Healthcare in Belgium
Healthcare in Belgium is composed of three parts. Firstly there is a primarily publicly funded healthcare and social security service run by the federal government, which organises and regulates healthcare; independent private/public practitioners, university/semi-private hospitals and care institutions. There are a few (commercially run for-profit) private hospitals. Secondly is the insurance coverage provided for patients. Finally, industry coverage; which covers the production and distribution of healthcare products for research and development. The primary aspect of this research is done in universities and hospitals.
Healthcare in Belgium is mainly the responsibility of the federal minister and the "FOD Volksgezondheid en Sociale Zekerheid / SPF Santé Publique et Securité Sociale" ("Public Administration for Public Health and Social Security"). The responsibility is exercised by the governments of the Flemish, Walloon regions and the German-speaking community. Both the Belgian federal government and the Regional governments have ministers for public health and a supportive administrative civil service.
Political and regulatory
|Territorial Competence||Administrative service|
|Public Administration for Public Health, Food Chain Safety and the environment  (FOD Volksgezondheid, Veiligheid van de Voedselketen en Leefmilieu / SPF Santé publique, Sécurité de la Chaîne alimentaire et Environnement) |
Safety of the food chain
Plants and animals
|The competent administration is the Flemish Public service for family-matters, wellbeing and health. 
|French Speaking Community
|The competent administration is the "Direction de la Santé Publique de la federation Wallonie- Bruxelles". 
|The competent administration is the "Ministerium der DG". 
|The Provincial authority for welfare is competent for matters that transcend the local level or local competences.
The provincial authority is also competent for catastrophe planning and management of the emergency services.
|The Public Centre for Social Welfare is a local authority public service.
In larger cities these public services manage large budgets, with a substantial administrative burden. They operate hospitals, clinics, rehabilitation centers, retirement/pensioners residences and day care centres. The largest PCSW is the one in Antwerp. In 2013, it managed a budget of 461 million euros, and paid benefits to people with no or very low incomes, for a total of 125 million. The PCSW employs a workforce of over 1000 people. Hospitals and other care institutions are grouped into a separate organisation called ZNA.  (Care Network Antwerp) employs another 7000 people, and in 2010, had a budget of approximately 568 million euros.
A recent decision (made public in January 2015) by the Flemish regional government, aims at abolishing this local authority service, which had a substantial measure of independence and authority from the political elected councillors. It will bring it under the authority of the communal council within the next 2 years. This decision is being contested by the opposition, and by legal impediments at the federal governmental level.
Organisation of Care
Generally speaking, health care is organised in three layers:
- First line: the primary care function that is provided by physicians (GPs), emergency services and Emergency Rooms in hospitals. Polyclinics provide non urgent first line care (such as diagnostic or follow up of patients).
- Second line: acute and immediate care provided by hospitals for patients requiring technical interventions (surgery, technical diagnostics etc.) and acute curative care.
- chronic or long-term care: is provided by rehab-clinics, service-flat care providers, old-age homes and home-care services.
For common diseases like cold, flu, injuries and pain, patients contact their GPs.
Physicians in private practice are generally self-employed. Officially, they are categorized in the following framework:
- Private practice:
- General Practitioners (family doctors): usually operate from their private practice, although some group practices are emerging. These doctors are also syndicated in local chapters that organize out-of-hours services during weekend and holidays and for the evening hours and during vacations. A patient can call a duty-GP 24/7 who has access to their medical records.
- Specialists: many combine their private practice with a hospital posting or with a teaching position or similar research posting. Only a few operate private clinics (mostly ophthalmologists or dentists).
- Experts and Assessment consultants: these specialists don't see general patients, rather they evaluate patients either as a second opinion at the request of the patient or are appointed to assess patients and treatments for insurance purposes or by appointment by a court.
- Clinical practice:
- Specialists: many clinical specialists have a teaching position in hospitals (teaching staff, assistants or trainees and nurses on the job) or combine their hospital position with a teaching position at a university.
- Research clinicians: run clinical trials and do research.
Most doctors working in hospitals also have a private practice. Exceptions include neurosurgeons or radiologists because they cannot invest in the high tech equipment required. Doctors are usually paid on a per medical act basis either by the patient at their private practice or by the hospital. Some specialists are employees on a hospital payroll or for research labs or universities. Assessment consultants are paid a fixed fee for their assessment report by whoever hired them.
