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FINAL REPORT

Inventory and analysis of existing data sources and indicators to meet as a Member State of the European Union the scientific

requirements of the European system of health indicators

IPH: OD Public Health Juliette Wytsmanstraat 14 Brussels B-1050 Brussel | België www.wiv-isp.be

DRAFT d.d. 10/03/2010

Science in the Service of Public Health, Safety of the Food Chain and the Environment. 2

IPH: Department of Public Health | March 2010 | Brussel, Belgium Internal reference number: PHS report 2010-030 Depotnumber of ISSN: D/2010/2505/40

Authors Johan van Bussel*, Katrien Vanthomme, Laila Higazi, Herman Van Oyen, Denise Walckiers * Juliette Wytsmanstraat 14, B-1050 Brussels, [email protected] This project is financed by the Federal Public Service (FPS)for Public Health, Safety of the Food Chain

and the Environment, Directorate-General Basic Health Care and Crisis Management (DG2) and

the Federal Public Service (FPS)of Social Security.

mailto:[email protected]



Acknowledgements

The authors of this report extend their express thanks to the following persons for their

contributions:

The members of the core and the coordination group of the Focal Point

WHO/OECD/EUROSTAT for their meticuluous proof-reading and constructive feedback:

The core of the Focal Point:

Denise WalckiersWIV OD Volksgezondheid / ISP DO SantéPublique

Contact person Focal Point

Dirk Moens(FOD Sociale Zekerheid / SPF Sécuritésociale)

Alternate contact person

Lieven De Raedt Secretariat(FOD VVVL - Internationale Betrekkingen / SPF SSCE - Relations internationales)

The members of the Focal Point Coordination Group:Lieven De Raedt FOD VVVL - Internationale Betrekkingen / SPF SSCE -

Relations internationalesFrancis Loosen FOD VVVL - DG Organisatie

Gezondheidszorgvoorzieningen (DG1) / SPF SSCE -DG de l’Organisation des Etablissements de soins (DG1)

Daniel ReyndersDominique Wagner

FOD VVVL - DG Basisgezondheidszorg en Crisisbeheer(DG2) / SPF SSCE DG Soins de Santé primaries etGestion de Crise (DG2)

Pascal Meeus RIZIV / INAMILeila Bellamammer ADSEI / DGSIEDirk Moens FOD Sociale Zekerheid / SPF Sécurité socialeHerman Van OyenJean Tafforeau

WIV OD Volksgezondheid / ISP DO Santé Publique

Lien Braeckevelt Flemish CommunityPhilippe Demoulin French Community

German Community

© Institut Scientifique de Santé Publique | Wetenschappelijk Instituut Volksgezondheid, Brussels 2010.This report may not be reproduced, published or distributed without the consent of the SI-ISP.


Anouck Billiet Walloon RegionMurielle Deguerry COCOM

Particular appreciation likewise goes out to the reviewers of the DocumentationSheets:

Anja Baele FOD VVVL - DG1 / SPF SSCE - DG1Leila Bellamammer ADSEI / DGSIETom Bevers FOD Werkgelegenheid, Arbeid en Sociaal Overleg / SPF

Emploi, Travail et Concertation socialeRana Charafeddine WIV OD Volksgezondheid / ISP DO Santé PubliqueBianca Cox WIV OD Volksgezondheid / ISP DO Santé PubliqueBernard Debbaut CM / MCStefan Demarest WIV OD Volksgezondheid / ISP DO Santé Publique

Dominique Dicker FOD VVVL - DG1 / SPF SSCE - DG1Sabine Drieskens WIV OD Volksgezondheid / ISP DO Santé Publique

Frans Fierens IRCEL / CELINELydia Gisle WIV OD Volksgezondheid / ISP DO Santé Publique

Jean Legrand FOD VVVL - DG1 / SPF SSCE - DG1Francis Loosen FOD VVVL - DG1 / SPF SSCE - DG1

Francoise Mambourg KCE

Ingrid Mertens FOD VVVL - DG1 / SPF SSCE - DG1

Dirk Moens FOD Sociale Zekerheid / SPF Sécurité socialeCindy Simoens WIV OD Volksgezondheid / ISP DO Santé PubliqueJean Tafforeau WIV OD Volksgezondheid / ISP DO Santé PubliqueMartine Sabbe WIV OD Volksgezondheid / ISP DO Santé PubliqueAndre Sasse WIV OD Volksgezondheid / ISP DO Santé PubliqueChris Segaert RIZIV / INAMIJohan Van der Heyden WIV OD Volksgezondheid / ISP DO Santé PubliqueLiesbet Van Eycken Kankerregister / Registre du CancerGuy Van Gyes Hoger Instituut voor de ArbeidMichel Willems ADSEI / DGSIE



Contents

Summary........................................................................................................................9

List of abbreviations ...................................................................................................11

List of tables ................................................................................................................15

List of figures...............................................................................................................17

Introduction .................................................................................................................18

Objectives ....................................................................................................................28

Methods and techniques ............................................................................................29

Results .........................................................................................................................34

A. The availability of the Belgian health data in international databases ....................34

B. Overview of the primary sources and their managers............................................41

C. The correspondence between ECHIM and ECHIM.be on the definition, calculation,

dimensions, data collection method and source of indicators...............................54

D. Overview of the availability of the ECHIM shortlist indicators in Belgium for the

years 2000-2008...................................................................................................61

E. Overview of actions necessary for the implementation of ECHIM in Belgium ........67

Discussion ...................................................................................................................74

Conclusion...................................................................................................................85

References...................................................................................................................86

Annexes .......................................................................................................................91


Keywords (MeSH):

Belgium

Community Health Services

Europe/epidemiology

European Union

Health Planning

Health Policy

Health Promotion

Health Status

Health Status Indicators

Health Surveys

Humans

Internet

Public Health

Public Health Informatics

Registries


Summary

This research and implementation report inventorizes and analyzes the existing data

sources and indicators to satisfy as a Member State of the EU to the scientific

requirements of the European health indicators system. To this end the databases of the

WHO (WHO/European Health For All database), the OECD (OECD Health Data) and

EUROSTAT (EUROSTAT Public Health Database) were explored in order to inventorize

the availability of data for Belgium and the applied definitions and data sources.

Publications and the media of the identified databases and managers were also

explored. The definitions of the indicators, calculation and dimensions, availability and

periodicity and quality of the data were analyzed during this process. The guidelines of

the European Community Health Indicators Monitoring (ECHIM) project were used as

‘standard’. In addition alternative Belgian (national) data sources were consulted and

examined for their comparability with these ECHIM guidelines.

The results of this study show that the availability of Belgian data in the

international databases is high. The correspondence between ECHIM and the national

indicators with regard to the definitions, calculations, dimensions, data collection method

and sources of the indicators is also high, and this within each group of indicators. A

cyclical pattern, caused by the substantial number of indicators measured by HIS-Belgium,

is also described in the availability of data. The report closes by mapping out points of

action of a limited and more extensive nature necessary for the implementation of ECHIM

in Belgium.

In the short term certain changes will have to be made for a limited number of

indicators in concerning the calculation and data collection. No substantial resources need

to be provided as far as the calculations are concerned. These changes may also be

effected direct. The action points for data collection (processing of birth and death

certificates; the national register for breastfeeding, extension of existing surveys with

random samples of pregnant women, …), however, require more extensive means.

With the execution of the above actions Belgium satisfies the current state of the

art within the ECHIM project. However, no (definitive) guidelines for operationalization are

as yet available in the present study for a good third of the ECHIM shortlist indicators.

Structural actions are therefore necessary to follow these scientific developments in terms

of content in a continuous manner. An overarching data collection concept and strategy

must also be established and executed with the managers of the databases. A structured

dialogue in cooperation the concerned authorities and institutions such as Focal Point


WHO, OECD and EUROSTAT, and an integrated legal framework are necessary for that

purpose. An expansion of the scientific personnel is necessary for the follow-up and

support of these structural actions.

The study ends by emphasizing that transfer to the international databases may

not to the only priority of Belgian data collection. In point of fact such data collection is also

used for the evaluation and improvement of the Public health in Belgium and in the

Communities and for the justification of the allocated resources.


List of abbreviations

ADSEI / DGSIE Algemene Directie Statistiek en Economische informatie / Direction

générale Statistique et Information économique

JZS / SHA Jaarlijkse Ziekenhuisstatistieken / Statistiques Hospitalières

Annuelles

AMI Acute myocardial infarction (heart infarct)ATC Anatomic Therapeutic Chemical Classification System (WHO

Collaborating Centre for Drug Statistics Methodology)BDR / RBD Belgian Diabetes Register / Registre belge du diabète

Be-MoMo Belgian Mortality Monitoring

BCHWO Observatorium voor gezondheid en welzijn van Brussel-Hoofdstad /

l’Observatoire de la Santé et du Social de Bruxelles-Capitale

BKR / RBC Belgisch kankerregister / Registre belge du cancer

BS / MB Belgisch Staatsblad / Moniteur belge

CBG / CPS Centraal Bestand Gezondheidsberoepen / Cadastre des professions

de la santé

CBPL / CPVP Commissie voor de bescherming van de persoonlijke levenssfeer /

Commision de la Protection de la vie privée

CIC Centraal Instellingen Bestand / Fichier des Institutions Centralisé

CIHI Canadian Institute for Health Information (Canada)COCOM Commission communautaire commune (Brussels Capital Region)COPD Chronic Obstructive Pulmonary Disease

CORPH Centre for Operational Research in Public Health

CR Clinical Cancer Register

CT Computed tomography

/dev Under development

DGSANCO Directorate General for Health and Consumer Affairs

DGSanté Direction générale de la santé (French Community)

DSM-IV Diagnostic and Statistical Manual of Mental Disorders, Fourth edition

EAK / EFT Enquete naar de ArbeidsKrachten / Enquête sur les forces de travail

EC European Commission

ECHI European Community Health Indicators

ECHIM European Community Health Indicators Monitoring

EHEMU European Health Expectancy Monitoring Unit


EHIS European Health Interview Survey

EMCDDA European Monitoring Centre for Drugs and Drug Addiction

ESeC European Socio-Economic Classification

ETS Environmental Tobacco Smoke

EU European Union

EUPHIX EU Public Health Information & Knowledge System

EURO-MOMO European monitoring of excess mortality for public health action

EURO-PERISTAT European Perinatal Health Indicators

EUROTHINE Tackling Health Inequalities in Europe

EWCS European Working Conditions Surveys

EWCO European Working Conditions Observatory

FBFC Federal Breastfeeding Committee

FOD BZ / SPF Int Federal Government Department Internal Affairs

FOD Justitie / SPFJustice

Federal Government Department Justice

FOD SZ / SPF SS Federal Government Department Social Security

FOD VVVL / SPFSSCE

Federal Government Department Public Health, Food Chain Safetyand the Environment

GHQ-12 General Health Questionnaire (12 item version)

HES Health Examination Survey

HIS-Belgium Health Interview Survey Belgium

HISIA Belgian Health Interview Survey - Interactive Analysis

HIVA Hoger Instituut voor de Arbeid

ICD-9-CM International Classification of Diseases, 9th revision, ClinicalModification (WHO)

ICD-10 International Classification of Diseases, 10th revision (WHO)

ICD-O International Classification of Diseases for Oncology (WHO)

ICF International Classification of Functioning, Disability and Health(WHO)

ICHI International Compendium of Health Indicators (DGSANCO)

ICPC-2 International Classification of Primary Care, 2nd edition (WHO)

ILCS Income and living conditions survey

IMA / AIM Intermutualistisch Agentschap / l’Agence intermutualiste

IRCEL / CELINE Intergewestelijke Cel voor Leefmilieu / Cellule interregional pour


l'Environnement

ISARE Health Indicators in the European Regions

ISCED97 International Standard Classification of Education - version 1997ISCO-88 International Standard Classification of OccupationsISHMT International Shortlist for Hospital Morbidity Tabulation

(EUROSTAT/OECD/WHO)K&G Kind en Gezin

KCE Federaal Kenniscentrum voor de Gezondheidssorg / Centre Fédéral

d’Expertise des Soins de Santé

LFS Labour Force Survey (EU)

MHI-5 Mental Health Index (RAND Short Form 36)

MKG / RCM Minimale Klinische Gegevens / Résumé Clinique Minimum

MPG / RPM Minimale Psychiatrische Gegevens / Résumé Psychiatrique

Minimum

MRI Magnetic Resonance Imaging

ni Not indexed

NUTRIA Nationale voedselconsumptiepeiling / Enquête nationale de

consommation alimentaire

NVGP / PNNS Nationaal voedings- en Gezondheidsplan / Plan National Nutrition

Santé

OECD Organization for Economic Co-operation and Development

ONE Office de la Naissance et de l’Enfance

PM10 Particulate Matter (fine particles) 10

PS / EP Permanente Steekproef / l’Echantillion Permanente

PTCA Percutaneous Transluminal Coronary Angioplasty

RIVM Rijksinstituut voor Volksgezondheid en Milieu (Netherlands)

RIZIV / INAMI Rijksinstituut voor Ziekte- en Invaliditeitsverzekering / Institut national

d'assurance maladie-invalidité

SKR Stichting Kankerregister

SPMA Standardized Procedures for Mortality Analysis

THL National Institute for Health and Welfare (Finland)

VAZG Vlaams Agentschap Zorg en Gezondheid

WHO World Health Organization

WIV ODVolksgezondheid/ ISP DO SantéPublique

Wetenschappelijk Instituut Volksgezondheid - Operationele DirectieVolksgezondheid en Surveillance / Institut Scientifique de SantéPublique - Direction Opérationelle Santé Publique etSurveillance



List of tables

Table 1. The ECHIM shortlist and indicator status (d.d. 02/09/2009) ............................22

Table 2. The objectives of the research and implementation assignment and the

corresponding sections of the adapted Documentation Sheets ....................32

Table 3. Global overview of availability of Belgian health data (ECHIM shortlist) in the

databases of the WHO, OECD and EUROSTAT..........................................35

Table 4. Demographic and socio-economic indicators: overview of availability of Belgian

data in the databases of the WHO, OECD and EUROSTAT ........................36

Table 5. Health status indicators: overview of availability of the Belgian data in the


Table 6. Health determinants: overview of availability of Belgian data in the databases of

the WHO, OECD and EUROSTAT...............................................................38

Table 7. Healthcare indicators: overview of availability of Belgian data in the databases

of the WHO, OECD and EUROSTAT...........................................................39

Table 8. Health promotion indicators: overview of availability of Belgian data in the


Table 9. Global overview of the national sources for the implementation of ECHIM in

Belgium........................................................................................................43

Table 10. Overview of characteristics of national databases (according to Van de Sande

et al., 2006)..................................................................................................45

Table 11. Distribution of indicators according to level of data collection and level of

financing. .....................................................................................................51

Table 12. Types of national sources of health data, their advantages and disadvantages

or limitations (Habers et al., 2008)................................................................52

Table 13. Global overview of the correspondence between ECHIM and ECHIM.be on the

definition, calculation, dimensions, data collection method and source of

indicators. ....................................................................................................56

Table 14. Demographic and socio-economic indicators: overview of the correspondence

between ECHIM and ECHIM.be on the definition, calculation, dimensions,

data collection method and source of indicators...........................................56

