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Belgian Health system Salvador, December 3d 2012
Belgian Health system
Salvador, December 3d 2012
Belgium2
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Belgium
11 millions inhab (2012)
353 hab/km2
3 communities (3 langages), 3 regions
GDP per capita : 38200$ - 78% services, 22% industry, <1% agriculture (2010)
GINI: 28* (Dan 25, USA 38, Bra 53**)
Crude Bith Rate 12‰ (2011)
Crude Mortality Rate 9‰ (2011)
Infant mortality rate 3,5‰ (2010)
Mean Life expectancy at birth 80y (Men 78y, women 83y) (2010)
Subjective evaluation of health status:
77% > 15y : good or very good – 5% : bad or very bad
*OECD 2008 **UNDP 2009
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Belgium5
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and Social protection in Health
Social Security7
Social security
« extended » Bismarck Model : « universal » social Insurance
Based on employment;
Contributions from employers and from workers● graduated according to income, based on salaries
Special insurance budget
Obligatory and accessible for every citizen
● =/= Beveridge : public system based on taxes, included in the state budget;
● =/= USA : no- or private insurance
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Social security
Illness – incapacity - invalidity
Professionnal sickness / work injuries
Unemployment benefit
Pension
Family allowance
Remunerated Holidays (20 days/year)
Maternity (14 weeks)
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+ Social assistance:
Minimum integration benefit
Garanted benefit for old-age persons
Garanted family allowance
Disabled benefit
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Social security
Financing:
Employment Contributions 60-65%
Taxes: ● State ‘dotation’● « alternative financing » (VAT – others)
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Social security
Universal coverage
Solidarity
Equity : contribution according to revenues – utilisation according to needs
« security »
Freedom
Security – peacefull society
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BUT
For health care: also direct out-of-the pocket payments (28% of costs – directly and indirectly):
Co-payments
Non – reimbursed material or services
also private insurance
costs increase if sickness increase
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Health care system15
Characteristics of the system
National Office of Social security
National Institute for illness – invalidity (disability) insurance (INAMI – RIZIV)
● Mutual sickness funds (7) – institutions, professionnals, …
+ out-of-pocket payments
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Actors
Mutual funds
Administration of reimbursment
Co-managers of the health protection
Social and health services
Complementary insurances
Why ? piece of history
Voluntary sickness funds (villages, professions, sectors, ….) since mid 19e
1944 universal system: 44% population were already covered
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Actors
GP : 11000 = 1/1000 Inhab
8500 FTE = 1/1300 inhab
Specialists MD : 20000 = 2/1000 inhab
Hospital based and ambulatory
Other professionals
nurses, physiotherapists, dentists, pharmacists, etc…
Hospital beds: 6,5‰inhab
Rest homes and nursing homes
Mental health services
Rehabilitation services
Home care (and services)
Family planning, addictions treatment and prevention, …
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Characteristics of the system
Public funding – private workers :
Sickness funds: private non profit
Hospitals : private non profit OR public
Physicians: self-employed● GP’s: solo professionals, in private office (at home),
or groups (in development)● SP’s: in hospitals + private offices
Nurses, physiotherapists: ● Salaried in hospitals● Self employed, solo, or group, ● Salaried in fist line ambulatory services
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Characteristics of the system
With REGULATION
Finances : reimbursed activities
Supplementary financing
Training programs (basic and continued)
List of authorized and forbidden activities for professionnals
Accreditation (with minimum basic training, and obligatory activities)
Control of the professionnals and institutions
Disciplinary measures
Benchmark
Etc
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Characteristics of the system
IN CONSULTATION !
Belgian specialty
Social security budgets: consultation between employers, syndicates, and authorities
Health insurance : consultation between sickness funds, professionnals, and authorities (administration INAMI)
● In commissions by sector: physicians, nurses, dentists, hospitals, …
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Characteristics of the system
« Cultural » values :
Freedom of choice for the patient
Freedom of installation
Freedom of therapeutic decisions
Good Patient-centredness
But a few public-health concern
Hospital- and specialist-centered
For a few years, more support for first line
Shortage of General practitionners in comparison with nb of specialists
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Effects on organisation
Effects:
+ Commitment of the professionnals
+ Quality of care
+ Motivation
+ Cultural adaptation (BUT patients?)
- « NO System » system
- informal coordination
- measures above measures complexity
- reform is low
- cost-effectiveness?