For accidents and medical emergencies everybody can call on the emergency services. There are two phone numbers to contact the Emergency Services Network, 100 or 112. 100 gives access to the Ambulance service or Fire department. In larger cities the Fire department operates the Ambulances, elsewhere Ambulances might be allocated to hospitals or ran by private organisations. 112 gives access to the Police, Ambulance Services and Fire department. The dispatching centers for the 100 and 112 services, dispatches an available ambulance from the closest hospital or ambulance center. The operator is qualified to decide to dispatch regular ambulances, Medical Emergency Response vehicles (MUG/SMUR) or Paramedical Intervention Teams (PIT's). Additionally, the Red Cross operates a number of ambulances as do privately owned companies that operate ambulances for the emergency network. The Red Cross and a number of other "cross" charities own ambulances and have volunteers that man first-aid posts during events like football matches, cycling races, sports or other mass events. They don't participate in the daily Emergency services network, but they do liberate the Emergency Services network from allocating too many assets and resources during those mass events. In case of (potential) mass casualty events, the Red Cross assists the regular emergency services to avoid occupying all other medical recources in the area by deploying First Intervention Teams (FIT's), ambulances and intervention vehicles and more.
An ambulance is manned by two paramedic. The ambulance will usually bring the patient to the nearest hospital. Depending on the medical condition, a Medical Emergency Response vehicles (MUG/SMUR) may be dispatched. They are manned by at least two people - an ER-doctor and a senior ER-nurse a,d are stationed at a hospital. Sometimes there is an aditional nurse or paramedic (in training) on board. The ER-doctor will choose the nearest appropriate hospital that has the necessary facilities based on the patient's symptoms and condition, or a hospital in which the patient is under active treatment. Besides regular Medical Emergency Response vehicle, there are also two Medical Emergency Response helicopters in Belgium, based in Bruges (Flanders) and Bra-sur-Lienne (Wallonia). These helicopers are privately funded for the most part. Currently there are also a few dozen of Paramedical Intervention Teams (PIT's). These are usually manned by one paramedic and one ER-nurse and have some additional equipment that the ER-nurse can use.
Calling an ambulance is not free. As of January 1st of 2019, the fee is 60€.
The Federal Service for Public Health describes the hospital sector in the following manner:
There are two distinct types of hospitals: General hospitals and Psychiatric hospitals. Psychiatric patients are not mixed with the general hospital population.
There are 209 hospitals:
- 68 Psychiatric hospitals care for psychiatric patients that require care in a controlled, restricted environment. Some of these hospitals also offer therapy day clinics for patients that stay at home.
- 141 General hospitals mostly involved in providing non-surgical care for adults with services such as cardiology, pneumology, gastro-enterology & endocrinology. They also provide a maternity ward and most of them have an emergency response unit.
- 113 general acute hospitals.
- 7 are University hospitals directly linked to universities and provide for teaching and research facilities.
- 16 general hospitals with University status that have special provisions to collaborate with universities and colleges for teaching and research purposes.
- 20 smaller specialized hospitals which provide care for heart and vascular diseases, pulmonary diseases, locomotor disorders, neurological problems, palliative care, chronic diseases or psychogeriatric care.
- 8 geriatric hospitals with care specifically for the elderly.
- 113 general acute hospitals.
The vast majority of hospitals are publicly funded. They are independent units or part of a larger organization that get funding from the public health service based on the activities they deploy, number of beds operated, specialist knowledge etc... In Belgium, there are only a handful of privately owned/operated hospitals that work outside and without the public health service funding. They provide luxury services and luxury accommodation for patients that can afford such exclusive services.
Outside these categories there are:
- day-clinics where ambulant patients can have therapy and return home. Many hospitals have sections for dayclinics.
- polyclinics where different specialists see patients who do not need to stay overnight in the hospital for diagnosis or post therapy controle. Many general hospitals operate polyclinics, but there are institutions outside hospitals that operate only as a polyclinic.
In a general hospital any of the following departments may be at the disposal of patients, but not all general hospitals offer all these facilities and departments:
- Emergencies and trauma center usually backed up by an intensive care unit.
- Operating theatres.
- Polyclinic consultations, ambulance or out-patient care: patients can come during office hours to see a specialist either in the diagnostic phase, therapeutic phase or post-therapy follow-up consultations.
- Technical diagnostics such as collection of blood or bodily fluid-samples, and lab testing; medical imaging; X-rays, CT-scan, MRI or ultrasound); EEG, ECG and extended monitoring outside acute illness situations;
- Nursing units: standard hospital ward type of sections where patients get 24/7 care, post-op recovery
- Specialized units may be sections in a general hospital, independent units within a general hospital or independent specialized clinics:
- Neo-natal and Pediatric clinics
- Re-hab and recovery clinics
- Geriatric clinics
- Palliative care units
- Psychological assistance units
- Research units: units within a general hospital that are specialized in running and caring for and following of patients/participants in clinical trials.