Table 15. Health status indicators: overview of the correspondence between ECHIM and

ECHIM.be on the definition, calculation, dimensions, data collection method

and source of indicators. ..............................................................................57


Table 16. Health determinants: overview of the correspondence between ECHIM and

ECHIM.be on the definition, calculation, dimensions, data collection method

and source of indicators. ..............................................................................58

Table 17. Healthcare indicators: of the correspondence between ECHIM and ECHIM.be

on the definition, calculation, dimensions, data collection method and source

of indicators..................................................................................................59

Table 18. Health promotion indictors: overview of the correspondence between ECHIM

and ECHIM.be on the definition, calculation, dimensions, data collection

method and source of indicators. .................................................................60

Table 19. ECHIM shortlist indicators: global overview of availability in Belgium for the

years 2000-2008 ..........................................................................................61

Table 20. Demographic and socio-economic indicators: overview of availability in

Belgium for the years 2000-2008 .................................................................62

Table 21. Health status indicators: overview of availability in Belgium for the years 2000-

2008.............................................................................................................63

Table 22. Health determinants: overview of availability in Belgium for the years 2000-

2008.............................................................................................................64

Table 23. Healthcare indicators: overview of availability in Belgium for the years 2000-

2008.............................................................................................................65

Table 24. Health promotion indicators: overview of availability in Belgium for the years

2000-2008....................................................................................................66

Table 25. Global overview of actions necessary for the implementation of ECHIM in

Belgium........................................................................................................68

Table 26. Demographic and socio-economic indicators: overview of actions necessary

for the implementation of ECHIM in Belgium................................................70

Table 27. Health status indicators: overview of actions necessary for the implementation

of ECHIM in Belgium....................................................................................71

Table 28. Health determinants: overview of actions necessary for the implementation of

ECHIM in Belgium........................................................................................72

Table 29. Healthcare indicators: overview of actions necessary for the implementation of

ECHIM in Belgium........................................................................................73


List of figures

Figure 1. Basic health domains model according to Lalonde (Kramers et al., 2005). .....19

Figure 2. Conversion of the basic health domains model into a causal line (Kramers et

al., 2005)............................................................................................................20

Figure 3. Main categories for the ECHI-1 indicator list and the ECHI-2 subdivision of the

category Healthcare systems (Kramers et al., 2005)..........................................21

Figure 4. Portal websites (top to bottom) of the EUPHIX project, the ECHIM project and

the ICHI of DG SANCO......................................................................................25

Figure 5. Division (absolute figures) of indicators according to scale of national data bank

..........................................................................................................................44

Figure 6. Division of indicators according to data collection method of used national data

bank (absolute figures) ......................................................................................49

Figure 7. Portal websites of the Nationaal Kompas Volksgezondheid (RIVM) and the

Health Indicators Report (CIHI). .........................................................................83


Introduction

This report is situated in the recent development of a sustainable European system for

health monitoring. Such a monitor systematically brings together data from all EU Member

States on health (degree of distribution of chronic, serious and rare disorders, …), health-

related behaviour (lifestyles and other health determinants) and healthcare systems

(access to health services, quality of the provided health services, personnel resources,

…). The aim of this health monitoring is the facilitation of the planning, control and

evaluation of EU programmes and actions, the provision of relevant health information for

benchmarking to the EU Member States, and the support of the health policy of the EU

Member States (European Council, 1995).

International organizations with a tradition of systematic tracking of the public

health on the basis of indicators are the World Health Organization (WHO) and the

Organization for Economic Co-operation and Development (OECD). Both organizations

started in the 1980s with the development of a database with statistical data on the public

health and health services of the respective Member States. EUROSTAT, the Statistical

Office of the EU, recently also began to collect health data on the EU Member States.

Given the high degree of correspondence with regard to content and the differences in

statistical data the WHO, OECD and EUROSTAT embarked on the coordinated collection

of national statistical data by means of the so-called Joint Questionnaires. In the early

days this joint data collection concerned only the monetary aspects of health. In January

2010 a start was also made on a Joint Questionnaire for non-monetary health data. The

Focal Point WHO, OECD en EUROSTAT (Interministerial Conference on Public health of

28/09/2009) was set up in Belgium to coordinate the joint transfer of this data.

The European Community Health Indicators Monitoring project (ECHIM) plays a central

role in the design and implementation of a European health monitoring system. Building up

on the work of the ECHI-1 and ECHI-2 projects, and financed by the Joint Action of the

second European Commission public health programme ‘Public Health Programme 2008-

2013’, the ECHIM project coordinates the harmonization, collection and presentation of the

data from the EU Member States for 88 health indicators, the so-called “ECHIM shortlist”.


The genesis of the ECHIM shortlist 1

The ECHIM shortlist (Table 1) is no arbitrary list of health indicators. The selection of these

indicators fits within a conceptual framework that refers to a Canadian health services

model, named after the former Minister for Public health, Marc Lalonde. This (see Figure

1) states that health is determined by four groups of factors or “health determinants”: (a)

biological and genetic factors, (b) lifestyle, (c) the physical and social environment, and (d)

the healthcare system. According to this integral model health is more than the absence of

disease or disorder, but also includes dimensions such as “functioning” and “well-being”.

The model further implies that the policy-makers can have an efficient effect on the public

health through each of these four determinants.

Health

Health CareSystem

Lifestyle

Biological andGenetic Factors

Physical andSocial

Environment

Figure 1. Basic health domains model according to Lalonde (Kramers et al., 2005).

In various publications by the Nederlandse Rijksinstituut voor Volksgezondheid en

Milieu (RIVM: Harteloh et al., 1995; Ruwaard and Kramers, 1997; van Oers 2002;

Hollander et al., 2007) Lalonde’s model is converted and refined to a causal model (Figure

2) in which health is influenced by various health determinants and in which different

activities, such as prevention and health promotion have a positive impact on the public

1 This section is a summary of the introductory chapters of the ECHI-2 final report (ECHI project, 2005) andthe ECHIM final report (Kilpelaïnen, Aromaa, and the ECHIM Core Group, 2008). An annotated timeline isavailable in the ECHIM final report.


health by influencing these health determinants. The policy choices that have a direct or

indirect effect on health also have a significant function in the RIVM models. When all is

said and done, these policy choices must create the best possible conditions for these

health actions.

A simplified version of the RIVM model (Figure 2) was already used as guiding

principle during the early ECHI-1 project. Within each block in Figure 2 it is possible to

define themes and indicators for which data can be collected. This structure is still applied

in the present ECHIM project, although the health determinant “healthcare systems” was

split during the ECHI-2 project into health actions within the healthcare system (curative

medicine, paramedical care and classical prevention) and outside that system (health

promotion in specific settings such as schools, factories, prisons, …).

Health (and other) policies

Health promoting activities, preventive interventions

Health status, functioning, well-being, health-related quality of life

LifestylesBiological and

geneticfactors

Physical andsocial

environment

Health caresystem

Figure 2. Conversion of the basic health domains model into a causal line (Kramers et al.,2005).

The list of ECHI-1 indicators and the underlying structure were adopted by the

European Commission Directorate-General Health and Consumers (DG SANCO) as

frame of reference (DG SANCO, 2004). During the ECHI-2 project this list was extended,

among other things under the impulse of various other projects that were active under the

DG SANCO “Health Monitoring Programme“ and “Public Health Programme“. This

generated both an ECHI longlist and an ECHI shortlist. The longlist consists of an


inventory of more than 500 indicators, including a large number of indicators from the

databases of the World Health Organization (WHO Health for All) and the Organization for

Economic Cooperation and Development (OECD Health Data). These indicators are

included by the ECHI-2 project group in a solid conceptual framework.

1. Demographic and socio-economic situation

2. Health status

3. Determinants of health

4. Health systems

1.1. Population1.2. Socio-economic factors

2.1. Mortality2.2. Morbidity, disease-specific2.3. Generic health status2.4. Composite health status measures

3.1. Personal and biological factors3.2. Health behaviours3.3. Living and working conditions

4.1. Health care4.1.1. Health care resources4.1.2. Health care utilisation4.1.3. Health expenditures and financing

4.2. Health promotion4.1.4. Health care quality/performance

4.2.1. Prevention, health protection and health promotion

Figure 3. Main categories for the ECHI-1 indicator list and the ECHI-2 subdivision of thecategory Healthcare systems (Kramers et al., 2005).

The 82 indicators in the ECHI-2 shortlist were selected from the longlist as “priority

for implementation”. The selection was effected by a panel of epidemiologists applying the

following criteria: a) the interest for the general health status and the major health

problems in the population; b) the level of evidence concerning disparity in health; and c)

the interest for effective interventions and policy measures. In this way the data for the

shortlist indicators should give a general idea of public health. It was also expected that

the shortlist, on the basis of the detected gaps, would indicate new areas for innovation

and development. This expectation is now seen to be met for more than one third of the

current indicators for which considerable conceptual and operational uncertainties still

persist (RIVM and THL, 2009).


Table 1. The ECHIM shortlist and indicator status (d.d. 02/09/2009) 2

A B C D(n) 46 10 16 16(%) 52.27 11.36 18.18 18.18

A) Demographic and socio-economic indicators (n=9) 6 0 3 0(%) 66.67 0.00 33.33 0.00

1. Population by sex/age 12. Birth rate, crude 13. Mother’s age distribution 14. Total fertility rate 15. Population projections 16. Population by education 17. Population by occupation 18. Total unemployment 19. Population below poverty line and income inequality 1

B) Health status (n=32) 19 4 3 6(%) 59.38 12.50 9.38 18.75

10. Life expectancy 111. Infant mortality 112. Perinatal mortality 113. Disease-specific mortality; Eurostat, 65 causes 114. Drug-related deaths 115. Smoking-related deaths 116. Alcohol-related deaths 117. Excess mortality by heatwaves 118. Selected communicable diseases 119. HIV/AIDS 120. Cancer incidence 121. Diabetes 122. Dementia 123. Depression 124. AMI 125. Stroke 126. Asthma 127. COPD 128. (Low) birth weight 129. Injuries: home/leisure, violence 130. Injuries: road traffic 131. Injuries: workplace 132. Suicide attempt 133. Self-perceived health 134. Self-reported chronic morbidity 1

2 A: Finalized definition and operationalization; B: Small remaining issues to be sorted out by ECHIM; C:Complex remaining issues to be sorted out by ECHIM; D: In developmental stage of ECHIM programme(RIVM and THL, 2009).


Table 1 (Continued). The ECHIM shortlist and indicator status (d.d. 02/09/2009)

A B C D35. Long-term activity limitations 136. Physical and sensory functional limitations 137. General musculoskeletal pain 138. Psychological distress 139. Psychological well-being 140. Health expectancy: Healthy Life Years (HLY) 141. Health expectancy, others 1

C) Determinants of health (n=14) 7 1 3 3(%) 50.00 7.14 21.43 21.43

42. Body mass index 143. Blood pressure 144. Regular smokers 145. Pregnant women smoking 146. Total alcohol consumption 147. Hazardous alcohol consumption 148. Use of illicit drugs 149. Consumption/availability of fruit 150. Consumption/availability of vegetables 151. Breastfeeding 152. Physical activity 153. Work-related health risks 154. Social support 155. PM10 (particulate matter) exposure 1

D) Health interventions: health services (n=29) 14 5 6 4(%) 48.28 17.24 20.69 13.79

56. Vaccination coverage in children 157. Influenza vaccination rate in elderly 158. Breast cancer screening 159. Cervical cancer screening 160. Colon cancer screening 161. Timing of first antenatal visits among pregnant women 162. Hospital beds 163. Physicians employed 164. Nurses employed 165. Mobility of professionals 166. Medical technologies: MRI units and CT scans 167. Hospital in-patient discharges, limited diagnoses 168. Hospital daycases, limited diagnoses 169. Hospital daycase/in-patient discharge ratio, limited diagnoses 170. Average length of stay (ALOS), limited diagnoses 171. General practitioner (GP) utilisation 172. Other outpatient visits 173. Surgeries: PTCA, hip, cataract 174. Medicine use, selected groups 175. Patient mobility 1


Table 1 (Continued). The ECHIM shortlist and indicator status (d.d. 02/09/2009)

A B C D76. Insurance coverage 177. Expenditures on health 178. Survival rates cancer 179. 30-day in-hospital case-fatality AMI and stroke 180. Equity of access to health care services 181. Waiting times for elective surgeries 182. Surgical wound infections 183. Cancer treatment delay 184. Diabetes control 1

E) Health interventions: health promotion (4) 0 0 1 3(%) 0.00 0.00 25.00 75.00

85. Policies on ETS exposure (Environmental Tobacco Smoke) 186. Policies on healthy nutrition 187. Policies and practices on healthy lifestyles 188. Integrated programmes in settings, including workplace, schools, hospital 1

As successor of the ECHI-1 and ECHI-2 projects the ECHIM project was given the

objective of consolidating the ECHI indicator system and expanding it into a durable health

monitoring system. The focus in the present project phase (joint action) is clearly on the

collection and exchange by EU Member States of comparable data and information on the

indicators of the ECHIM shortlist. In the course of this project phase (June 2008) the

shortlist itself should grow to a list of 88 indicators (Kilpelaïnen, Aromaa, and the ECHIM

Core Group, 2008). More specifically, it concerns (a) the documentation of the ECHIM

indicators, b) the development of guidelines for implementation, (c) the maintenance of a

network of national experts, (d) the testing of the data collection from the Member States

to a central European database, and (e) the presentation and (f) interpretation of that data.

For Belgium the WIV OD Volksgezondheid / ISP DO Santé Publique is closely involved in

these activities as one of the so-called ECHIM Core Group members.


Figure 4: Websites of (top to bottom) the EUPHIXproject, the ECHIM-project and the ICHI of DGSANCO.

The first steps towards a

comparative presentation of the European

health data on the basis of the ECHI and

ECHIM projects are visible in the portal

websites of the EU Public Health

Information & Knowledge System

(EUPHIX) project, the DGSANCO

International Compendium of Health

Indicators (ICHI) and the ECHIM project

itself (healthindicators.eu) (Figure 5). The

Eurostat Public Health database finally also

integrates all the data from a selection of

the ECHIM indicators.

Figure 4. Portaalwebsites van (boven naar onder)het EUPHIX-project, het ECHIM-project en het ICHIvan de DGSANCOECHIM evaluation of the availability of

Belgian health data

In early 2008 the ECHIM project group

brought out a first report with the results of

the availability of the indicators in the EU

Member States (Kilpelaïnen, Aromaa, and

the ECHIM Core Group, 2008). The ECHIM

project group here conducted an analysis of

the availability of data in the databases of

the WHO, the OECD and EUROSTAT (the

so-called Country Report) and an inquiry

with the national contact persons (the so-

called ECHIM survey). On the basis of the

Country Report the authors concluded that

the Belgian health data are to a large extent

available (82% of the ECHIM shortlist

indicators). However, on the basis of the

ECHIM survey, the availability of national health data (71%) was found to be somewhat


below the European average (77%). Reference is made to the lack of any indicators in the

sections “Health determinants” and “Health services”. The authors judged the availability of

so-called “registers” (such as Minimale Klinische Gegevens / Résumé Clinique Minimum

(MKG / RCM), …) as excellent. However, reference was then also made to (a) the

absence of a national health research (the so-called Health Examination Survey: HES)

and (b) the low degree of coverage of the Cancer Register. The installation of the Belgisch

Kankerregister / Registre de Cancer belge (BKR / RBC) was also noted as being an

important positive attainment, as was the inclusion of models from the European Health

Interview Survey (EHIS) in the fourth round of the national health survey (HIS Belgium). It

was further ascertained that no national publications appear offering a general overview of

the health data in Belgium.

