4. SCOPE AND METHODS 10 -- 4.1. SCOPE OF THE POSITION PAPER: FOCUS ON CHRONIC CARE AND SUPPORT -- DELIVERED BY THE HEALTHCARE SYSTEM 10 -- 4.1.1. Importance of health in all policies 10 -- 4.1.2. Scope of the position paper: focus on care and support delivered by the healthcare -- system 10 -- 4.2. COMBINATION OF METHODS 11 -- 5. A VISION ON THE FUTURE ORGANISATION OF CHRONIC CARE IN BELGIUM 11 -- 5.1. VISION OF THE PROVISION OF CHRONIC CARE IN THE BELGIAN HEALTH CARE SYSTEM 11 -- 5.1.1. Sources 11 -- 5.1.2. Core vision 12 -- 5.1.3. Additional qualifications 12 -- 5.1.4. Expanded vision of the provision of chronic care within the health care system 13 -- 5.2. CONCEPTUAL MODEL: ACTIVITIES TO IMPLEMENT THE VISION OF CHRONIC CARE 13 -- 5.2.1. Module 1: plan, provide and coordinate routine care 14 -- 5.2.2. Module 2: provide acute episode response and specialized services 14 -- 5.2.3. Module 3: conduct early identification 14 -- 5.2.4. Module 4: support patient/informal caregiver empowerment (including self-management) 14 -- 5.2.5. Module 5: conduct health promotion and prevention activities 14 -- 5.2.6. Module 6: implement and follow-up a dynamic care model 15 -- 5.2.7. Requirements for the above mentioned activities 15 -- 5.2.8. Overview of the conceptual model proposed for a health care system oriented -- towards chronic care 15 -- 5.3. FROM ACTIVITY MODEL TO POLICY RECOMMENDATIONS 16 -- 6. POLICY RECOMMENDATIONS 16 -- 6.1. PLAN, PROVIDE AND COORDINATE ROUTINE CARE IN THE PRIMARY CARE SETTING 16 -- 6.1.1. Individualized care plan 16 -- 6.1.2. Provide routine care and support for the chronic patient 19 -- 6.1.3. Monitor and evaluate progress and quality of care 23 -- 6.1.4. Provide care coordination 26 -- 6.2. PROVIDE ACUTE EPISODE RESPONSE AND SPECIALISED SERVICES 28 -- 6.3. CONDUCT EARLY IDENTIFICATION 30 -- 6.4. SUPPORT PATIENT AND INFORMAL CAREGIVER EMPOWERMENT 31 -- 6.4.1. Develop provider skills and tools for patient empowerment 31 -- 6.4.2. Provide patient empowerment services and support 33 -- 6.5. CONDUCT HEALTH PROMOTION AND PRIMARY PREVENTION ACTIVITIES 34 -- 6.6. IMPLEMENTATION AND FOLLOW-UP OF A DYNAMIC CARE MODEL 34 -- 7. REFERENCES OF THE POSITION PAPER 39 -- APPENDIX OF THE POSITION PAPER 49 -- APPENDIX 1. RECAPITULATIVE INVENTORY OF THE MAIN ACTION FIELDS AND OF THE -- ACTORS INVOLVED 49 -- APPENDIX 1.1. EDUCATION 49 -- APPENDIX 1.2. DEVELOPMENT OF PROTOCOLS AND TOOLS FOR COMMUNICATION 50 -- APPENDIX 1.3. DEVELOPMENT OF INFORMATION AND COMMUNICATION TECHNOLOGY -- APPLICATIONS 50 -- APPENDIX 1.4. QUALITY IMPROVEMENT INITIATIVES 50 -- APPENDIX 1.5. EMPOWERMENT 51 -- APPENDIX 1.6. MANPOWER 51 -- APPENDIX 1.7. ORGANIZATIONAL REFORMS 52
This report presents the outcomes of the “Pilot on eHealth Indicators” study,
carried out by empirica in association with IPSOS on behalf of the European
Commission, Information Society and Media Directorate-General. The data
used for this report were collected by means of a survey of primary care
physicians and their use of ICT for eHealth purposes. The survey was carried
out in all 27 Member States of the European Union and in Norway and Iceland
in 2007.
Home care is defined as a health care provision aimed to keep patients at home, which is the place where the patient really lives. Key disciplines involved are informal care, general practice, nursing care, home help and social work in conjunction with Networks, service orga- nizations and institutional care. In Flanders the coordination of home care is performed by 'Samenwerkingsinitiatieven in de Thuiszorg' while in Wallonia it is done by 'Centres de Coordination de Soins et Services a Domicile (CSSD)'. Identified problems are the coordination of care, multidisciplinarity and the very complex Belgian legislation. The future will show if the new services will solve the identified problems.
