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Chapter 1 | The impact of the crisis on the health system and health in Belgium
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acting in the interests of attaining financial balance in their sector. In 2012,
the association of dentists and sickness funds (Nationale Dento-Mutualiste)
developed legal instruments to sanction the outliers, which became effective
from 2013. Such action illustrates the goodwill of providers and sickness funds
to collaborate to fight excesses.
5.2 Content and process of change
As discussed above, the process of change in Belgium following the crisis has
been determined to a large extent by the measures and mechanisms already in
place before the crisis. A few observations can be made. First, the health care
budget tends to be estimated on an annual basis and a long-term sustainable
plan seems to be lacking. A report from the Organisation for Economic Cooperation
and Development (OECD) in 2013 recommended the introduction
of a detailed medium-term budget to enhance strategic reflection on the desired
level of spending (OECD, 2013a). A focus on the medium term would also be
useful to reflect the effect of new measures in a transparent way (OECD, 2013a).
Second, between 1993 and 2008 the main objectives of health care policy were
defined as keeping health care expenditure within acceptable limits, guaranteeing
accessibility and quality while ensuring respect for therapeutic freedom and
freedom of choice. During implementation, it was realized that accessibility and
quality of care were not always compatible with therapeutic freedom and freedom
of choice, but the former were maintained as basic objectives.
The basic principle applied during health policy changes was to first use the
existing reserves to take measures that would not be felt directly. Once the
reserves were exhausted, measures started to focus on increasing efficiency (e.g.
INN prescribing, day hospitalization, DMPs) and fighting malpractice (e.g.
in dental care). Belgium is currently in the process of considering efficiency
measures requiring more structural changes (e.g. alternative ways to finance
hospital services and development of additional DMP pathways with adapted
financing). With the exception of pharmaceuticals, the health system did not
particularly focus on lowering input prices in its process of change. More
indirect measures, which ultimately have an impact on average input costs,
include the legal means provided to sickness funds to control medical services
and to recover incorrectly charged reimbursements, the means to monitor and
sanction outliers in terms of volume, and more accurate financing of dialysis
and medical imaging based on needs rather than on supply or financing.
Intersectoral collaboration between institutional health care and ambulatory
health care has been relatively weak in Belgium. The examples of DMPs are
limited to two clinical care pathways, one for end-stage kidney disease and one
for type 2 diabetes, introduced in 2009. The intersectoral clinical care pathways