The following were cited as the major obstacles to the implementation of ECHIM in

Belgium: a) the federal structure of Belgium, with a spread of competences regarding

health services and health promotion or prevention, b) the number of concerned facilities

and c) the regional differences in policy emphases.

As possible solution for the implementation of ECHIM in Belgium the authors point

in the first instance to a better definition of the indicators, of the calculation method and of

the data source. They also stressed the importance of a national contact point where

representatives of the various concerned facilities could help to prepare the process of

implementation. The authors also regard the EUROSTAT regulation on the provision of

public health data (European Council, 2008) as an opportunity for improving the data flow

and division of labour between the various partners.

ECHIM in Belgium: ECHIM.be

Belgium is obliged through its membership of the European Union to cooperate in the

development of EU health indicators, one of the priority themes of the second public

health programme ‘Public Health Programme 2008-2013’ of the European Commission.

The conducting of an inventory and an analysis of the existing databases and indicators is

necessary if the country wants to be able to contribute, as a Member State, to the process

of harmonization of the 88 ECHIM basic indicators (shortlist). There is also a need for a

scientifically sound instrument and implementation plan for the benefit of the partners and

policy-makers in order to, as Member States of the European Union, in the gathering of

information and knowledge for the setting of policy priorities for public health. These


conclusions were the point of departure for the Federale Overheidsdienst

Volksgezondheid, Veiligheid van de Voedselketen en Leefmilieu (FOD VVVL) / Service

Public Fédéral Santé publique, Sécurité de la Chaîne alimentaire et Environnement (SPF

SSCE) and for the Federale Overheidsdienst Sociale Zekerheid (FOD SZ) / Service

Public Fédéral Sécurité Sociale (SPF SS) when entrusting a research and implementation

assignment “Inventory and analysos of the existing data sources and indicators to meet as

a Member State of the European Union the scientific requirements of the European

system of health indicators” to the Operational Direction Public Health and Surveillance of

the Wetenschappelijk Instituut voor Volksgezondheid (WIV OD Volksgezondheid / ISP DO

Santé Publique) (23 March 2009). The objectives of this assignment, the methodology

used, the results and the summarizing conclusion are described underneath.


Objectives

The objectives of this research and implementation assignment are formulated in the

agreement with the Contracting Authorities as following:

Objective 1: Investigating the international databases on the basis of the

indicators from the priority list of ECHIM indicators referred to as ‘shortlist indicators’

with a view to determining the availability and quality of data delivered by the various

concerned Belgian correspondents.

Objective 2: Mapping the currently available data sources and indicators from

the priority list of ECHIM indicators. This also involves updating the work of earlier

similar projects (KCE, WIV OD Volksgezondheid / ISP DO Santé Publique …).

Objective 3: Critical scientific analysis of the definitions used in Belgium at

different levels and indicating the necessary refinements and improvements of the data

sources and indicators used in order to arrive at a harmonization of contents of the

European ‘ shortlist indicators’.

Objective 4: Identifying the roles and competences of the players in the field

and at different policy levels in order to provide the shortlist indicators, including the run

of the timeline of the flow of information from source to the coordination point at national

level.

Objective 5: Examining the feasibility and organizing alternatives to satisfy the

European criteria for the collection of ‘shortlist indicators’ over the medium term.

Quantitative and qualitative aspects will here be taken into account.

A cooperation model and methodology will be developed in order to deliver the

Belgian data in compliance with the European criteria. A realistic process, timeline and

budgetary implication are described. Description of the technical specifications and

procedures for the organization of the delivery of acceptable quality European ‘shortlist

indicators’.


Methods and techniques

Data collection

The data collection was effected via a versatile search strategy. Use was made here of

the literature, documents, databases, available information n the Internet and individual

contacts with the data managers.

The databases of the international organizations WHO, OECD and EUROSTAT

were investigated in a first phase (April 2009 - September 2009). Attention was also paid

to the description of the data in de metadocumentation of those databases. In this way

the availability of the data, the definitions used (and differences with the accepted WHO,

OECD and EUROSTAT definitions) and the sources of the indicators from Belgium were

inventorized.

In the next phase the publications and the websites of the identified players and

organizations were explored. The definitions of the indicators, the calculation and

dimensions, the availability and periodicity and the quality of the data were also analyzed

in the process.

By way of supplement alternative Belgian (national) data sources were consulted

and examined for their conformity with the ECHIM criteria. The direction was set here by

the Morbidat database of the WIV OD Volksgezondheid / ISP DO Santé Publique (1998)

and by the report “Inventaris van databanken gezondheidszorg” by the Federaal

Kenniscentrum voor de Gezondheidssorg (KCE: Van De Sande et al., 2006).

Inventorization and analysis of the data

Given the importance of harmonization, the ECHIM project group method was applied.

This developed the so-called Documentation Sheets for each of the shortlist indicators

(for a detailed description see: Kilpelaïnen, Aromaa, and the ECHIM Core Group, 2008).

Considering the parallel activities within the ECHIM project group, it was decided to take

the most recent edition (d.d. June 2008) of the Documentation Sheets as benchmark.

Because the operationalization of a substantial number of ECHIM shortlist indicators is

not yet complete (Table 1) significant revisions and additions can still be expected. Given

the timeframe of this research and implementation assignment these revisions could not

be included in this final report.


The format of the Documentation Sheets was also adapted for the purposes of

national implementation. The adapted Documentation Sheets (drafted in English, see in

annex) contain 3 parts and10 sections. Sections 3, 4, 5, 6 and 7 have a grey and a white

text field. The grey text field gives the content of the ECHIM Documentation Sheets

(version 02.09.2009); the white text field concerns the equivalent for Belgium and, thus,

the result of the research and implementation assignment.

The first part of the Documentation Sheets includes a detailed description of the

indicator and its availability in national and international sources and databases.

1) The text field “ECHIM indicator name” gives the name of the ECHIM indicator

to be measured and the section to which that indicator belongs: Demographic and socio-

economic indicators; Health status; Health determinants; Health interventions:

Healthcare; or Health interventions: Health promotion.

2) The section “Status of indicator according to ECHIM (dd. 02/09/2009)”states whether the indicator is operational according to the ECHIM project group,

requires minor or major revisions or specifications or is still in the development phase.

The benchmark adopted was the status as reported in the ECHIM memorandum

“Proposal for tackling ECHI shortlist definition/operationalization problems (WP1)” of 2

September 2009.

3) The section “Definition of indicator” describes what the ECHIM indicator

must measure. If the ECHIM Documentation Sheets mention different alternatives the

corresponding number for the definition is given in the text field for Belgium.

4) The section “Calculation of the indicator (numerator, denominator)”describes how the indicator in question is calculated (i.c. numerator and denominator,

etc.). If the ECHIM Documentation Sheets mention different alternatives the

corresponding number for the calculation is given in the text field for Belgium.

5) The section “Relevant dimensions (subgroups)” describes the subgroups

according to which the indicator can be classified (for example, region, age, gender,

socio-economic status, …).

6) The known and available national sources for the indicator in question are

listed and described In the section “Data source(s)”. For the international databases

availability is reported as standard in (a) the WHO/European health for all databases, (b)

the OECD Health Data and (c) the EUROSTAT Public Health Database. For the national

databases these may be registers (such as the MKG / RCM Federal Death Register),

surveys (such as HIS-Belgium or the Enquête naar de Arbeidskrachten: EAK / EFT), or

for example networks of clinical-biological laboratories (such as the AIDS Reference


Laboratories of Belgium: ARL). The preferred source is listed first. In certain cases

several sources may enter into consideration. The choice is based, among others, on

possible comparability with the other EU Member States and the continuity of data

collection.

7) The section “Data availability, quality, periodicity” gives a detailed

description of the availability of the preferred national source (including access to the

micro data), the quality of the data and the periodicity of the data. Regarding the quality

of the data, it examines whether (a) the data concern the total population or is only a

sample (b) gives the response ratio and states (c) whether participation/registration is

obligatory or voluntary and (d) whether there are data on the reliability and validity of the

data collection, (e) whether international classification systems or calculation methods

were used, (f) whether documentation is available on the methodology and (g) whether

the reporting of the data is unambiguous.

8) The section “Partners & Information flow in Belgium” describes the players

that collect the data for the indicator in question in Belgium. If several players contribute

to the collection of data their contributions are summarized in chronological order.

9) The section “Belgian contact person for the indicator” gives the name and

contact details of the contact person for the indicator in question in Belgium.

The second part of the Documentation Sheet concerns a number of conclusions

(Section Conclusions). More specifically it states via closed options whether the Belgian

definition and calculation of the indicator coincide, whether and, if so, to what extent the

data are available at national level, whether the source and the method of data collection

corresponds with the preference(s) of the ECHIM project, and whether and, if so, to what

extent the dimensions are available. This second part closes with the question as to

whether small yet important initiatives are necessary in order to collect (correctly and

efficiently) the relevant data for Belgium. The initiative to be taken is here formulated in

concrete terms, a player is named and there is indication as to whether extra resources

will have to be provided. It also assesses whether such initiative may be taken

immediately or rather requires a longer implementation phase.

The third part of the Documentation Sheet (Section References) includes references to

the consulted online databases and to the literature. The list of references also includes

the cited institutions.


How can the five objectives be found in de Documentation Sheet?

The five objectives of this research and implementation assignment can be found per

indicator in the adapted Documentation Sheets (Table 2).

Table 2. The objectives of the research and implementation assignment and thecorresponding sections of the adapted Documentation Sheets

Objective Section

1. Examination of the international databases on the basis of theindicators from the ECHI priority list.

Section 6: Internationaldatabases

2. Mapping the currently available data sources and indicatorsfrom the ECHI priority list.

Section 6: National (federal)data sources

3. A critical scientific analysis of the definitions used in Belgiumand indication of the necessary refinements andimprovements of the used data sources and indicators.

Section 3: Definition;Section 4: Calculation;Section 5: Dimensions;Section 7: Availability, …Section 10: Conclusions.

4. Identification of the roles and competences of the players in thefield and at the various policy levels to deliver the shortlistindicators.

Section 8: Partners &Information flow

5. Examining the feasibility of and organizing alternatives tosatisfy the European criteria for the collection of ‘shortlistindicators’ in the medium term.

Section 10: Conclusions


Documentation Sheet review process

After a Documentation Sheet is prepared for each indicator of the ECHIM shortlist (first

author), these Documentation Sheets are made over to the hierarchical manager of the

concerned national source. The latter is asked for a) a considered opinion, any further

additions, corrections or control of the description and analysis. If the data are not in

compliance with the European criteria the manager is asked b) whether the necessary

corrections can be made (Section 10). A c) realistic process, timeline and budgetary

implication are required here (Section 10). The whole process (a, b and c) is regarded as

validation of the Documentation Sheet.


Results

The results of this research and implementation assignment were reported in two parts.

First there are the 88 Documentation Sheets. These are included in the annex to this

final report. Then there is the summarizing analysis that we give below. We discuss

successively (a) the availability of the Belgian health data in the international databases

(WHO, OECD and EUROSTAT) (Objective 1); (b) the primary national sources and their

managers (Objectives 2 and 4); (c) the correspondence between ECHIM and ECHIM.be

regarding the definition, calculation, dimensions, data collection method and source of

indicators (Objective 3); the availability of the ECHIM shortlist indicators in Belgium for

the years 2000-2008 (Objective 3); and (d) the actions necessary for Belgium for the

implementation of ECHIM (Objective 5).

A. The availability of the Belgian health data in international databases(Objective 1)

When exploring the online databases of the WHO (WHO/European Health for All

database), the OECD (OECD Health Data) and EUROSTAT (EUROSTAT Public Health

Database) for the presence of the 88 ECHIM indicators for Belgium, data were recorded

for respectively 39, 44 and 42 indicators, or approximately half of the 88 indicators (see

Table 3). This availability is to all intents and purposes complete when corrected in the

calculation of the relative proportion for the number of indicators actually inventorized in

the three databases. Indeed, roughly half of the 88 ECHIM indicators are not available in

the WHO/European Health for All database (n = 49, 56%), the OECD Health Data

(n =43, 49%), or the EUROSTAT Public Health Database (n =45, 51%).

The ECHIM indicators that are in fact included in the international databases and

for which no data for Belgium is available are “Medical technologies: MRI units and CT

scanners” (Ind. 66: not in Eurostat Public Health Database, but in OECD Health Data)

and “30-Days hospital fatality: AMI and CVA” (Ind. 79), both indicators from the group

“Healthcase indicators” (Table 7).

The fact that the Belgian data are available in the international databases does

not mean that these data are also complete, current or of a high quality. For the mortality

data (Ind. 10-16), for example, the annual data are generally available up to 1999, after


which only data for 2004 are available. It should however be pointed out that the

availability of the data is determined by the periodicity of the data collection. Data on the

basis of the HIS-Belgium or the European Working Conditions Survey Belgium are

therefore available every four or five years only.

It must also be emphasized that the available data in the international databases

sometimes are based on other databases than the in this report preferred national

databases. For instance for the indicator Acute myocardial infarct (Ind. 25) are the

relevant hospital admission and/or mortality for Belgium (respectively ECHIM

preferences 1 and 2) available in the WHO/European Health for All database, the OECD

Health Data and the EUROSTAT Public Health Database, but not the data of HIS-

Belgium (preference for implementation Belgium).

