Maintenance and Improvement of quality health care
The Belgian
Health Care System Revisited
Dr. M.
MOENS
Secretary-general
VBS-GBS
Brussels,
September 27, 2003
1.
INTRODUCTION
I am grateful to
Prof. Luc BAERT for having invited me on the occasion of this symposium to
formulate a number of considerations concerning "the maintenance and
improvement of quality health care in Belgium" from the viewpoint of a
professional association of medical practitioners.
As elsewhere in
the industrialized world, the Belgian health care system is under to pressure.
The cornerstones, which Prof DILLEMANS has just described, are they in need of
replacement or, will the addition of contemporary accents be sufficient ?
Belgian
physicians have always had misgivings about the interference of the Government
in their practice. For almost 40 years,
or more precisely since 25.06.1964, a system of conventions has existed between
the physicians and the sickness funds for the admission of certain medical
treatments into the Government financed health care package and on the fees for
the provision of health care services .
Until 1993,
physicians could, in mutual agreement with the sickness funds, proceed quasi
autonomously. Under Minister Philippe
MOUREAUX (Socialist party) however, this system was changed by the law of
15.02.1993. This law considerably reduced the power of both pressure
groups. Each convention concluded
between the physicians and the sickness funds now needs to be in accordance with
the governmental budget and will then need approval of the minister in charge.
Consultations
between the Government and the time-honoured partners of the system, sickness
funds and care providers (in casu the physicians) are regarded as highly
important. During the ministry of 1999-2003, with Frank VANDENBROUCKE as
minister of Social affairs, now minister of Labour and Pensions, consultations
seldom led to results that were supported by the concerned professional groups
or institutions.
In spite of
considerable investment in the health care system, almost all professional
groups felt passed over by the Government: the physiotherapists, the
pharmacists, the physicians, the hospital administrators, the pharmaceutical
industry, …
In short, any
attempt to express some entrepreneurship in a private practice or within an
institution would stay without a result under the preceding government. A great majority of health care providers
were left unhappy and frustrated. What is going wrong? Is there a way out of
this situation?
2.
PEOPLE AND MEANS
In Belgium, there
are about 285.000 people engaged in the health care sector. On the one hand, +/- 227.000 are engaged in
hospitals and other health care institutions, in practices of health care
providers, in the pharmaceutical industry and business or in the sickness
funds.
On the other
hand, there are about 58.000 independent practitioners active as physicians,
dentists, nurses, physiotherapists, … (cf table 1).
Occupation in the
health care sector (year 1999)
|
Employees in
|
146.275 30.716 25.499 13.458 11.044 |
|
Subtotal |
226.992 |
|
Independents
|
23.846 22.628 6.817 4.514 |
|
Subtotal |
57.805 |
|
Total health care employment
|
284.797 6,5 |
Table 1
Source
: BIGE compendium health statistics
2001.
From those +/- 285.000 active in the health sector
there are, for the year 2002, roughly 169.000 providers who are registered at
the Rijksinstituut voor Ziekte- en Invaliditeitsverzekering (RIZIV) (National
Sickness and Invalidity Insurance Institute, NSIII) (cf. table 2), from which
40.763 for the year 2002 are physicians.
|
|
1994 |
1998 |
2002 |
|
Nurses and
midwives Physicians Physiotherapists Paramedics Pharmacists Dentists Opticians |
50.965 35.081 22.438 14.865 9.824 7.727 2.992 |
56.708 38.109 25.009 15.282 10.656 8.240 3.200 |
63.040 40.763 27.475 14.385 11.775 8.553 3.333 |
|
Total |
143.892 |
157.204 |
169.324 |
Table 2
Source
: NSIII annual report 1998 and 2002
There is in
Belgium a very high density of physicians: for 10,3 million inhabitants there
are 46.268 physicians or one physician per 223 inhabitants. Since 1980 the
number of physicians increased on average by more than 1000 per year (cf. table
3).
Evolution in the
number of physicians in Belgium
|
|
General
Practitioners |
Specialists |
Specialists
in training |
All
doctors |
|
1950 1960 1970 1980 1984 1988 1992 1996 2000 2001 2002 |
10.968 12.985 14.371 14.897 15.378 19.443 19.444 18.367 |
9.617 11.034 12.969 14.691 16.364 19.166 20.045 23.978 |
2.084 3.077 2.972 3.579 3.460 3.427 3.489 3.923 |
8.685 11.730 14.887 22.669 27.096 30.312 33.167 35.202 42.036 42.978 46.268 |
Table 3
Source
: Ministry of Social Affairs, Public Health and Environment.