Different levels of nursing training are available: basic nurse, midwife, full nurse
- Nursing in hospitals: in hospitals, the nursing work ranges from basic care nurse (doesn't perform any medical acts), nursing assistants, full-nurse, chief ward-nurse, trauma nurse or paramedics, ER- or OR- nurses and chief-nurse. Each of these positions require a different level of formal training, on-the-job training, accumulated experience and responsibilities. Nurses seldom work over their competence, because according to the Peter-principle, it would cause casualties. Nurses in care units work shifts two or 2 twohifts/day and 365d/year. Many nursing wards in general hospitals are currently chronically understaffed, exceptions being ER, OR and ICU. Some post surgical wards such as cardio-, thoracic- and neuro surgery units that operate MCMU's ( Mid-care monitoring units) often are less prone to understaffing because of the risks involved for patients.
- Nursing in research and polyclinic environment: nurses in research and polyclinic environments often have a more family friendly and limited 5d/w 8hr/d working patterns than their counterparts in the hospital care nursing units, however not all nurses like to work in such environments.
- Ambulant nursing (home care): when patients go home they often require follow-up of their hospital care like wound dressing, injections and bathing. Specialized ambulant nursing services provide such nurse-at-home services for recovering patients and for elderly people living at home. These services also dispatch basic care nurses, that do not perform medical acts for patients and elderly that require help with their daily hygiene and (clothes) changing.
- Community Pharmacies: drugs and medications can only be sold by pharmacies. Supermarkets and dietshops can sell products such as over the counter food-supplements, but any product claiming a medical effect even over the counter painkillers or stomach tablets are limited to pharmacies. Pharmacies are required to have an establishment permit and an exploitation permit
- Hospital Pharmacies: will only dispense drugs and medications for administration by nurses and doctors in a hospital environment. Many of these products are not available over the counter.
- Distribution of Care products: companies that wish to produce, import and distribute substances that can be qualified as medicinal are required to have a license and are strictly monitored. Their stock movements are controlled by a very close monitoring system.
Internet medication: if a patient buys medication in another EU country from a pharmacy for his personal use, by prescription or over the counter, he can import them into Belgium in his luggage or vehicle. Belgian patients may legally buy over the counter painkillers such as paracetamol in the Netherlands where they are cheaper, and take them to Belgium. However, attempting to import prescription drugs without a prescription, unregistered or forbidden medication, or narcotics purchased on the internet or for recreational drugs illegally on the street is prohibited and customs and police track this business rather strictly. Illegally imported drugs are confiscated, and the carrier might be fined or imprisoned.
Under the Healthcare Act of 30 October 2018 electronic prescriptions will be mandatory.
- May 26, 1813 (under the French regime): after a minepit disaster in Ourthe, an Imperial decree created a miners-fund. It is financed by the employers and workers and which pays miners an allowance in case of permanent disability or medical incapacitation.
- September 19, 1844 : A welfare fund "De Hulp- en Voorzorgskas voor Zeevarenden onder Belgische Vlag" ("Assistance- and providential fund for Belgian merchant navy sailors") allowing workers an insurance-like cover against illness, disability, old age pensions, work-related accidents and unemployment.
- April 16, 1849 : The Government subsidizes the cost of incorporation of the societies of mutual assistance .
- May 8, 1850: The Government creates the "Algemene Lijfrentekas (later state-owned ASLK-bank), where every Belgian can save money for his old-age pension.
- 1869 : Incorporation of the first Socialist Mutuality, "La Solidarité", at Fayt-lez-Manage, the forerunner of SOCMUT (Socialistische mutualiteit), one of the three most important entities in the modern Belgian social security system
- 1894 : The first national law concerning the finance and provision of health care in Belgium was enacted, with social insurance being introduced in 1945.
Health insurance is only one of the pillars of the system of social security provided for every Belgian citizen. Every Belgian citizen has access to the social security system—it is compulsory—but there are gaps in the system where people can drop out. For example, not paying contributions is one such exit and another is homelessness (social security is only available to people with an address).
Every wage-earning worker or employee in a factory, office, working as house personnel (maids, chauffeurs etc.), and anyone working in Belgium is registered to a central system as well as the unemployed. The self-employed, such as shopkeepers, innkeepers, lawyers, and doctors are also registered.
Workers are paid a daily or monthly wage their gross salary. From that gross salary, their employer has to deduct a certain amount (approx 13%) for social security and another (approx 20%) for taxes. The employer has to pay these amounts directly to the Social Security Services and the Inland Revenue Service (employers make these payments for the employee and deduct these payments from his wage). On top of the gross salary, the employer has to pay an employer's contribution for social security of approx 15–22% to the Social Security Services. Failing to make these payments regularly and on-time is closely monitored and often causes failing businesses to be taken to court for failing to comply with their social security and fiscal obligations towards their workers. This reduces the risk for workers when they remain unpaid or when their contributions are not paid for them.
