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8 Economic crisis, health systems and health in Europe: country experience
total public expenditure (National Bank of Belgium, 2013). Another indication
of the importance attached to health care is the establishment (in 1995) of the
real growth cap for setting the federal health budget and its gradual increase
until 2012, when a cap of 4.5% was no longer considered acceptable given the
pressure on public spending induced by the financial crisis. 2 Given its generosity,
rather than acting as an excessive restraint on health care spending, the cap
actually guaranteed annual increases to the financial resources devoted to health
care. Moreover, given the application of the real growth cap in the years well
before those of the financial crisis, the health care sector was better prepared to
absorb the full effects of the crisis, which occurred in 2012. Lower growth caps
for the federal health budget were set at 2% in 2013 and 3% in 2014.
A related problem for health system financing is the heavy reliance on social
security contributions for financing. 3 The low participation rate of people aged
55–64 in the workforce and the growing proportion of inactive (non-working)
people are a potential threat to financing (Eurostat, 2013a).
In addition, the level of private expenditure for health care is relatively high,
ranging from 20% of total health care expenditure for patients' out-of-pocket
(OOP) costs to 24% for expenditure on private health insurance (PHI) plus
patients' OOP costs in 2011 (Assuralia, 2013). This level has remained more
or less stable since the early 2000s. From the citizen's point of view, the
supplements that can be asked by non-contracted physicians over and above
the reimbursement tariff are a potential threat for the affordability of health
care. As supplements are not included in social protection mechanisms (such
as maximum billing), they risk reducing the effectiveness of these protection
measures. The economic crisis may not have created a sudden increase in such
supplements as yet, but this is unclear as data on (ambulatory) supplements are
not systematically recorded.
Health care delivery
A weakness in health care delivery is the shortages in certain categories of health
care personnel. In terms of supply, there is no problem with the number of
physicians supplying services in the country. While the total number of physicians
registered at the Belgium National Institute for Health and Disability Insurance
(Dutch, Rijksinstituut voor ziekte- en invaliditeitsverzekering (RIZIV); French
L'institut national d'assurance maladie invalidité) per 1000 population is
among the highest in the world (Vlayen et al., 2010), these data overstate the
2 In 1995, the real growth cap was fixed at 1.5% per year, then raised to 2.5% in the period 2000–2004 and to 4.5% in
the period 2005–2011. In 2012, the real growth cap of 4.5% was not applied at all.
3 Belgium has a system of compulsory health insurance covering 99% of the population. Altogether there are seven health
insurance entities: five national associations of health insurers are the main players and are nongovernmental, non-profitmaking
organizations known as sickness funds. There is also one public fund that acts as the insurer of last resort (for
those not wishing to join any of the other five sickness funds) and a separate fund only for railway employees. The five
national associations are made up of around 60 local sickness funds. The RIZIV manages and supervises the compulsory
health insurance system.