In particular the
number of specialists continues to increase steadily while, since 2000, the
number of general practitioners has come at a standstill and even drops in 2002
(cf. table 4).
Evolution of the
number of medical doctors in Belgium since 1980 (1980 = 100)
|
|
General
Practitioners |
Specialists |
Specialists
in training |
All
doctors |
|
1980 1984 1988 1992 1996 2000 2001 2002 |
100 118 131 136 140 177 177 167 |
100 115 135 153 170 199 208 249 |
100 148 143 172 166 164 167 188 |
100 120 134 146 155 185 190 204 |
Table 4
Source
: Ministry of Social Affairs, Public Health and Environment.
Not all physicians have a practice. Yet, the number of
practicing Belgian physicians is important in comparison with the other
European countries: 40.299, or one active physician per 256 inhabitants, of
which 14.541 general practitioners (1 per 709 inhabitants) and 25.758
specialists (1 per 400 inhabitants) (cf. tables 5 and 6).
Number of
physicians, per category, with and without a clinical practice (31.12.2002)
|
Category |
With practice |
Without
practice |
Total |
|
General
practitioners Generalists in
training |
13.718 823 |
3.825 1 |
17.543 824 |
|
Subtotal |
14.541 |
3.826 |
18.367 |
|
Specialists Specialists in
training |
21.897 3.861 |
2.081 62 |
23.978 3.923 |
|
Subtotal |
25.758 |
2.143 |
27.901 |
|
Total |
40.299 |
5.969 |
46.268 |
Table 5
Source
: Ministry of Social Affairs, Public Health and Environment.
(formulated in terms as one per number of inhabitants)
|
General
practitioner Specialist All doctors |
709 400 256 |
Table 6
Source
: Ministry of Social Affairs, Public Health and Environment.
From a budgetary
perspective, Belgium has spent more in the course of 2000 than the average
figure for the OECD and the European Union : 8,7% of the Gross Domestic Product
(GDP) against 8% for the OECD- and the EU-average. For 1990, Belgium's
expenditure was only just in balance with the European average, namely 7,4% of
the Gross Domestic Product (cf. table 7). During the past decennium Belgium has
thus seen a very significant increase in health care expenditure.
Growth of
expenditure on health (1990-2000)
|
|
Health spending
% GDP |
|
|
|
1990 |
2000 |
|
Belgium Germany Poland Ireland Finland UK The Netherlands OECD EU |
7,4 8,7 5,3 6,6 7,9 6,0 8,0 7,2 7,4 |
8,7 10,6 6,2 6,7 6,6 7,3 8,1 8,0 8,0 |
Table 7
Source : J. DE COCK;
NSIII; INSEAD symposium, Brussels, 23.05.2003
Amongst the
NSIII-expenses on health care, the share of doctor’s fees is considerable: 30,3
% in 2002. In terms of percentage we notice a decreasing trend : 32,6 % in 1997
and 42 % in 1970 (cf. table 8). New health care professions and new sectors
have claimed their place and their share of the budget.
Share in the
NSIII-expenditure in terms of percentage, per different categories of acts
and/or care providers
|
|
1997 |
2002 |
|
Physicians * Hospitalisation Pharmaceuticals Other care
providers ** The remaining |
32,6 25,7 18,3 11,6 11,8 |
30,3 24,2 19,3 11,4 14,8 |
|
Total |
100,0 |
100,0 |
Table 8
Source
: NSIII annual report 2000 and 2002
* In
1970 the physicians' share was 42%
** Share
of fee for service remuneration for dentists, nurses, physiotherapists and
paramedics
Despite the
rapidly growing number of physicians, their fees have seen the slowest increase
amongst all the sectors involved in health care. While during the period
1992-2002 the average yearly growth for the whole sector was 4,8%, it was only
2,5 % for doctors fees. The average yearly inflation over this period amounts
to 1,85% (cf. table 9). In the period 1992-1997 we notice a negative growth for
the doctors fees as the average index increase was 2,0 % against an average budget
growth of only 0,8 %.
|
|
1992-1997 |
1997-2002 |
1992-2002 |
|
Physicians Pharmaceuticals Hospitals Others Total |
0,8 5,7 4,5 6,7 3,8 |
4,3 7,0 4,6 8,4 5,9 |
2,5 6,4 4,5 7,6 4,8 |
Table 9
Source : J. DE COCK;
NSIII; INSEAD-symposium, Brussels, 23.05.2003
*
Inflation not taken into account
On
basis of 1988 the 12.1992 index was: 113,46,
12.1997 : 125,21, 12.2002 : 136,30.
Average
yearly inflation : 1992-1997 : 2,0 %
1997-2002 : 1,7 %
1992-2002 : 1,85 %