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Chapter 1 | The impact of the crisis on the health system and health in Belgium 33 Disease prevalence Long-term disability Between 2005 and 2010, there was a steep increase of 82% in the number of people with long-term disability. It is believed that this partly reflected stricter eligibility conditions being imposed to receive a retirement pension; however, it is difficult to confirm a causal relationship. Mental disorders A survey conducted in 2012 by the socialist sickness funds in Wallonia and Brussels and interviews with GPs, psychiatrists and psychologists revealed that 1 in 10 people (very) regularly suffers from depression or anxiety. This is mainly caused by being/becoming unemployed. 14 Health care expenditure data show an increase in the use of antidepressants by 45% between 2004 and 2012. The increase was strongest between 2006 and 2008, but since 2010 the increase has been limited to 4.6%. Of all age groups, those aged between 51 and 70 years have experienced the largest increase. The use of antidepressants decreased in children (0–10 years) from 2004 onwards and in adolescents and younger adults (to 30 years of age) from 2008 onwards because alerts were published concerning the increased risk of suicidal thoughts, suicide and self-mutilation associated with the use of antidepressants in children and adolescents. The biggest users of antidepressants are aged between 41 and 80 years. The use of antipsychotic drugs has increased significantly since 2004 (by 50% between 2004 and 2012) and the financial crisis did have an accelerating impact. The biggest users are between 41 and 60 years of age. A consistent growth in their use also has been reported for adolescents and children, particularly for those aged between 12 and 17 years. The number of patients in this age group increased by 16% while the population decreased by 3% (RIZIV, 2013c). Mental illnesses are the primary cause of invalidity in Belgium, with 27% of long-term absenteeism being related to mental issues. There also has been a rapid increase in disability benefit claims because of mental health disorders in recent years: 1% of the Belgian population or one-third of all claims (95 000 people in June 2012 compared with 86 000 in June 2010). Claimants were mainly aged between 40 and 55, but the number of young people is increasing (Solidaris Mutualité, 2012). Moreover, the life expectancy of psychiatric patients is, on average, 15 year shorter than the average (Van Herck & Van de Cloot, 2013). 14 Telephone survey in 2012 of 1000 adults between 18 and 75 years and web-based questionnaire for physicians.
34 Economic crisis, health systems and health in Europe: country experience 5. Discussion 5.1 Drivers of change The drivers of change in the health system in response to the crisis can only be understood against the background of European obligations and some specific characteristics of the Belgian health care sector. European obligations In 2009, Belgium was urged by the Council of the EU to take measures to reduce its government deficit, which accounted for 5.6% of GDP at that time. Between 2010 and 2012, the deficit needed to decline by 0.75% of GDP per year (Council of the European Union, 2009). By the end of 2012, the objective had not yet been reached, mainly because of the capital injections the government made into the banking sector (about 0.8% of GDP) (European Commission, 2013). Instruments available since the beginning of the 1990s Despite this fiscal pressure, the need and possibilities for change in the health care sector were limited in the early years of the crisis. Several factors contributed to this. First, at the outbreak of the crisis in 2008, Belgian policy-makers had a set of instruments at their disposal that postponed the impact of the crisis on the health sector. These instruments were introduced at the beginning of the 1990s to fulfil the convergence criteria as outlined by the Maastricht Treaty, which entered into force in 1993. The convergence criteria with respect to government finance imply that the ratio of gross government debt to GDP must not exceed 60% 15 and the ratio of the annual government deficit to GDP must not exceed 3% at the end of the preceding fiscal year. In 1993, the gross government debt was 137.8% of GDP (National Bank of Belgium, 2013) and the government deficit was 7.5% of GDP (OECD, 2013c). The main purpose of the reforms in the 1990s was to increase the costconsciousness and cost-participation of all the partners in the health care sector. The idea of monitoring the development of health spending within an a-priori budget and close monitoring of subsector budget overruns was the first important innovation. A real growth cap was introduced in 1995 to restrict the annual maximum increase in the health budget to 1.5% in real terms. In 1999, when Belgium entered the Economic and Monetary Union, the growth cap was raised to 2.5%, and then to 4.5% from 2005, resulting in annual health budget surpluses since that year. Between 2005 and 2010, this budget surplus 15 This rule was not enforced, as most members of the Economic and Monetary Union were unable to meet this criterion before 1999.
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34 Economic <strong>crisis</strong>, <strong>health</strong> <strong>systems</strong> <strong>and</strong> <strong>health</strong> in Europe: country experience<br />
5. Discussion<br />
5.1 Drivers of change<br />
The drivers of change in the <strong>health</strong> system in response to the <strong>crisis</strong> can only be<br />
understood against the background of European obligations <strong>and</strong> some specific<br />
characteristics of the Belgian <strong>health</strong> care sector.<br />
European obligations<br />
In 2009, Belgium was urged by the Council of the EU to take measures to<br />
reduce its government deficit, which accounted for 5.6% of GDP at that time.<br />
Between 2010 <strong>and</strong> 2012, the deficit needed to decline by 0.75% of GDP<br />
per year (Council of the European Union, 2009). By the end of 2012, the<br />
objective had not yet been reached, mainly because of the capital injections the<br />
government made into the banking sector (about 0.8% of GDP) (European<br />
Commission, 2013).<br />
Instruments available since the beginning of the 1990s<br />
Despite this fiscal pressure, the need <strong>and</strong> possibilities for change in the <strong>health</strong><br />
care sector were limited in the early years of the <strong>crisis</strong>. Several factors contributed<br />
to this. First, at the outbreak of the <strong>crisis</strong> in 2008, Belgian policy-makers had<br />
a set of instruments at their disposal that postponed the impact of the <strong>crisis</strong> on<br />
the <strong>health</strong> sector. These instruments were introduced at the beginning of the<br />
1990s to fulfil the convergence criteria as outlined by the Maastricht Treaty,<br />
which entered into force in 1993. The convergence criteria with respect to<br />
government finance imply that the ratio of gross government debt to GDP<br />
must not exceed 60% 15 <strong>and</strong> the ratio of the annual government deficit to GDP<br />
must not exceed 3% at the end of the preceding fiscal year. In 1993, the gross<br />
government debt was 137.8% of GDP (National Bank of Belgium, 2013) <strong>and</strong><br />
the government deficit was 7.5% of GDP (OECD, 2013c).<br />
The main purpose of the reforms in the 1990s was to increase the costconsciousness<br />
<strong>and</strong> cost-participation of all the partners in the <strong>health</strong> care<br />
sector. The idea of monitoring the development of <strong>health</strong> spending within an<br />
a-priori budget <strong>and</strong> close monitoring of subsector budget overruns was the first<br />
important innovation. A real growth cap was introduced in 1995 to restrict the<br />
annual maximum increase in the <strong>health</strong> budget to 1.5% in real terms. In 1999,<br />
when Belgium entered the Economic <strong>and</strong> Monetary Union, the growth cap<br />
was raised to 2.5%, <strong>and</strong> then to 4.5% from 2005, resulting in annual <strong>health</strong><br />
budget surpluses since that year. Between 2005 <strong>and</strong> 2010, this budget surplus<br />
15 This rule was not enforced, as most members of the Economic <strong>and</strong> Monetary Union were unable to meet this criterion<br />
before 1999.
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