Table 3. Global overview of availability of Belgian health data (ECHIM shortlist) in thedatabases of the WHO, OECD and EUROSTAT

WHO-EU OECD EUROSTAT

A A) Demographic and socio-economicindicators (9) 6 5 8

B Health status (n = 32) 18 18 19

C Determinants of health (n=14) 6 5 3

D Health interventions:Health services (n = 29)

E Health interventions:Health promotion (n = 4)

Total number available (n) 39 45 42Proportion available (%) 44.32 51.14 47.73Corrected proportion available (%)* 100.00 100.00 97.67

0 0 0

9

ni

ni: indicator(s) not available in database

ni ni

* Relative proportion with the real number of indexed ECHIM-indicators as denominator

17 12


Table 4. Demographic and socio-economic indicators: overview of availability of Belgiandata in the databases of the WHO, OECD and EUROSTAT


1 Population by sex/age 1 1 12 Birth rate 1 1 13 Mother's age distribution 1 ni 14 Total fertility rate 1 1 15 Population projections ni ni 16 Population by education 1 1 17 Population by occupation ni ni ni

8 Total unemployment 1 1 19 Population below poverty line

and income inequality


*: Relative proportion with finalized and almost finalized ECHIM-indicators (d.d. 02/09/2009: cfr. Table 1) as denominatorni: indicator not available in database

ni ni 1


Table 5. Health status indicators: overview of availability of the Belgian data in thedatabases of the WHO, OECD and EUROSTAT


10 Life expectancy 1 1 111 Infant mortality 1 1 112 Perinatal mortality 1 1 113 Disease-specific mortality;

Eurostat list of 65 causes14 Drug-related deaths ni 1 115 Smoking-related deaths 1 ni ni

16 Alcohol-related deaths 1 ni 117 Excess mortality by heatwaves ni ni ni

18 Communicable diseases (selection) 1 1 ni

19 HIV/AIDS 1 1 ni

20 Cancer incidence 1 1 ni

21 Diabetes 1 ni 122 Dementia ni 1 123 Depression ni ni ni

24 Acute myocardial infarct (heartinfarct) 1 1 1

25 Cerebrovascular accident 1 1 126 Asthma ni 1 127 Chronic obstructive pulmonary

disease 1 1 1

28 (Low) Birth weight 1 1 129 Injuries: home/leisure,

violence30 Injuries: road traffic 1 1 ni

31 Injuries: workplace 1 1 132 Suicide attempt ni ni ni

33 Self-perceied health 1 1 134 Self-reported chronic

morbidity35 Long-term activity

limitations36 Physical and sensory

functional limitations37 General musculoskeletal

pain38 Psychological distress ni ni ni

39 Psychological well-being (vitality) ni ni ni

40 Health expectancy:Healthy Life Years (HLY)

41 Health expectancy: Other ni ni ni


ni


ni

ni ni ni

ni ni 1

1 1 1

ni ni

ni 1

ni ni 1

1 1 1


Table 6. Health determinants: overview of availability of Belgian data in the databases ofthe WHO, OECD and EUROSTAT


42 Body mass index ni 1 143 Blood pressure ni ni ni

44 Regular smokers 1 1 145 Pregnant women smoking ni ni ni

46 Total alcohol consumption 1 1 ni

47 Hazardous alcohol consumption ni ni ni

48 Use of illicit drugs ni ni ni

49 Consumption/availabilityof fruit

50 Consumption/availabilityof vegetables

51 Breastfeeding 1 ni ni

52 Physical activity ni ni ni

53 Work-relatedhealth risks

54 Social support ni ni ni

55 PM10 (particulate matter) exposure 1 ni 1Total number available (n) 6 5 3Proportion available (%) 42.86 35.71 21.43Corrected proportion available (%)* 100.00 100.00 100.00

1 1 ni


1 1 ni

ni ni ni


Table 7. Healthcare indicators: overview of availability of Belgian data in the databasesof the WHO, OECD and EUROSTAT


56 Vaccination coverage in children 1 1 ni

57 Influenza vaccination rate in elderly ni 1 ni

58 Breast cancer screening ni 1 159 Cervical cancer screening ni 1 160 Colon cancer screening ni ni ni

61 Timing of first antenatal visit ni ni ni

62 Hospital beds 1 1 163 Physicians employed 1 1 164 Active nurses 1 1 165 Mobility of professionals ni 1 ni

66 Medical technologies:MRI units and CT scanners

67 Hospital discharges,per diagnosis group

68 Hospital daycasesper diagnosis group

69 Hospital daycases / Hospitaldischarges per diagnosis group

70 Average length of stayper diagnosis group

71 General practitioner (GP) utilization 1 1 172 Other outpatient visits ni 1 173 Surgeries: PTCA,

hip, cataract74 Medicine use,

selected groups75 Patient mobility ni ni ni

76 Insurance coverage ni 1 ni

77 Expenditure on health 1 1 178 Survival rates cancer ni ni ni

79 30-day in-hospital mortality:AMI and stroke

80 Equity of access to healthcareservices

ni ni ni

81 Waiting times for electivesurgeries

82 Postoperative wound infections 1 ni ni

83 Cancer treatment delay ni ni ni

84 Diabetes control ni ni ni

Total number available (n) 9 17 12Proportion available (%) 31.03 58.62 41.38Corrected proportion available %)* 100.00 100.00 92.31

ni ni ni

ni 0

ni 1 ni

ni

11 1

ni 1 1

ni 1

ni ni ni


ni 1 0

1 1 1

ni


Table 8. Health promotion indicators: overview of availability of Belgian data in thedatabases of the WHO, OECD and EUROSTAT


85 Policies onETS exposure

86 Policies forhealthy nutrition

87 Policies and practicesfor healthy lifestyles

88 Integrated programmes inspecific contexts: school, workplace,…

Total number available (n) ni ni niProportion available (%) ni ni niCorrected proportion available (%)* 0 0 0


ni ni ni

ni ni

ni ni ni

ni ni ni

ni


B. Overview of the primary sources and their managers (Objectives 2 and 4)

On the basis of the ECHIM guidelines, and taking account of the national sources for the

international databases, the KCE report on the Inventory of health services databases

(Van de Sande et al., 2006) and the Morbidat database of the WIV OD Volksgezondheid

/ ISP DO Santé Publique (1998), a primary national database (or source) was identified

for each ECHIM indicator. An overview of these databases is available in Table 9. Here it

must be said that this division of sources and their managers by indicators is in no way a

real reflection of the volume of the data, nor of the extent of the data collection. It should

also be noted that several sources were used in the calculation of certain indicators, for

example the MKG / RCM and the Minimum Psychiatric Data (MPG / RPM) for the

indicators around hospital admission (Ind. 67-70). For these reasons no general total is

given in Table 9.

A substantial part of the ECHIM indicators is based on HIS-Belgium data from the

WIV OD Volksgezondheid / ISP DO Santé Publique. These indicators belong mainly to

the groups Health status (n =19), Health determinants (n =10) and Healthcare (n =7).

The FOD VVVL / SPF SSCE, with its registers for health services facilities

(Centraal instellingen bestand: CIC, Annual Hospital Statistics: JZS / SHA, MKG / RCM

and MPG / RPM) and healthcare professionals (Centraal bestand

gezondheidsberoepen: CBG / CPS) has data for the personnel-, care, equipment and

outcome indicators of the indicator group Healthcare. Finally the MKG / RCM and MPG /

RPM should be used by preference for the indicator Dementia (Ind. 22) from the

indicator group Health status.

The data for the demographic and socio-economic indicators (n =9) are totally

obtained from the registers and surveys of the Algemene Directie Statistiek en

Economische informatie (ADSEI / DGSIE). The ADSEI / DGSIE also attends to the

dissemination of the data collected in the National Register of the FOD BZ / SPF Int.,

data that are necessary, among others, for calculation of the indicators Excess mortality

by heatwave (Ind. 17), Health expectancy (Ind. 40 and 41) and Survival ratios for cancer

(Ind. 78). The federal births and deaths registers of the ADSEI / DGSIE are moreover the

primary source for the births and deaths indicators (n = 7) of the ECHIM-shortlist.

National sources available for more specific indicators are the Belgian Cancer

Register (Ind. 22, 78 and 83), the Permanent Sampling (Ind. 61 and 84), the pool of

permitted medical care outside Belgium (Ind. 75) and File Document Nbis (Ind. 76) - all


three of the Rijksinstituut voor Ziekte- en Invaliditeitsverzekering (RIZIV / INAMI), the

Healthcare calculations of FOD SZ / SPF SS (Ind. 77), the PM10 file of the

Intercommunal Cell for the Environment (Ind. 55), and the European Working Conditions

Survey Belgium by the Hoger Instituut voor de Arbeid (Ind. 53).

No national database was identified for a few of the indicators: Breastfeeding

(Ind. 51) and Waiting times for elective surgeries (Ind. 81). Whereas a harmonization

and aggregation of the regional data (supplied by Kind en Gezin (K&G) and the Office de

la Naissance et de l’Enfance: ONE) is feasible for the indicator Breastfeeding, the

operationalization of Waiting times for elective surgeries requires a thorough study of the

possibilities in the relevant databases (MKG / RCM, PS / EP, …).

A further difficulty concerns the indicator Mobility of professionals (Ind. 65). This

indicator supposes two directions of mobility: (a) Belgian health services professionals

going to work in other countries and, (b) foreign health services professionals coming to

work in Belgium. For this latter group the CBG / CPS enters into consideration, as this

also contains the visa issued by the International Mobility Cell of the health services

professionals (FOD VVVL / SPF SSCE: DG2). For the first group only one file is

available at present for applicants for a Certificate of Equivalence (EG/EU/EER) to be

allowed to practice their profession abroad. However, the issuing of such a certificate

cannot be taken as the same thing as actual practice of the profession abroad.


Table 9. Global overview of the national sources for the implementation of ECHIM in Belgium

Manager Database indicators n %

41 44.32Aids Reference Laboratories Belgium 19 1 1.14Belgian Mortality Monitoring 17 1 1.14Gezondheidsenquête in België door Interview / Enquête de santé belge par interview21, 23-27, 29-45, 47-50, 52, 53, 57-60, 71, 72, 74 36 40.91PediSurv 18 1 1.14Sentinel laboratories Infectious diseases Belgium 18 1 1.14Vaccine Preventable Diseases 56 1 1.14

24 27.27Centraal bestand gezondheidsberoepen / Cadastre des professions de la santé63-65 3 3.41Centraal instellingen bestand / Fichier des Institutions Centralisé62 1 1.14Jaarlijkse Ziekenhuisstatistieken / Statistiques Hospitalières Annuelles66 1 1.14Minimale Klinische Gegevens / Résumé Clinique Minimum22, 67-70, 73, 75, 79, 82 9 10.23Minimale Psychiatrische Gegevens / Résumé Psychiatrique minimum22, 67-70, 75 6 6.82Nationaal voedings- en Gezondheidsplan / Plan National Nutrition Santé85-88 4 4.55

15 11.36Enquete naar de ArbeidsKrachten / Enquête sur les forces de travail6-8 3 3.41Federaal Geboorteregister / Registre nationale des naissances3-5, 28 4 4.55Federaal Overlijdensregister / Registre nationale des décès11-16 6 6.82Inkomens en levensomstandigheden huishoudens / Enquête sur les revenus et les conditions de vie9, 80 2 2.27

9 10.23Rijksregister / Registre Nationale 1, 2, 4, 5, 10, 17, 40, 41, 78 9 10.23

FOD Justitie / SPF Justice 4 4.55Belgisch Staatsblad / Moniteur belge 85-88 4 4.55

3 3.410 20, 78, 83 3 3.41

FOD Sociale Zekerheid / SPF Sécurité Sociale 1 1.14Health Accounts Belgium 77 1 1.14

3 3.41File Consented medical care abroad 75 1 1.14Document Nbis 76 1 1.14Permanente Steekproef / L'échantillion permanent 61, 84 2 2.27

1 1.14PM10 55 1 1.14

1 1.14European Working Conditions Survey Belgium 53 1 1.14

* The calculation of certain indicators (e.g., Survival rates for cancer, Ind. 78) is effected using several data banks. For that reason no general total is given in this table

Hoger Instituut voor de Arbeid

Intercommunal Cell for the Environment

Belgian Cancer Register Foundation

Rijksinstituut voor ziekte- en invaliditeitsverzekering / Institut national d'assurance maladie-invalidité

WIV:OD Volksgezondheid en Surveillance / ISP: DO Santé Publique et Surveillance

FOD Economie, K.M.O., Middenstand en Energie: ADSEI / SPF Economie, P.M.E., Classes moyennes et Energie: DGSIE

FOD Volksgezondheid, Veiligheid van de Voedselketen en Leefmilieu: DG1 & DG2 / SPF Santé publique, Sécurité de la Chaîne alimentaire et Environnement: DG1 & DG2

FOD Binnenlandse Zaken / SPF Intérieur


On the basis of the model of Van de Sande et al. (2006) a summary table was

drawn up of the available databases for the implementation of ECHIM in Belgium (Table

10). This table shows the domains, the primary finality, the physical scope and the time

dimension of each database.

For half (n = 47, 53.41%) of the total number of ECHIM indicators (n = 88) the

data was collected by means of sampling (Figure 5), such as the HIS-Belgium and the

EAK / EFT. For one quarter of the total number of indicators (n = 22, 25.00%) the data

were collected at total population level. These were mainly data from the Federal

Register of Births and Deaths and the National Register for the calculation of indicators

from the group Demographic and socio-economic indicators (n = 5) and the group Health

status (n = 11). The Belgisch Staatsblad / Moniteur belge, the most important source for

the indicators from the group Health promotion (Ind. 85-88), was also regarded as a data

source with a population range. The data for the indicator group Healthcare are taken for

the most part (n = 14) from hospital data such as the MKG / RCM and the CIC.

Total population (BE)Sample of the population (BE)Hospital data (BE)Other

25

47

10

5

Figure 5. Division (absolute figures) of indicators according to the coverage of national database

It is interesting to note that the data of the 38 ECHIM indicators (43.18% of the

total number of indicators) were collected via compulsory registration, (MKG / RCM,

National Register, …) or with the participation of the EAK / EFT.


