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Chapter 1 | The impact of the crisis on the health system and health in Belgium
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was transferred to the so-called Fund for the Future, to other subsectors of
social security or was used for new initiatives. Moreover, the budget surplus
allowed policy-makers to focus on protection measures to shelter citizens from
potential access barriers to health care. A second innovation of the reforms at
the beginning of the 1990s was the introduction of individual and collective
financial responsibility for the sickness funds. These structural reforms had
been in place for more than 15 years before the outbreak of the crisis, and
accorded important protection to the system.
No government for 541 days
A second factor limiting the need for change was that between June 2010 and
December 2011 Belgium had a caretaker government that could not impose
austerity measures. The health budget for 2011 was consequently established
under special circumstances: by a government that could not take new legal
initiatives, in a context where the general government deficit was very large and
where there was a surplus in the health care budget of €1.8 billion. Stakeholders
were aware that this situation had protected the health care sector probably more
than other sectors. They realized that the need to implement savings was inevitable
and that the real growth cap could not be maintained given the economic
situation. This is illustrated, for example, by the advice of RIZIV's Health Care
Insurance Committee, consisting of representatives of the major stakeholders, to
transfer €1464.9 million of the surplus in the health care budget (about 5.3% of
the total health care budget) to other social security sectors. Moreover, while new
initiatives costing €125.8 million in total were still honoured, at the same time
savings measures were taken (worth €116.5 million) to compensate for the costs
of the new initiatives. In 2012, there was no increase in the health care budget
and the decision was taken to reduce the real growth cap for 2013 and 2014,
although it still remained positive.
Fiscal federalism reform
The fiscal federalism reform (called the Sixth State Reform or Butterfly
Agreement: Dutch, Vlinderakkoord; French L'accord papillon) is a third
factor explaining health system changes. The reform gives more spending
responsibilities to the federated entities (regions) (estimated at 4.5% of GDP
in 2011), mainly in the areas of family allowances, health care and labour
market policies (OECD, 2013a). The transfer of competencies in the health
care sector relates to residential nursing care for older patients, hospital
infrastructure and investment in the organization of primary care. The main
option chosen in the reform was to maintain the financing and accreditation of
basic (para)medical activities at the federal level and to transfer infrastructurerelated
and organizational competences to the communities, with effect from