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Effects on stasfaction
Satisfaction of population ?
moderated satisfied to very satisfied: ● GP’s : 95%● Dentists: 94%● Specialised MD : 92%● Home care: 92%● Hospitals: 87%
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Little detour
● *Giusti and al, 1997)
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Public Purpose? 5 criteria’s *
Social perspective
concern for people’s well-being, autonomy, human promotion, dialogue, taking to context into account
Non-discrimation
with regard to tace, gender, religion, political affiliation, social status, incomelevel, … (sometimes positive discrimination for a kind of population or a specific disease with vertical program))
Population-based
to take responsibility for, and be accountable to a defined population
Government policy guided
a concerne to comply with government health policies and to fit in broader master plan (with discussion, agreements with authorities)
Non lucrative goals:
Concen not to reduce the purpose of the service to profit making. Good working and living conditions are a right for staff. After that, profits should be reinvested in the service or other activities of social interest
– * (Giusti and al, 1997)
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(a little bit) more than cure
Preventive services :
Mother- child protection,
Schools preventive medicine,
work protection
Vaccination
Screening
Health promotion?
Prevention – health education when disease
Other topics: Not considered as a mission of health care professionnals (Community development, …)
● OECD : 2% of the health budget ● for prevention or health promotion
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Primary care29
Family physician: base of the 1st line
GP are first contact professionnals
Nurses, physiotherapists: only after physician’s prescribing
Dentists can also be directly contacted
GP : 5 contacts / year/inhab
95% of population declares having a family physician
95% of population has been seen in 3 years
No gate keeping
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Missions of family physicians
Care of every person adressing a demand
Accessibility : No discrimination for age, sex, social status, kind of health problem
Integrated care● Mainly to Cure● Also prevention (1ary, 2ary, 3ary), palliative,
rehabilitation
Contributes to Continuity of care● « from the cradle to the grave »● Information follows patient? / Responsible for global
medical file
Responsible for the permanency● 24h/24h, 7days a week
Holistic, patient-centered care
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Organisation of GP’s
Organisation of GP’s:
Majority: solo self-employed practitionners● Increasing number of groupe practices● Some multidiscipinary practices
« Circles » : organisation of the family physicians, together on a defined territory
● To organise the permanence of first line care– By rotation of the on call periods– By special places « guard posts »
● Some other activities (training, …)
Multidisciplinary networks● To support Chronic disease programs : diabetes II,
renal failure● Multidisciplinary coordination around a specific
patient
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Other actors
Nurses, physiotherapists, …
Solo or in at-home-service coordinations
Specific centers
Mental health
Family planification
Addictions
Social help
…
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Community oriented Primary care centers
An alternative35
Primary care centers
Multidisciplinary :
family physician, nurse, physiotherapist, receptionnist,
● Social worker, dietist, psychotherapist● Health promotor
Capitation for the majority
Non–lucrative private,
Public accreditation
With complementary financing
And missions: ● Accessibility, quality of reception, opening
hours, multidisciplinary coordination, recording of data’s, quality development, health promotion and community developpement
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Primary care centers
Since 1972 - increasing number since 1990
Today: 120 centers
3-8 new centers a year
5% of GP’s, 30% of GP’s <40
2% of population 15% in some places
Members of federations (3)
Our federation: 95 members
With a charter, objectives, values● Solidarity, universal social security, equity,
accessibility for all, support of autonomy of individuals and communities
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International perspective?
Willing to make an international network of community oriented primary care centers
With common values and objectives:
Quality of care● Holistic care (medical, mental, social), People
centred, Effectiveness, cost-effectiveness, continuity
Multidisciplinary collaboration
With a public purpose (see before)
Accessible
Integrating prevention and health promotion
Individual and collective Patient participation
Community development and public involvement
Action on the factors determining the health (broadly)
Coordination and collaboration with other actors in health system, social system, and beyond
– Are there interested persons here?
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From my own opinion
Issues for tomorrow40
Health issues : Ageing and chronic diseases41
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1881 2001
Complexity , co morbidities, holistic care
Health issues
Social inequalities on health
Increasing after crisis?
action on social inequalities!
health promotion
Mental health
Health at work , and environmental health
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Organisational issues
« shortage » of GP’s and nurses
And willing of better balance private /profess life
Needs new concepts of care organisation● Home visits more consultations
● Teams● Evolution of tasks of each professional
Place of new technologies:
Electronic medical file, Telemedecine, computer in the relationship , internet, …
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Organisational issues
Greater role for the primary care
« soft » gate keeping
definition of tasks/roles/place of each professionnal betw 1st and 2d lines
Transfer of financings from hospitals to primary care (ex mental health projects)
Integration of prevention/health promotion with health care
Territorial organisation
OR responsibility for a population
First line – hospitals - health promotion services, specialized services,…
Based on « community life territories »?
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Organisational issues
Vertical or Integrated? 45
And more…
Universal Social security: to defend!
Large scale solidarity, equity
Marchandisation
Place of the users / citizens in the system – co-decision?
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Muito Obrigada