Table 10. Overview of characteristics of national databases (according to Van de Sande et al., 2006)

ContinuityPeriodicity

Enquête naar de Employment; Education DiscontinuousArbeidskrachten Population data Occupation annual

Socio-economic statusFederaal geboorteregister/ Registre nationale desnaissances

Birth Administrative Continuousannual

characteristics Birth-properties Since 1997only 2004

Federaaloverlijdensregister /Registre nationale desdécès

Administrative; (1948) Continuousannual

Causes of death 1991 Since 1997only 2004

Health determinants; Discontinuous

Population data Yearly

European Working Education; Working conditions DiscontinuousConditions SurveyBelgium

Occupation; Socio-economic status;income

5-yearly

FOD BZ /SPF Int

RRN Continuous

Civil personal data DailyBelgisch Staatsblad /Moniteur belge

Continuous

DailyFOD SZ /SPF SS

Gezondheids-rekeningenBelgië / Comptes de laSanté en Belgique

Health careExpenditure

BE Exhaustive N/A 2003 ContinuousYearly

-

-BE Exhaustive N/A 1983Rijksregister / RegistreNationale

Population data Demographics Inhabitants Belgium

-

EWCO Working condition Employees BE Sample N/A 1990 -

BE Sample N/A 2005ADSEI /DGSIE

Lifestyles &environment; Socio-economic status

Socio-economic FamiliesInkomens en delevensomstandig-hedenvan de huis-houdens /Enquête sur les revenus

-

ADSEI /DGSIE

Health status Mortality causes Inhabitants Belgium BE Exhaustive N/A -

BE

Source

Exhaustive N/A 1991ADSEI /DGSIE

Health status Inhabitants Belgium

-ADSEI /DGSIE

Socio-economic Working power BE Sample N/A 1983

Time aspects

Principal Domain Subdomain(s) Core data Maindiscriminant(s) Use Target

population Care lines Start StopDatabase

Classification Primary finality Range

N/AFODJustitie /SPFJustice

Legislation Legislation Inhabitants andinstitutions Belgium

BE Exhaustive 1845 -


Table 10 (cont.). Overview of characteristics of national databases (according to Van de Sande et al., 2006)


Centraal bestand Health care Resources; All recognizedpractitioners

Continuous

Gezondheids- production Infrastructure; ‘Real time’beroepen / Cadastre desprofessions de la santé

Human capital

Centraal Health care Resources Divers ContinuousInstellingen production Technology; Recognitions & Yearlybestand / Fichier desInstitutions Centralisé

Infrastructure; care activities;

Human capital; Contact info;Specific healthcare Organisationprograms

FODVVVL /SPFSSCE

JaarlijkseZiekenhuisstatistieken /Statistiques HospitalièresAnnuelles

Health careoutcome; Healthcare production

Productivity; Humanresources

Infrastructure &Equipment;Organization & IT;Personnel data

Healthcareinstitutions

BE All hospitals n/a 2000 Continuousannual

-

FODVVVL /SPFSSCE

Minimale KlinischeGegevens / RésuméClinique Minimum

Health careconsumption

Utilization; D&TSpecifications

Clinical data Non-psychiatrichospitals

BE All non-psychiatrichospital stays

Intramural 1995 Continuousannual

-

FODVVVL /SPFSSCE

Minimale PsychiatrischeGegevens / RésuméPsychiatrique Minimum


Utilization;D&TSpecifications

Clinico-psychiatric PsychiatrichospitalsPsychiatricDepartment ofGeneral Hospitals

BE All psychiatrichospital stays

Intramural 1996 Continuousannual

-

FODVVVL /SPFSSCE

Nationaal voedings- enGezondheidsplan / PlanNational Nutrition Santé

Health promotion Morbidities; Lifestyles;Utilization

Health promotionand prevention

Inhabitants andinstitutions Belgium

BE Inhabitants andinstitutionsBelgium

n/a 2005-2010

Discontinuous 2010

Stop

Range Time aspects

Principal Domain Subdomain(s) Core data Maindiscriminant(s) Use Target

population Care lines StartSource Database

Classification Primary finality

2006 ? -

N/A **?**FODVVVL /SPFSSCE

Care institutions BE All hospitals

FODVVVL /SPFSSCE

Profession personalia Care suppliers BE

-

N/A




Air quality; ContinuousEnvironment Daily

RIZIV /INAMI

Document NBis Health careconsumption

Expenditure Compulsory healthinsurancecontributions

RIZIV/INAMInomenclature;Social securitystatus

BE All withcompulsoryinsurance

All carelines 2006 ContinuousAnnual

-

RIZIV /INAMI

Permanente Steekproef /L'échantillion permanent


Expenditure Compulsory healthinsurancecontributions;Patient's personalconribution

Insured person(s);Prescribing-attending doctor

BE Sampling ofpersons withcompulsoryinsurance


-

RIZIV /INAMI

File of permitted foreignmedical treatments


Expenditure Compulsory healthinsurancecontribution;Patient's personalcontribution

Insured person(s) ; BE All withcompulsoryinsurance withhealth insurer'sapproval forforeign treatment


-

SKR Belgisch Kankerregister /Registre de Cancer belge

Health; Health care Morbidity; Utilization;D&T specifications

Personal details;Clinical data

Patients withcancer; D&T

BE Complete Intramural -1983;1997;2005

ContinuousAnnual

-

WIV / ISP AIDS ReferentceLaboratories Belgium

Health Morbidity; Utilization;D&T specifications

Clinical biology Patients with HIV-AIDS

BE Incomplete Intramural **** ContinuousAnnual

-

WIV / ISP Belgian MortalityMonitoring

Health status Mortality Excess mortality Inhabitants Belgium BE Complete n/a 2004 ContinousAnnual

-

WIV / ISP Health survey by interviewBelgium

Health status,Health careconsumption,Population data

Morbidities; Lifestyles;Utilization; Expendi-ture; Socio-economicstatus; income

Public health Inhabitants Belgium BE Sampling n/a 1997 DiscontinuousFour/five-yearly

-

Start StopMaindiscriminant(s) Use Target

population Care linesSource Database

Classification Primary finality Range Time aspects

Principal Domain Subdomain(s) Core data

1999 -n/aIRCEL PM10 Air quality Degree ofurbanization

BE Sampling




WIV / ISP Pedisurv Health status Morbidity; D&Tspecifications

Clinical data Children withcommunicabledisease

BE Sampling Intramural **** ContinuousAnnual

-

WIV / ISP Sentinel laboratories forcommunicable diseasesBelgium

Health status Morbidity; D&Tspecifications

Clinical biology Patients withcommunicabledisease

BE Incomplete Intramural **** ContinuousAnnual

-

ContinuousAnnual

StopCore data Maindiscriminant(s) Use Target

populationSource Database

Classification Primary finality Range Time aspects

Principal Domain Subdomain(s)

Children BE Sampling

Care lines Start

WIV / ISP Vaccine PreventableDiseases


Utilization n/a **** -Clinical data

D & T: Diagnosis and Treatment


This has a clear influence on the response ratio of the data collections. The response

ratio of the compulsory EAK / EFT is higher than 80%, with only 3% refusal to take part

in the survey. The response ratio in, for example, HIS-Belgium where participation is

voluntary, is usually lower (30.9% of the contacted households refused to participate in

2004).

Oral interviewWritten questionnaireClinical diagnosis / registrationLaboratory examinationAdministrative registration

26

17

21

319

Figure 6. Division of indicators according to data collection method of used national database(absolute figures)

Seeing the diversity of primary finality the national primary databases likewise

differ in their method of data collection. More than one quarter of the 88 ECHIM

indicators (n = 26, 29.55%) were calculated using data that were collected via an oral

interview (HIS-Belgium, EAK / EFT, ILCS) (Figure 6). Another large fraction of the

indicators is based on a clinical diagnosis or on a clinical registration (n = 21, 23.86%),

such as the MKG / RCM or the Belgian Cancer Register. Only three indicators (3.41%)

(AIDS/HIV, Infectious conditions and PM10) were measured by reference to (clinico-

)biological researches.

As described above, the data collection for the ECHIM indicators in Belgium

displays a good diversity in data collection method, ranging from subjective reporting of

the health status to, for example, clinical registrations. When interpreting the subjective


reports and the clinical registrations account must be taken of the respective limitations

with regard to representativeness, reliability and validity (Table 12).

Another important characteristic that sets apart the various methods and,

consequently, the databases is the temporal dimension. Mortality and birth rates, like

hospital and healthcare insurance data, are - under optimum circumstances - available

every year. A legal, institutionalized framework would facilitate this complex data flow.

Despite similar methodologies, the EAK / EFT and Income and Living Conditions survey

(SILC) (both on an annual basis) differ markedly qua periodicity from the European

Working Conditions Survey Belgium (five-yearly) and the HIS-Belgium (once every four

to five years). The impact of this on the availability of the Belgian data for the ECHIM

indicators (for the period 2000-2008) will be discussed later in this report.

In closing it should be noted that, for an appreciable part of the data collection,

the contribution of the regions is necessary in a direct or indirect manner (Table 11). The

collection and processing of birth and death certificates and hospital statistics, for

instance is routed via the regional public health departments (Vlaams Agentschap Zorg

en Gezondheid: VAZG and the Direction générale de la santé: DGSanté). These

regional departments also attend to the measurements of the degree of Vaccination

among young children (Ind. 56). The regional environmental institutions also run the

network of PM10 measuring stations. Finally, the regional and Community authorities

also finance the HIS-Belgium, the BKR / RBC, the Belgian sentinel laboratories for

infectious diseases and the ARL.


Table 11. Distribution of indicators according to level of data collection and level of financing.

Level of first datacollection Level of financing Database Indicators

National Federal Belgian Mortality Monitoring 18Belgisch Staatsblad / Moniteur Belge 85-88File Consented medical care abroad 75

Centraal Bestand Gezondheidszorgberoepen / Cadastre des professions de la santé63-65Document Nbis 76Enquête naar de Arbeidskrachten / Enquête sur les forces de travail6-8European Working Conditions Survey Belgium 53Gezondheidsrekeningen / Comptes de la Santé 77Income and Living Conditions of Households 9, 80Jaarlijkse Ziekenhuisstatistieken / Statistiques Hospitalières Annuelles66Minimale Klinische Gegevens / Résumé Clinique Minimum22, 67-70, 73, 75, 79, 82Minimale Psychiatrische Gegevens / Résumé Psychiatrique Minimum22, 67-70, 75Nationaal voedings- en Gezondheidsplan / Plan National Nutrition Santé85-88Permanente Steekproef / L'échantillion permanent 61, 84Rijksregister / Registre nationale 1, 2, 4, 5, 10, 17, 40, 41, 78

National Federal + Aids Reference Laboratories Belgium 19Regional / Communities Gezondheidsenquête in België door Interview / Enquête de santé belge par interview17

Belgisch Kankerregister / Registre de Cancer belge 20, 78, 83

National Regional / Sentinel laboratories communicable disease 18Communities PediSurv 21, 23-27, 29-45, 47-50, 52, 53, 57-60, 71, 72, 74

Regional / Regional / Centraal Instellingen Bestand / Fichier des Institutions Centralisé62Communities Communities Federaal geboorteregister / Registre nationale des naissances3-5, 28

Federaal overlijdensregister / Registre nationale des décès11-16PM10 55Vaccine Preventable Diseases 56


Table 12. Types of national sources of health data, their advantages and disadvantages or limitations (Habers et al., 2008)

Source Advantages Disadvantages or limitationsGovernment registers Obligatory data collection, reasonable validity. Data concerns only period up to end of condition or wound.Cancer registers Excellent degree of coverage, good validity. Generally incidence,

death rates and survival data.Low degree of comparability between EU countries because the degree ofcoverage and the possibility of linking of files varies considerably (because ofprotection of personal data).

Registers concerning otherspecific conditions

Could have a good degree of coverage and a good validity, forexample for communicable diseases. Data on incidence.

Concern only diagnosed cases of a number of conditions. No problems withincidence, but no reflection of prevalencer. Differences in healthcare systemsmay affect degree of coverage and validity.

Registers concerningfunctional restrictions

In principle important information could be available in registers ofpersons with disabilities and persons receiving social benefits.

The registers often have a low degree of coverage and depend on thehealthcare system. Comparability between countries is therefore low.

Registers concerninghospital admission/discharge

Could have high validity re. the type of patients and the treatment ofserious conditions.

Concern only hospitalized patients; coupling at individual level is not alwayspossible, so true incidence is difficult to estimate. Private healthcare is notalways registered. It is often not possible to distinguish between suspected andconfirmed diagnoses. Overreporting of serious cases is possible if therefunding system is linked to a diagnosis and procedures.

Registers first-line healthcare(general practitioner medicine)

In certain countries with an equivalent healthcare system there isreasonable validity for type of patients and for the circumstanceswarranting consultation.

Dependent on healthcare system. Codification systems differ, so comparison isdifficult. Data concerns only a few EU countries as regards total population.Private healthcare is not always registered. It is often difficult to distinguishbetween suspected and confirmed diagnoses. Overreporting of serious casesis possible if the refunding system is linked to a diagnosis and procedures.

Electronicpatient files

Different countries are planning th use of electronic patients files.The comments concerning the registers in first-line healthcarelikewise apply here.

In the years to come e-Health systems will probably differ in degree ofcoverage and codification. Their introduction will probably lead to uncertainty inthe first years in, e.g., the areas of validity and comparability.

Registers concerninghealth insurance

Could contain data for healthcare (including drugs and medicines)and for incapacitation.

Dependent on healthcare system; comparisons between countries may giverise to difficulties.

Registers concerningpresciption of pharmaceuticals

Accurate description of the use of drugs and medicines and of theirusers.

Dependent on healthcare system; comparison is possible for only a few EUcountries.

Registers concerning implants (e.g.,hip, knee) and transplantations (e.g.,kidney, liver, heart, lungs)

Good validity of the existing registers. Could contain data for patientsincluded on a waiting list and patients having already undergone theoperation.

Dependent on healthcare system; completely unequaly delivery of data indifferent EU countries. Degree of coverage may vary.


Table 12. (cont.). Types of national sources of health data, their advantages and disadvantages or limitations (Habers et al., 2008)Source Advantages Disadvantages or limitationsRegisters concerningaccidents and wounds

Good degree of coverage and validity Dependent on healthcare system; The sources used differ; this data is notalways available in different EU countries.

Health surveys (EHIS and nationalHIS)

A broad focus on health and the use of health services; subjectssuch as self-perception, known conditions, self-reported functionallimitations, consultation with doctors and dentists, the use of drugsand medicines. Simultaneous access to socio-economic data.Reasonable comparability if the EHIS protocol is used.

Response rates are rather low (60–70%) in national HISs and will have to beimproved. However, even high response rates may lead to distorted resultsand to marked differences between countries. A number of HIS subjects areinfluences by cultural factors and the healthcare system. Ther is a need formethods to remove these differences in datacollection or interpretation. Atpresent the national HISs are comparable to a limited extent only.

Health studies (EHES and nationaeHES)

To supplement the health surveys data could be collected on risjfactors (BP, lipids), anthropometry and physiological measurements,and the clinical diagnosis of conditioons and functional limitations.Validity is good. Comparability depends on standaardization. Theother advantages of health surveys ikewise apply for the healthstudies.

The relative response rates may distort the results. Results might be influencedby differences in protocol, instruments and environment. A standaardizationscheme (EHES) is under development and will be tested in certain nationalHESs.


C. The correspondence between ECHIM and ECHIM.be on the definition,calculation, dimensions, data collection method and source of indicators(Objective 3)

The correspondence between ECHIM and ECHIM.be on the definitions, calculations,

dimensions, data collection method and sources of indicators is high in each indicator

group (Table 13). More specifically, this means that the Belgian data collection to a large

extent makes use of internationally standardized calculations and classifications, such as

the International Classification of Diseases (ICD-9/10: for example, for the mortality

indicators); the Clinical Modification of the International Classification of Diseases (ICD-

9-CM); the International Classification of Diseases for Oncology (ICD-O: for example, for

the cancer-related indicators); the International Shortlist for Hospital Morbidity Tabulation

(ISHMT: for example, for hospital admissions; the Eurostat Shortlist of 65 diseases

(Eurostat, 1998); the EHIS calculations (for example, the preventive screening

indicators: Ind. 58-60); and the so-called Peto selection of ICD codes (Peto et al., 1996:

calculation of tobacco-related mortality, Ind. 15).

The existing differences between the ECHIM guidelines and the characteristics of

the Belgian data are often small and usually concern the calculation of the indicator. In

Belgium, for instance, the age group 15 to 49 years is used for the calculation of the total

fertility rate (Table 14). Here ECHIM uses the age group 15 to 44 years. A similar

difference can be found in the calculation of Total Unemployment (Table 14). In Belgium

the age group 15 to 65 years is used, bearing in mind the official pensionable age; the

ECHIM calculation uses the 18 to 78 year age band instead.

More substantial differences appear, for instance, in the calculations of the

indicators “Population by occupation group” (Ind. 7, Table 14) and “General musculo-

skeletal” (Ind. 37, Table 15). For the former Belgium applies the international

classification of the International Standard Classification of Occupations (ISCO-88:

International Labour Organization, 1991), whereas the ECHIM, makes reference to the

recommendations of working group (e.g., European Socio-Economic Classification:

ESeC). Furthemore the Belgian data collection (i.c., EAK / EFT) fits in with the European

Labour Force Survey (LFS), which influences the advice for implementation (see

Objective 5). Finally it should also be noted that this indicator is still in the ECHIM

development phase and the ECHIM guidelines may be revised in future.