In 1997 a Health Interview Survey takes places in Belgium. A total of 10 000 individuals will be interviewed. The individuals are selected within families which are selected by a multistage sampling procedure from the National Register. The individuals are questioned on a variety of health related domains: general health perception, morbidity and functional status, use of health services, life style and socio-economic characteristics. The paper gives a general description of the objectives, the questionnaire (content and development), the sampling procedure and the pilot study.
A review of epidemiological surveys on dental caries prevalence, published between 1980 and 2006 in Belgian children, was compiled through a literature search. The number of studies performed in Belgium to date still remains limited, although in recent years more data on caries prevalence have been published. Methodological differences and confounding factors, especially socio-demographic influences, limit national comparisons of caries prevalence data. Although exact comparisons are difficult, data suggest a decline in caries prevalence in 5-, 7- and 12-year-old Belgian schoolchildren in the last 26 years. In the primary dentition mean dmft1 values have decreased from 2.66 (1981) to 1.38 (1994) in 5-year-olds and from 4.1 (1983) to 2.24 (1996) in 7-year-olds. A recent 2003 study (1) showed a dmft of 0.83 amongst 2-3 year olds, 50% being cariesfree. In 12-year-olds DMFT values in the permanent dentition have decreased from 3.9 (1983) to 0.92 (2001). WHO goals for the year 2010 appear to have been almost reached in Flanders, with a recent estimate of 0.92 for DMFT in 12-year-olds and 56% of children being recorded as cariesfree at the age of 5. Continuing efforts are needed to screen the oral health of different age groups but standardised criteria and sampling procedures should be used if benefits are to be gained from national and international comparison. Data are often limited to small selected areas and information representing the entire community of Flanders or Wallonia would be of particular value.
The present review describes the evolution of dental health in the Belgian population in the last 30 years, comparing it to other West European countries. Moreover, this paper reports on the Belgian achievements regarding the oral health goals established by the WHO for the year 2000. The studies carried out in the individual regions of Wallonia, Brussels and Flanders and in some municipalities, give a general idea about dental health in the country. In the last decade, dental health in Belgian children and adolescents has improved markedly. However, a specific health policy is required for risk groups such as socio-economically underprivileged, disabled and immigrant children. Belgium may be placed among other European countries which show from moderate to low caries prevalence in schoolchildren population. The objective of the WHO for 12-yr-old children has been achieved. Further investigation in young adults and adults are required. The lack of representative data for the whole country suggests that the implementation of a data base system for monitoring the evolution of dental health in Belgium would be useful.
Evaluation of professional practice in medicine falls in the framework of a wider evaluation of the quality of care and the return on the financial and human resources used by the Social Security. In Belgium, this action began in 1993. It involves accreditation of physicians, and this is now based on three principal criteria: medical practice criteria (especially the minimal threshold of patients contacts), continuing medical education (learning activities with accumulation of a minimum number of credit points), and an evaluation of medical practice (participation in meetings with a local medical evaluation group). This accreditation is not obligatory, but it is encouraged by non-negligible financial incentives for accredited physicians (increased consultation fees, and an annual contractual indemnity). On the other hand, the physicians who are responsible for the organization of the accreditation decisions carry out their responsibility without being paid, which together with the administrative workload makes the system rather slow.
This is the second national report on the performance of the Dutch health care system. Its focus is on quality, access and costs in 2006/7. The Dutch Health Care Performance Report presents a broad picture based on 110 indicators. Where possible, comparisons in time and between countries are presented. Dutch health care is accessible, cost increases are average, but further improvements in quality can be made. The Netherlands has an accessible health care system. Since 2004, health care expenditure has risen annually by 5%. This rate of growth is comparable to that of neighbouring countries. Although for many aspects of care the quality is high, the Netherlands does not excel at an international level. The general public and care users are positive about the care provided, but there are differences between the various types of care. One concern is the availability of nursing and care personnel. Coordination and cooperation in health care and patient safety score relatively low. The efficiency of health care in the Netherlands is not optimal. Quality is not a driving force in the health care market.
This report describes the organization of the Belgian long‐term care system. It can be characterized as a mixed system with extensive public care provision and substantial support from informal care mainly within the family. While the current volume and quality of services appears to be adequate, the future increase in the number of dependent elderly persons over the next two decades as a result of demographic ageing can be expected to become a serious challenge, both in terms of required formal and informal care capacity and financially.