The Self-employed have a system in which they have to declare their earnings and based on their earnings a contribution is calculated which is roughly 20%-22%, but they are not covered like workers. People can opt into the system through this self-employed scheme. The government forms its tax earnings finances in part the social security system. This is a wealth re-distribution mechanism, because the contributions are incremental, this means that the more someone earns the more this person will contribute. Moreover, for health services, the compulsory health insurance and the refund system is the same for everybody (corrected for the lowest incomes) : i.e. for a consultation at the GP everybody pays the same and gets the same refund (irrespective of their income).
Financing the system: complementary systems
There is a complementary system of health insurance offered by the mutualities (extended hospital cover and travel cover), available to all mutuality members, and there is private insurance with commercial insurance companies for extended care (hospital and aftercare) and for travel care.
These systems are pure premium based insurance system.
Covering healthcare costs
1. Consultations with GPs or specialists in their private practise
- patients pay a fee for the consultation (approx 20-€25 for a GP) and for any medical acts (e.g. dental care at the dentist) (s)he may perform directly to the doctor, in return the patient gets a receipt that lists all the medical acts performed, and if necessary a prescription for medication.
- the patient gives this receipt to his mutuality, and they refund the patient in part (depending on the patients status), average patients get about 75% refunded
- some patients have a special social security code; they pay only €1 to the doctor, and do not receive a refund receipt. The doctor is paid directly by the mutuality (3rd payer system)
- the patient takes his prescription to a pharmacist, paying only part of its price; for each medication dispensed the supplier is paid a supplement by the social security services. In some cases the medication requires extra checks and such medication is often free to the patient, although very expensive. Each sale of the medication is tracked, and the supplier paid by the social security services directly.
2. Consultations at hospitals (polyclinic)
- patients see a doctor at the hospital polyclinic just link in their private practise.
- some patients pay the hospital as they leave and get a receipt for their mutuality, just like in a private practise; however many patient come in for follow-up consultations after a medical intervention or hospitalisation. The hospitals send the bill to the mutuality (3rd payer system) and patients get invoiced for their personal part.
3. Hospitalisations and medical interventions
- patients are hospitalised and they have to pay weekly advances for their medical expenses (usually 50-€100 per week).
- all consultations and interventions, medications etc. are directly invoiced to the mutuality and to and insurance cover the patient may have (3rd payer system)
- they receive an invoice for their personal part, which is often in part refundable by their complementary insurance.
- patients who suffer accidents might never have to pay any medical expenses, as accident insurers are often charged immediately, once responsibility is established.
Managing healthcare money streams
- Private insurance : private insurance companies collect premiums and provide cover, when an "insured risk" is realised the insurance company pays.
- Legal systems protect patients, doctors and hospitals from abusive denials of refunds by insurers a governmental complaints authority keeps an eye on policy conditions and execution.
- Access to private insurance is of course free, however an independent ombudsman service (not an individual) oversees refusals to ensure or termination (by the insurers) due to changes in medical condition of the patient. A governmental arbitration service reviews patient cases referred to it by the ombudsman and determines fair conditions/premiums for refuses / terminated patients
- Mutuality complementary insurance: the mutuality collects premiums and pays according to the selected cover.
- Mutualities compulsory health insurance:
- The mutualities' front-office workers evaluate any refund claims superficially: is the medical act refundable and what rate, and refunds the patient nearly immediately (used to be in cash, now directly to the patients bank account)
- The receipt is the controlled through the mutuality back-office system such that one doesn't get double refunds and other abuses
- Some claims (based on the patient's status) incur supplemental refunds, which are sent by the mutuality back office to the patient's bank account
- The mutuality gets paid by the social security services
- the amounts they pay as refund
- a fee for operating cost: mutualities have an extensive network of offices and the number of staff runs in the thousands; they also have large computer networks and difficult software programs that are often tailor-made (because apart from the 6 or 7 mutualities no one else needs that software, and the amount of data treated is so extensive it requires much effort)
In the 1980s an "SIS-card" (plastic creditcard-size chipcard like bank card) was introduced, the social security card. With it the Federal Government introduced a "national number", that identified each individual uniquely based on his/her birthday. Every individual had such an SIS card, and it established their entitlement to social security.
In 2014 that system was superseded by the plastic ID card (Belgium EID card) with social security information on a card chip, readable with a simple card-reader.
Social security encompasses health, old-age (and other) pensions, unemployment, disability and handicap, both managing the finances (collection of contributions, subsidies and payment of refund, allowances etc.), but also the management of different kinds of care, regulation of the market of medicines, health and safety at work, health and safety of any public service rendered to the general public, Monitoring and safety of the food chain etc.
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