For the indicator “General musculo-skeletal pain”, finally, Belgium asks about

physical pain in general using the ‘Bodily Pain’ subscale of RAND Short Form 36,

whereas the ECHIM guidelines seek to map the location of the pain by a process of their

own design (head - neck - shoulder(s) - upper back - elbows - wrist(s) / hand(s) - lower

back - hip(s) / thigh(s) - knee(s) - ankles / foot(feet). This indicator is likewise still in the

ECHIM development phase.

In Belgium the indicators “Drug-related mortality” (Ind. 14) and “Alcohol-related

mortality” (Ind. 16) are generally not reported according to the ECHIM calculations,

respectively the ‘B selection’ of ICD codes determined by the European Monitoring

Centre for Drugs and Drug Addiction (EMCDDA); and the ‘WHO selection’ of ICD codes.

It may however be expected, as far as concerns the international conventions, that these

ECHIM calculations too will change in future and the use of the respective attributable

fractions will be recommended (RIVM and THL, 2009).

The ECHIM calculation of the indicator “Psychological distress” as recommended

by the ECHIM project group (the Mental Health Index (MHI-5) of the RAND Short Form

36 Health Survey: Hays et al., 1993) differs from the calculation as used in Belgium. In

fact, the HIS Belgium uses the 12-item version of the General Health Questionnaire

(GHQ-12; Goldberg & Williams, 1988), also frequently used at international level and a

validated screening instrument for mental suffering (Goldberg et al. 1997). Here again,

it must be pointed out that this ECHIM indicator is in the development phase and that the

ECHIM guidelines will most likely be revised on the basis of a EUROSTAT

recommendation (ECHIM, 2009).

Indicators for which ECHIM does not as yet have any (final) definition and

calculation guideline are: Mobility of professionals (Ind. 65), Mobility of patients (Ind. 75)

and the indicators of the group Health promotion (Ind. 85 - 88).

In addition to the above differences in calculation, there are also a number of

indicators for which Belgium uses a different definition. However, this difference for the

indicators Consumption/availability of fruit (Ind. 49) and vegetables (Ind. 50) reference

may be made of the inconsistency between definition and calculation in the ECHIM

Documentation Sheets. The ECHIM definition refers after all to annual availability (in

grammes per person) of fruit and vegetables, while the preferred calculations refer to the

daily consumption of fruit and vegetables.


Table 13. Global overview of the correspondence between ECHIM and ECHIM.be onthe definition, calculation, dimensions, data collection method and source of indicators.

Def. Cal. Dim. Method. Source.

A Demographic and socio-economic indicators (n = 9)

B Health status (n = 32) 31 28 32 32 32

C Health determinants (n=14) 12 14 13 14 14



Total number of correspondences (n) 77 72 80 80 79Proportion correspondences (%) 87.50 81.82 90.91 90.91 89.77Corrected proportion correspondences (%)* 94.64 92.86 98.21 96.43 96.43

9 9

25 2425 26

8

*: Relative proportion with finalized and almost finalized ECHIM-indicators (d.d. 02/09/2009: cfr. Table 1) as denominator/dev: indicator(s) in developmental phase (d.d. 02/09/2009)

5 9

/dev /dev /dev

26

/dev/dev

Table 14. Demographic and socio-economic indicators: overview of the correspondencebetween ECHIM and ECHIM.be on the definition, calculation, dimensions, data collectionmethod and source of indicators.


1 Population by sex/age 1 1 1 1 12 Birth rate 1 1 1 1 13 Mother's age distribution 1 1 1 1 14 Total fertility rate 1 0 1 1 15 Population projections 1 1 1 1 16 Population by education 0 0 1 1 17 Population by occupation 1 0 1 1 18 Total unemployment 1 0 1 1 19 Population below poverty line

and income inequalityTotal number of correspondences (n) 8 5 9 9 9Proportion of correspondences (%) 88.89 55.56 100.00 100.00 100.00Corrected proportion of correspondences (%)* 100.00 66.67 100.00 100.00 100.00*: Relative proportion with finalized and almost finalized ECHIM-indicators (d.d. 02/09/2009: cfr. Table 1) as denominator

1 11 1 1


Table 15. Health status indicators: overview of the correspondence between ECHIM andECHIM.be on the definition, calculation, dimensions, data collection method and sourceof indicators.


10 Life expectancy 1 0 1 1 111 Infant mortality 1 1 1 1 112 Perinatal mortality 1 1 1 1 113 Disease-specific mortality;

Eurostat list of 65 causes14 Drug-related deaths 1 1 1 1 115 Smoking-related deaths 1 1 1 1 116 Alcohol-related deaths 1 0 1 1 117 Excess mortality by heatwaves 1 1 1 1 118 Communicable diseases (selection) 1 1 1 1 119 HIV/AIDS 1 1 1 1 120 Cancer incidence 1 1 1 1 121 Diabetes 1 1 1 1 122 Dementia 1 1 1 1 123 Depression 1 1 1 1 124 Acute myocardial infarct (heart infarct) 1 1 1 1 1

25 Cerebrovascular accident 1 1 1 1 126 Asthma 1 1 1 1 127 Chronic obstructive pulmonary disease 1 1 1 1 1

28 (Low) Birth weight 1 1 1 1 129 Injuries: home/leisure,

violence30 Injuries: road traffic 1 1 1 1 131 Injuries: workplace 1 1 1 1 132 Suicide attempt 1 1 1 1 133 Self-perceied health 1 1 1 1 134 Self-reported chronic




pain38 Psychological distress 1 0 1 1 139 Psychological well-being (vitality) 1 1 1 1 140 Health expectancy:

Healthy Life Years (HLY)41 Health expectancy: Other 1 1 1 1 1Total number of correspondences (n) 31 28 32 32 32Proportion of correspondences (%) 96.88 87.50 100.00 100.00 100.00Corrected proportion of correspondences (%)* 100.00 95.65 100.00 100.00 100.00

1 1

1 1 1

0

1

1

1

0

1 1 1

1 1 1

1

1 1

1

1 1 1

1

1

1

1

*: Relative proportion with finalized and almost finalized ECHIM-indicators (d.d. 02/09/2009: cfr. Table 1) as denominator

1 1 11 1

1 1 1


Table 16. Health determinants: overview of the correspondence between ECHIM andECHIM.be on the definition, calculation, dimensions, data collection method and sourceof indicators.


42 Body mass index 1 1 1 1 143 Blood pressure 1 1 1 1 144 Regular smokers 1 1 1 1 145 Pregnant women smoking 1 1 1 1 146 Total alcohol consumption 1 1 1 1 147 Hazardous alcohol consumption 1 1 1 1 148 Use of illicit drugs 1 1 1 1 149 Consumption/availability

of fruit50 Consumption/availability

of vegetables51 Breastfeeding 1 1 0 1 152 Physical activity 1 1 1 1 153 Work-related

health risks54 Social support 1 1 1 1 155 PM10 (particulate matter) exposure

Total number of correspondences (n) 12 14 13 14 14Proportion of correspondences (%) 85.71 100.00 92.86 100.00 100.00Corrected proportion of correspondences (%)* 75.00 100.00 100.00 100.00 100.00

1

1

11

1

1

1

1

1 1

1 1


11

1

0 11

1

0


Table 17. Healthcare indicators: of the correspondence between ECHIM and ECHIM.beon the definition, calculation, dimensions, data collection method and source ofindicators.


56 Vaccination coverage in children 1 1 1 1 157 Influenza vaccination rate in elderly 1 1 1 1 158 Breast cancer screening 1 1 1 1 159 Cervical cancer screening 1 1 1 1 160 Colon cancer screening 1 1 1 1 161 Timing of first antenatal visit 1 1 1 0 062 Hospital beds 1 1 1 1 163 Physicians employed 1 1 1 1 164 Active nurses 1 1 1 1 165 Mobility of professionals 1 /dev /dev /dev /dev66 Medical technologies:

MRI units and CT scanners67 Hospital discharges,

per diagnosis group68 Hospital daycases

per diagnosis group69 Hospital daycases / Hospital

discharges per diagnosis group70 Average length of stay

per diagnosis group71 General practitioner (GP) utilization 1 1 1 1 172 Other outpatient visits 1 1 1 1 173 Surgeries: PTCA,


selected groups75 Patient mobility 0 /dev /dev /dev /dev76 Insurance coverage 1 1 1 1 177 Expenditure on health 1 1 1 1 178 Survival rates cancer 1 1 1 1 179 30-day in-hospital mortality:

AMI and stroke80 Equity of access to healthcare services 1 1 1 1 181 Waiting times for elective

surgeries82 Postoperative wound infections 1 1 1 1 183 Cancer treatment delay 0 /dev 1 1 184 Diabetes control 1 1 1 1 /dev

Total number of correspondences (n) 26 25 26 25 24Proportion of correspondences (%) 89.66 86.21 89.66 86.21 82.76Corrected proportion of correspondences (%)* 100.00 100.00 100.00 94.74 94.74

1

1 1 1

1

0 0 000

1

1 1 11

11

1 1

1

1

1

1 1

1

1

1

1 1 1

*: Relative proportion with finalized and almost finalized ECHIM-indicators (d.d. 02/09/2009: cfr. Table 1) as denominator/dev: indicator in developmental phase (d.d. 02/09/2009)

1

1

1 1

1

1 1 1

1 1

11

1 1 1


Table 18. Health promotion indictors: overview of the correspondence between ECHIMand ECHIM.be on the definition, calculation, dimensions, data collection method andsource of indicators.





88 Integrated programmes inspecific contexts: school, workplace, …

Total number of correspondences (n) /dev /dev /dev /dev /devProportion of correspondences (%) /dev /dev /dev /dev /devCorrected proportion of correspondences (%)* /dev /dev /dev /dev /dev

/dev

/dev

/dev

/dev

/dev

/dev

/dev /dev /dev

/dev

/dev

/dev /dev


/dev /dev /dev/dev

/dev /dev /dev


D. Overview of the availability of the ECHIM shortlist indicators in Belgium for theyears 2000-2008 (Objective 3)

The availability of Belgian data on the ECHIM indicators during the years 2000 - 2008 is

high (Table 19). The availability of the demographic and socio-economic indicators in

particular is practically complete (Table 20), taking account of the fact that the SILC,

necessary for the calculation of the indicator “Population below the poverty line and

inequalities of income” was not started until 2003.

A clear periodicity of the data (years with a low degree of available data,

alternating with a year of high availability) is perceptible in the indicator groups “Health

status” (Table 21) and “Health determinants” (Table 22). This periodicity may be

explained by the fact that these data are drawn mainly from the four/five-year HIS-

Belgium. A more continuous availability of data is perceptible in the indicator group

“Healthcare” (Table 23) because of compulsory annual registrations such as the MKG /

RCM, CIC and JZS / SHA.

Table 19. ECHIM shortlist indicators: global overview of availability in Belgium for theyears 2000-2008

2000

2001

2002

2003

2004

2005

2006

2007

2008


B Health status (n = 32) 8 23 8 11 31 11 11 6 20

C Health determinants (n=14) 3 9 2 2 9 2 1 1 11



Total number available (n) 36 63 37 42 75 42 41 34 51Proportion available (%) 40.91 71.59 42.05 47.73 85.23 47.73 46.59 38.64 57.95Corrected proportion available (%)* 39.29 82.14 41.07 46.43 92.86 44.64 44.64 35.71 69.64

26

/dev

20

/dev

20

/dev/dev /dev /dev /dev

17 23 19 20

7

/dev

1520

/dev

9

*: Relative proportion with finalized and almost finalized ECHIM-indicators (d.d. 02/09/2009: cfr. Table 1) as denominator/dev: indicator(s) in developmental phase (d.d. 02/09/2009)

8 8 8 9 9 59


Table 20. Demographic and socio-economic indicators: overview of availability inBelgium for the years 2000-2008

20002001

20022003

20042005

20062007

2008

1 Population by sex/age 1 1 1 1 1 1 1 1 12 Birth rate 1 1 1 1 1 1 1 1 03 Mother's age distribution 1 1 1 1 1 1 1 0 04 Total fertility rate 1 1 1 1 1 1 1 0 05 Population projections 1 1 1 1 1 1 1 1 16 Population by education 1 1 1 1 1 1 1 1 17 Population by occupation 1 1 1 1 1 1 1 1 18 Total unemployment 1 1 1 1 1 1 1 1 19 Population below poverty line

and income inequalityTotal number available (n) 8 8 8 9 9 9 9 7 5Proportion available (%) 88.89 88.89 88.89 100.00 100.00 100.00 100.00 77.78 55.56Corrected proportion available (%)* 83.33 83.33 83.33 100.00 100.00 100.00 100.00 83.33 50.00

1


110 0 0 1 01


Table 21. Health status indicators: overview of availability in Belgium for the years 2000-2008

2000

2001

2002

2003

2004

2005

2006

2007

2008

10 Life expectancy 1 1 1 1 1 1 1 0 011 Infant mortality 0 0 0 1 1 1 1 0 012 Perinatal mortality 0 0 0 1 1 1 1 0 013 Disease-specific mortality;

Eurostat list of 65 causes14 Drug-related deaths 0 0 0 0 1 0 0 0 015 Smoking-related deaths 0 0 0 0 1 0 0 0 016 Alcohol-related deaths 0 0 0 0 1 0 0 0 017 Excess mortality by heatwaves 1 1 1 1 1 1 1 1 118 Communicable diseases (selection) 1 1 1 1 1 1 1 1 119 HIV/AIDS 1 1 1 1 1 1 1 1 120 Cancer incidence 1 1 1 1 1 1 1 0 021 Diabetes 0 1 0 0 1 0 0 0 122 Dementia 1 1 1 1 1 1 1 1 023 Depression 0 1 0 0 1 0 0 0 124 Acute myocardial infarct (heart

infarct) 0 1 0 0 1 0 0 0 1

25 Cerebrovascular accident 0 1 0 0 1 0 0 0 126 Asthma 0 1 0 0 1 0 0 0 127 Chronic obstructive pulmonary

disease 0 1 0 0 1 0 0 0 1

28 (Low) Birth weight 0 0 0 1 1 1 1 0 129 Injuries: home/leisure,

violence30 Injuries: road traffic 0 1 0 0 1 0 0 0 131 Injuries: workplace 0 1 0 0 1 0 0 0 132 Suicide attempt 0 0 0 0 1 0 0 0 133 Self-perceied health 0 1 0 0 1 0 0 0 134 Self-reported chronic




pain38 Psychological distress 0 1 0 0 1 0 0 0 139 Psychological well-being (vitality) 0 1 0 0 1 0 0 0 040 Health expectancy:

Healthy Life Years (HLY)41 Health expectancy: Other 1 1 1 1 1 1 1 1 0Total number available (n) 8 23 8 11 31 11 11 6 20Proportion available (%) 25.00 71.88 25.00 34.38 96.88 34.38 34.38 18.75 62.50Corrected proportion available (%)* 26.09 82.61 26.09 34.78 100.00 34.78 34.78 17.39 69.57

1

0

0

1

0

0

0

1

1

0

0

0

11

0

0

0

1

1

1

0

0

0

0

1

1

1

1

0

0 0 0 0 0

1 1 1

0 1 0 0

0 1 0 0

0 1 0 0

1

0 1 0 0 1


0 0 0 0 0000


Table 22. Health determinants: overview of availability in Belgium for the years 2000-2008

2000

2001

2002

2003

2004

2005

2006

2007

2008

42 Body mass index 0 1 0 0 1 0 0 0 143 Blood pressure 0 1 0 0 1 0 0 0 144 Regular smokers 0 0 0 0 1 0 0 0 145 Pregnant women smoking 0 0 0 0 0 0 0 0 046 Total alcohol consumption 1 1 1 1 0 0 0 0 047 Hazardous alcohol consumption 0 1 0 0 1 0 0 0 148 Use of illicit drugs 0 1 0 0 1 0 0 0 149 Consumption/availability

of fruit50 Consumption/availability

of vegetables51 Breastfeeding 0 0 0 0 0 0 0 0 152 Physical activity 0 1 0 0 1 0 0 0 153 Work-related

health risks54 Social support 0 0 0 0 0 0 0 0 155 PM10 (particulate matter) exposure


0

0

1

1

1

0

1

0

0

1

1

0

1

0

0

0

1

1

0

1

1 1 1 1

1 0 0 0


0

0 1 0 0

0 1 0


Table 23. Healthcare indicators: overview of availability in Belgium for the years 2000-2008

2000

2001

2002

2003

2004

2005

2006

2007

2008

56 Vaccination coverage in children 1 1 1 1 1 1 1 1 157 Influenza vaccination rate in elderly 0 1 0 0 1 0 0 0 158 Breast cancer screening 0 1 0 0 1 0 0 0 159 Cervical cancer screening 0 1 0 0 1 0 0 0 160 Colon cancer screening 0 0 0 0 0 0 0 0 161 Timing of first antenatal visit 0 0 1 1 1 1 1 1 062 Hospital beds 1 1 1 1 1 1 1 1 163 Physicians employed 1 1 1 1 1 1 1 1 164 Active nurses 1 1 1 1 1 1 1 1 165 Mobility of professionals 1 1 1 1 1 1 1 1 166 Medical technologies:

MRI units and CT scanners67 Hospital discharges,

per diagnosis group68 Hospital daycases

per diagnosis group69 Hospital daycases / Hospital

discharges per diagnosis group70 Average length of stay

per diagnosis group71 General practitioner (GP) utilization 0 1 0 0 1 0 0 0 172 Other outpatient visits 0 1 0 0 1 0 0 0 173 Surgeries: PTCA,


selected groups75 Patient mobility 1 1 1 1 1 1 1 1 076 Insurance coverage 1 1 1 1 1 1 1 1 177 Expenditure on health 1 1 1 1 1 1 1 1 078 Survival rates cancer 0 0 0 0 0 0 0 0 079 30-day in-hospital mortality:

AMI and stroke80 Equity of access to healthcare

services0 0 0 1 1 1 1 1 0

81 Waiting times for electivesurgeries

82 Postoperative wound infections 1 1 1 1 1 1 1 1 083 Cancer treatment delay 1 1 1 1 1 1 1 1 184 Diabetes control 0 0 1 1 1 1 1 1 0


1

1

1 0

00

11

1

1

0

0

1

1

1

1

0

0

0

0

0

1

0

0

0

0

0 0 0 0

0

1 1 1 1

1 1

1

1 1 1 1

0 1 0

1

1

1 1 1 1

1

1

1 1

1

1

1

1

1

1

1

1 1 1 1

1

1

11 1 1 1


1 1 1 1 1 1

1

1

Science in the Service of Public Health, Safety of the Food Chain and the Environment

Table 24. Health promotion indicators: overview of availability in Belgium for the years 2000-2008

2000

2001

2002

2003

2004

2005

2006

2007

2008




88 Integrated programmes inspecific contexts: school, workplace,…Total number available (n) 0 0 0 0 0 0 0 0 0

Proportion available (%) 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Corrected proportion available (%)* /dev /dev /dev /dev /dev /dev /dev /dev /dev

/dev

/dev/dev

/dev

/dev

/dev

/dev

/dev

/dev

/dev

/dev

/dev

/dev /dev /dev /dev

/dev

/dev/dev /dev

/dev

/dev /dev

/dev /dev

/dev /dev /dev

/dev


/dev /dev /dev /dev /dev/dev /dev


E. Overview of actions necessary for the implementation of ECHIM in Belgium(Objective 5)

On the basis of the conclusions formulated in the Documentation Sheets an overview was

drawn up of the actions necessary in order to bring about the implementation of ECHIM in

Belgium (Table 25 - 29). A distinction was made here between actions of a limited (minor)

and a more extensive (major) nature. The term “actions of a limited nature refers mainly to

adaptations of the Belgian definitions, calculations and disaggregations. Actions in which the

data collection must be started up or in which the data collection process must be adjusted

are regarded as extensive actions. No ‘necessary’ action point is proposed for indicators in

an initial stage of development within the ECHIM project, or for which significant changes are

expected in future in the guidelines with regard to calculation or data collection.

Summing up it may be said that actions are necessary in the short term for almost

one third (n =26, 29.55%) of the total number of ECHIM indicators (Table 26 - 28). The

indicator group “Health status”, in absolute nulbers, has the highest number of indicators for

which an extensive action is necessary (Table 25).

The adaptations of a limited nature concern, for example, the change of the age

group in the calculation of the indicator. Reference was made earlier to the indicators Total

fertility rate (Ind. 4) and Total unemployment (Ind. 8). The calculation must likewise be

adapted to a limited extent for the indicator Life expectancy (Ind. 10). More specifically the

calculation of the mortality tables should be corrected (nl. + 0.5) as proposed by Farr (1885).

Also limited in extent are the inclusion in HIS-Belgium of the EHIS questions for

calculation of the indicators General musculo-skeletal pain (Ind. 37) and Psychological

distress (Ind. 38).

The data for the MKG / RCM and MPG / RPM must also be compiled in order to

complete the psychiatric data, necessary for the calculation of the indicators Dementia (Ind.

22), Hospital discharges (Ind. 67), In-patient hospital care (Ind. 68), In-patient hospital

care/hospital discharge (Ind. 69), Average stay in hospital (Ind. 70) and - in future - Mobility

of patients (Ind. 75). One important area of concern in this compilation is the difference in

codification of the two registers (MKG / RCM: ICD-9-CM; MPG / RPM: DSM-IV).

The more extensive action points concern in the first instance the processing of the

federal birth and death certificates for the missing years (Birth: 2000-2002, 2007 and 2008;

Death: 2000-2003 and 2005-2008). The arrears was built up at regional level (DGSanté) and

made it impossible for ADSEI / DGSIE to make any aggregation of the three regions of

Belgium.


Table 25. Global overview of actions necessary for the implementation of ECHIM in Belgium

MinorMajo

r


B Health status (n = 32) 6 7

C Health determinants (n=14) 2 2


E Health interventions:Health promotion (n = 4)Total (n) 18 13Total (%) 20.45 14.77

7 2

/dev: indicator(s)in developmental phase (d.d. 02/09/2009)

3 2

/dev /dev

For the indicator Breastfeeding (Ind. 51) the contents and population of the data

collection for the 2 competent regional institutions (K&G and ONE) should be aligned with

each other. The breastfeeding periods to be registered are 46 hours, 3 months and 6 months

post partum. In Flanders, however, breastfeeding is not registered until 3 months post

partum. In Brussels and Wallonia the data collection reaches a too select population (i.c. a

lower socio-economic stratum). The regional data should also be compiled by a national

institution to be created for the purpose.

For the measurement of the indicator Degree of vaccination among children (Ind. 56)

the sampling research of the three competent regional institutions (VAZG, BCHWO and

DGSanté) must also be aligned with each other in time and periodicity. The VAZG, BCHWO

and DGSanté use the same WHO guidelines for their research but should thus best conduct

their research during the same calendar year.

For the completeness of the Hospital beds (Ind. 62) the institutional data of the

Military Hospital in Neder-Over-Heembeek should be included in the CIC.

The operationalization of the indicator Smoking during pregnancy can be executed

within the existing surveillances (HIS-Belgium, NUTRIA …) of WIV OD Volksgezondheid /

ISP DO Santé Publique, but will require a sensitive extension of the sampling with pregnant

participants. On the basis of the most recent birth rates (2007: n = 120 663), a margin of

error of 5% and a reliability level of 95%, the required sample size would be 383 pregnant

participants.

An alternative solution is the addition of a validated item in Section C of Form I

(Certificate of birth of a live child) and Form III D (Certificate of death of a child younger than


one year or of a stillborn child) completed by the doctor or by the obstetrician and forwarded

for processing to the competent regional administrative agencies (BCHWO, VAZG and

DGSanté). The adaptation of these forms is a power of the Regions. The dissemination of

this data at national level is a power of ADSEI / DGSIE.

Science in the Service of Public Health, Safety of the Food Chain and the Environment

Table 26. Demographic and socio-economic indicators: overview of actions necessary for the implementation of ECHIM in Belgium

Major

Minor Actions Actors

3 Mother's age distribution 1 0 Dataprocessing of the birth certificates (2000-2002, 2007-2008). ADSEI/DGSIE (Federal),OGWBH/OSSBC, VAZG, and DGSanté(Regional).

4 Total fertility rate 1 1 Major: Dataprocessing of the birth certificates (2000-2002, 2007-2008);Minor: Calculation of an "ECHIM/EUROSTAT Total fertility number”indicator based on age group 15 – 44 years.

Major) ADSEI/DGSIE (Federal),OGWBH/OSSBC, VAZG, and DGSanté(Regional); Minor) ADSEI/DGSIE

6 Population by education 0 1 Calculation of an “ECHIM/Eurostat Population by education” indicator bytransforming the ISCED97 groups to the three ECHIM groups (Low,average and high educational level).

ADSEI/DGSIE

8 Total unemployment 0 1 Calculation of an “ECHIM/Eurostat Total unemployment” indicator basedon the age group 15 – 74 years.

ADSEI/DGSIE

Total (n) 2 3Total (%) 22.22 33.33


Table 27. Health status indicators: overview of actions necessary for the implementation of ECHIM in Belgium

Major


10 Life expectancy 0 1 Calculation of an “ECHIM/Eurostat Life expectancy” indicator based onFarr’s mortality tables.

ADSEI/DGSIE

11 Infant mortality 1 0 Dataprocessing of the birth certificates (2000-2002, 2007-2008). ADSEI/DGSIE (Federal),OGWBH/OSSBC, VAZG, and DGSanté(Regional).

12 Perinatal mortality 1 0 Dataprocessing of the birth certificates (2000-2002, 2007-2008). ADSEI/DGSIE (Federal),OGWBH/OSSBC, VAZG, and DGSanté(Regional).

13 Disease-specific mortality; 1Eurostat list of 65 causes

14 Drug-related deaths 1 1 Major) Dataprocessing of the death certificats (2000-2003, 2005-2008);Minor) Calculation of an “ECHIM/Eurostat drug-related deaths” indicatorbased on EMCDDA “B Selection” of ICD-10 codes.


15 Smoking-related deaths 1 0 Dataprocessing of the death certificates (2000-2003, 2005-2008). ADSEI/DGSIE (Federal),OGWBH/OSSBC, VAZG, and DGSanté(Regional).

16 Alcohol-related deaths 1 1 Major) Dataprocessing of the death certificates (2000-2003, 2005-2008);Minor) Calculation of an “ECHIM/EUROSTAT alcohol-related death"indicator based on the WHO selection of ICD-10 codes.


22 Dementia 0 1 Aggregation of the number of persons with a dementia-related hospitaladmission or consultation registered in the MKG and the MPG.

FOD VVVL: DG1 / SPF SSCE: DG1

28 (Low) Birth weight 1 0 Dataprocessing of the birth certificates (2000-2002, 2007-2008). ADSEI/DGSIE (Federal),OGWBH/OSSBC, VAZG, and DGSanté(Regional).

37 General musculoskeletal 0 1pain

38 Psychological distress0 1

Incorporation of the EHIS-questioning (being the MHI-5) aboutmental unrest in the next edition of the Belgian HIS.

WIV: OD Volksgezondheid / ISP:DO Santé Publique

Total (n) 7 6Total (%) 21.88 18.75

0 ADSEI/DGSIE (Federal),OGWBH/OSSBC, VAZG, and DGSanté(Regional).

Incorporation of the EHIS-questioning to general muscle-, joint- or bonepain in the next edition othe Belgian HIS.

WIV: OD Volksgezondheid / ISP: DOSanté Publique

Dataprocessing of the death certificates (2000-2003, 2005-2008).


Table 28. Health determinants: overview of actions necessary for the implementation of ECHIM in Belgium

Major


45 Pregnant women smoking 1 1 Major) Data collection through a) a new ('hospital based") surveillance; orb) the expansion of the existing surveillances (Belgian HIS or the BelgianFood Consumption Survey by a group (ca. 400) of pregnant women(recruted in hospitals); or c) addition of a validated item in the Section C ofForm I (Declaration of birth of a living child) and Form III D (Declaration ofthe death of a child younger than one year or of a dead-born child) filled inby the physician or the midwife and transferred to the competent regionaladministrative agencies for the processing; Minor) Calculation of indicator

a) and b) WIV: OD Volksgezondheid /ISP: DO Santé Publique; c) OGWBH,VAZG and DG Santé

51 Breastfeeding 1 1 Major) a) Adjusting of the content and population of the data collectionconcerning the duration of the breast feeding by the two competentregional institutions. Breast feeding periodes to register are 46h, 3 monthsand 6 months postpartum. (Kind en Gezin: Flemish community; Office dela Naissance et de l’Enfance (ONE): French community); Minor) Regionaldata must be aggregated on a national level.

Major) K&G, ONE (Regional); Minor)WIV: OD Volksgezondheid / ISP: DOSanté Publique or FBVC (Federal)

Total (n) 2 2Total (%) 14.29 14.29


Table 29. Healthcare indicators: overview of actions necessary for the implementation of ECHIM in Belgium

Major


56 Vaccination coverage in children 1 0 Adjusting of the time and periodicity of the sampling and the research tothe vaccination rate by children by the 3 competent regional institutions.

VAZG, OGWBH/OSSBC and DGSanté(Regional)

61 Timing of first antenatal visit 0 1 Calculation of an “ECHIM/EUROSTAT Timing of the first antenatal consult”indicator based on the Permanent Sample.

RIZIV/INAMI

62 Hospital beds 1 0 Incorporation of the data (in particularly about the number of hospital bedsand– in the future - the available medical technology) of the MilitaryHospital of Neder-Over-Heembeek in the Centraal Instellingen Bestand(CIC).

FOD VVVL: DG1 / SPF SSCE: DG1

67 Hospital discharges, 0 1 FOD VVVL: DG1 / SPF SSCE: DG1per diagnosis group

68 Hospital daycases 0 1 FOD VVVL: DG1 / SPF SSCE: DG1per diagnosis group

69 Hospital daycases / Hospital 0 1 FOD VVVL: DG1 / SPF SSCE: DG1discharges per diagnosis group

70 Average length of stay 0 1 FOD VVVL: DG1 / SPF SSCE: DG1per diagnosis group

78 Survival rates cancer 0 1 Calculation of the five-year survival ratio for cancer. BKR / RCB

84 Diabetes control 0 1 Calculation of an “ECHIM/EUROSTAT Diabetes control” indicator based onthe number of retina examinations for patients with repayed diabetestreatment (insuline, oral medication ...) in the Permanent Sample.

RIZIV/INAMI

Total (n) 2 7Total (%) 6.90 24.14

Aggregation of the number of hospital admissions (longer than 24h)registered in the MKG and MPG, splitted up by diagnosis group.

Aggregation of the average number of hospital days registered in the MKGand the MPG, splitted up by diagnosis group.

Calculation of the Ambulant hospital care / hospital dismission ratio,splitted up by diagnosis group.

Aggregation of the number of ambulant hospital consultations registeredin the MKG and the MPG, splitted up by diagnosis group.


Discussion

This research and implementation inventorizes the availability of the Belgian data for the

indicators of the ECHIM shortlist. In this chapter we discuss the results described earlier and

formulate the areas for concern and recommendations for further implementation of the

Belgian data collection within the European health monitoring system.

Objective 1. Investigating the international databases

In sum it may be said that the availability of the Belgian data is high to complete in theexplored international databases (WHO/European Health for All database, the OECD

Health Data and the EUROSTAT Public Health Database). This study hereby confirms the

Country Report results of the ECHIM project group (Kilpelaïnen, Aromaa, and the ECHIM

Core Group, 2008) and even shows an increase in the number of available Belgian data. It

should however be pointed out that the data for a number of indicators (among others, the

cause-specific mortality figures, birth weight, …) are not updated, that the quality of the data

is not known, and that certain indicators are calculated on the basis of a source other than

the primary source as presented in this report.

Only half of the ECHIM shortlist indicators are included in the databases of theinternational organizations. In their ambition to extend the range of indicators and to align the

data and collection and presentation thereof with each other, the three international databases

develop so-called Joint Questionnaires to collect monetary and non-monetary health data from

the Member States of the EU. In order to track the technical and contents-related changes that

accompany these Joint Questionnaires and to prepare for the future extension of these

indicators Belgium must have at its disposal a streamlined process of data collection anddistribution and engage in systematic consultation with experts and the concernedauthorities (Kilpelaïnen, Aromaa and the ECHIM Core Group, 2008).

One important positive initiative concerning the organization of such a streamlined

process was the creation in Belgium of the Focal Point WHO, OECD and EUROSTAT

(Interministerial Public Health Conference of 28/09/2009). The assignment of this Focal Point

consists of the coordination of transfers of Belgian health data to the relevant databases. The

core of this Focal Point consists of a representative of the WIV OD Volksgezondheid / ISP DO

Santé Publique (contact person), from the FOD SZ / SPF SS (alternate contact person) and

from International Relations Department of the FOD VVVL / SPF SSCE (Secretariat). In de


Focal Point Coordination Group the following institutions and authorities have one

representative each: the International Relations Department of the FOD VVVL / SPF SSCE,

DG Organization of Health Services (DG1) and DG Basic Healthcare and Crisis Management

(DG2) of the FOD VVVL / SPF SSCE, RIZIV / INAMI, ADSEI / DGSIE, the FOD SZ / SPF SS,

the WIV OD Volksgezondheid / ISP DO Santé Publique and the Flemish, French and German

Communities, as do the Walloon Community and COCOM. One of the first areas for special

attention of the Focal Point concerns the need to update the cause-specific mortality figures

and the birth rates. Regarding such updating reference may also be made to the interregional

working group on mortality data that, among other things, assesses the administrative

processing of the birth and death certificates on a monthly basis.

Objective 2. Mapping the currently available data sources

This report gives a general picture of the primary national databases in Belgium and their

managers. The results confirm the conclusions of the ECHIM project group (Kilpelaïnen,

Aromaa, and the ECHIM Core Group, 2008) and, previously, those of Van de Sande et al.

(2006) with regard to the excellent availability of the so-called “registers” (such as the

MKG / RCM, the JZS / SHA, …). The present study shows moreover that the initially low

degree of coverage of the BKR / RBC has evolved to a reliable level.

It was mentioned earlier that a number of important registers present significantarrears in the processing of the collected data. These arrears have a high international

visibility (World Health Organization Regional Office for Europe, 2008). Belgium is still also

missing relevant on extramural health services, the retirement, rest and care homes, the

extra-legal obligatory insurances and the consumption of non-refunded health services (Van

de Sande et al., 2006). At the methodological level it may also be noted that a longitudinal

analysis of the data at patients level is hampered by the lack of any constant single identifier

in most of the registers (Van de Sande et al., 2006).

A considerable number of the indicators are measured by reference to the HIS-Belgium. During the preparation of the fourth edition (2008) attempts were made towards

the integration of the matter in the EHIS. A number of divergent EHIS questions were also

dropped because of comparability with the results of previous surveys (Demarest, 2008).

This finds expression, for instance, in the discordance of definition and calculation of the

indicator General musculo-skeletal pain (Ind. 37). The Mental Health Index (MHI-5) is

included in the EHIS for the measurement of Psychological distress (Ind. 38). However, the

use of the MHI-5 in the EHIS is a subject of discussion (ECHIM, 2009). The General Health


Questionnaire (GHQ-12), that also measures psychological distress and was also used in the

previous three editions of HIS-Belgium, is also retained in the fourth edition of HIS-Belgium

for that and for other reasons.

No Belgian (national) database was found for certain indicators, among others

for the indicators Waiting times for elective surgeries (Ind. 81) and Breastfeeding (Ind.

51). As far as concerns the first indicator, a so-called “care quality” indicator, there are no

indications for Belgium that the period between the diagnosis and the performance of the

necessary surgical operation is in any way problematic. The reason for this possible resides

in the organization of the Belgian healthcare system (free choice of doctor, independent

medical practice,…). Nevertheless, the quantification of this “care quality” indicator will

necessarily have to check for the absence of the problem in Belgium and follow future

developments and their causes.

Since family policy in Belgium is a regional power, peripartal and postpartal data,

including the breastfeeding period, is registered by regional institutions (K&G and ONE). At

present there is no national register that brings this data together (with the exception of data

registered by means of the birth certificate, cf. Federal Birth Register). There are also quite

considerable differences between the Regions regarding registration, notably the

breastfeeding periods to be registered. Harmonization of this registration by the competent

regional institutions, preferably on the ECHIM guidelines, is thus also necessary in order to

be able to transfer the Belgian data to the international databases.

Despite the fact that the indicators “Mobility of patients” (Ind. 75) and “Mobility of

professionals” (Ind. 65) are still in the development phase of the ECHIM project, registration

of that in Belgium merits special attention, among other things to estimate the financial and

non-financial consequences for the Belgian hospitals, the healthcare practitioners and the

federal and Community authorities. The analyses reveal that data on the “outflow” are

complex and difficult to collect. However, one positive initiative is the cooperation between

RIZIV / INAMI and the insurance institutions in the development of a pool of Permitted

Medical Care in countries outside Belgium.

In the operationalization of national epidemiological research deliberations are constantly made

regarding, for example, the scale of sampling and the method of data collection. It is known, for

instance, that the results of expensive, small-scale but accurate clinical research (such as

conducted in the HES) may differ significantly from the data of affordable, large-scale but also

subjective and often less accurate health surveys (Conti et al., 2007). The present study shows

that the Belgian data for the ECHIM indicators display a certain balance between thesubjective reportage of the health status and, for example, the clinical registrations.


However, a certain qualification must be taken into account in the clinical interpretation of, for

example, the MKG / RCM. This register is by origin not an epidemiological but an

administrative registration with a financial finality. The validity of its diagnosis and treatment

data was questioned earlier (Aelvoet, 2008; Gilbert et al., 2004; Van de Sande et al., 2006).

A balance is necessary in the ECHIM data collection between subjective reportage of

the health status and, for example, the clinical registrations. These types of data collection are,

as it so happens, not mutually exclusive but rather complement each other (Bullinger, 2003).

We must nonetheless continuously assess, also for the Belgian data collection for the

ECHIM indicators, whether the data for an indicator have in fact been drawn from the mostreliable and valid database. The ECHIM guidelines may prove to be restrictive in that sense,

because this project still works for the highest degree of comparability (Kilpelaïnen, Aromaa,

and the ECHIM Core Group, 2008). Belgium, with its Belgian Diabetes Register, has a

valuable instrument for measuring the incidence of Diabetes (Ind. 21) (Gorus et al., 2004).

However, such a clinical register is not present in every EU Member State. At ECHIM level the

option is therefore data collection via the health survey (self-reportage). A possible ECHIM

solution might consist of splitting up a number of indicators in the groups Health status

(diabetes) and Health determinants (BMI, blood pressure, …) into a “Self-reported” and a

“Clinically diagnosed” (sub)indicator. This would also require a clear explanation via, for

example the metadocumentation of the databases such that the interpretation of subjective

reportage and the clinical registrations can take into account the respective limitations as

regards representativeness, reliability and validity.

A further Belgian instrument that can make a valuable epidemiological contribution to

the ECHIM project is the Permanent Sampling by RIZIV/INAMI (for example, for the

indicators: Consultation with general practitioners Other polyclinic consultations, Surgical

operations: PTCA, hip, cataract). Here again, however, comparability with the databases of

other EU Member States is limited.

One important consideration in the preference for a particular database for the delivery of

health data concerns the periodicity of data collection. This report shows a great differencein periodicity: annual Belgian data are available for a number of indicators while the data for

other indicators are available only every four or five years. The need for data collection with

high regularity will to a large extent be determined by the objective of the data collection. If

the ECHIM project has the ambition of measuring, for instance, the effect of policy choices

on health status also in the future (Kilpelaïnen, Aromaa, and the ECHIM Core Group, 2008),

we will have to explore whether, for example, the four-yearly availability of the morbidity data


(diabetes, depression, acute myocardial infarct, cerebrovascular accident, asthma, …) is in

fact sufficient.

Given the considerable growth of the technological possibilities, the expectation is that careprocesses will become increasingly electronically registered. Sustainable health

monitoring systems, national or international, will therefore increasingly have to dispose

sufficient flexibility in order to be able to react on these rapid changes (Hollander et al.,

2007). In Belgium the Federal Government set up the eHealth-platform designed to

promote and support standardized electronic exchange of information between all actors in

healthcare (Federal Government Department Social Security, Belgisch Staatsblad / Moniteur

belge 13/10/2008). Epidemiologically relevant and all functional examples of this include the

Electronic birth certificate (eBirth), the Database for the tracking of pandemic influenza in the

hospital (eH1N1), the Registration of the A/H1N1-vaccination, the register "ORTHOpedic

Prosthesis Identification Data" (eCare-Orthopride), and the Cancer Registration. Because of

the epidemiological potential, here too, we must take account from the outset of thedifferent (types) of end-users and of comparability with the EU Member States. Positive

in that sense are the standardization initiatives within the eHealth-platform in which the use

of, for instance, the International Classification of Diseases (ICD-9/10 and ICD-9-CM), the

International Classification of Primary Care (ICPC-2), the International Classification of

Diseases for Oncology (ICD-O), and the International Classification of Functioning, Disability

and Health (ICF) is promoted and supported.

By extension the integration of specific clinical registers (BDR / RBD, BKR / RBC,…)

in, for example, the more administrative MKG / RCM might be considered in this context.


Objective 3. Scientific analysis of the definitions and calculations used in Belgium

In the ECHIM final report the authors advised for Belgium a better description of the definition

and calculation method of the indicators and of the data sources available in Belgium

(Kilpelaïnen, Aromaa, and the ECHIM Core Group, 2008). The inventories taken by the KCE

(Van de Sande et al., 2006) and the WIV OD Volksgezondheid / ISP DO Santé Publique

(Morbidat) were regarded as references in this respect.

The present study ascertains a high degree of correspondence between the Belgian

data and the ECHIM guidelines as regards definition, calculation, available dimensions and

data collection method. The abovementioned ECHIM survey (Kilpelaïnen, Aromaa, and the

ECHIM Core Group, 2008) still mentions various problems for Belgium in the indicator groups

“Health determinants” and “Healthcare” in the matter of availability and indicator characteristics.

The present study shows that almost all this data now satisfies the ECHIM guidelines.

Furthermore the existing differences mainly concern calculation level and not the data

collection method, nor the data source itself. This means that no substantial efforts or problems

are expected for harmonization of the Belgian data.

The data for a number of indicators may well in fact be available but the calculation of

the indicator has not as yet been (systematically) executed. This applies for instance to the

indicators Time of first antenatal consult (Ind. 61), Postponement of cancer treatment (Ind.

83) and Diabetes observation (Ind. 84). This concerns the more recent “quality of care”

indicators which, by definition, fall outside the timeframe of regular registrations (respectively

data relating to childbirth, cancer treatment and diabetes diagnosis).

The high degree of correspondence between the used definitions, calculations and

data collection method (including for the group of indicators that are still in development) may

be explained by the participation of Belgian institutions in various European researchand standardization projects. Let us take for instance the Wetenschappelijk Instituut voor

Volksgezondheid / Institut Scientifique de Santé Publique which, as core group member, is

involved in for example, the European Health Expectancy Monitoring Unit (EHEMU), EHIS,

the European monitoring of excess mortality for public health action (EURO-MOMO), the

Tackling Health Inequalities in Europe project (EUROTHINE) and the ECHIM project. The

FOD VVVL / SPF SSCE, FOD SZ / SPF SS and ADSEI / DGSIE are also represented in

various technical EUROSTAT (e.g., Health Care Statistics: CARE; Core Group Morbidity:

MORB; Causes of death: COD) and OECD working groups (System of Health Accounts:

SHA; Health Care Quality Indicators: HCQI). Bearing in mind their great impact on the

implementation of the European health monitoring system and, thus, their high degree of


effectiveness for implementation of data collection in Belgium, such participation will

also warrant the necessary support in the future.

Objective 4. Identifying the roles and competences of the players

The ECHIM final report identifies the federal structure of Belgium, with its spread of powers

concerning health services and health promotion, the multiplicity of concerned institutions

and its regional differences policy accents as the principal obstacle to the implementation of

Belgian data collection (Kilpelaïnen, Aromaa, and the ECHIM Core Group, 2008). The

authors here suggested the EUROSTAT regulation on the supply of health data (European

Council, 2008) as an opportunity for optimization of information throughflow and the division

of labour between the partners in Belgium.

The present study maps the direct (execution) and indirect (financing) contributions of

the various national and regional institutions and authorities in data collection. This overview

confirms the complexity of data collection and the lack of any underlying conceptualhealth model (Van de Sande et al., 2006). The adoption of the ECHIM model and the

ECHIM implementation guidelines by DGSANCO and EUROSTAT has the advantage that the

Federal and Regional authorities would be given a single conceptual framework with aninterpretation of content (definitions) and operational aspects (calculations and methods of

data collection). It can be stated here that, in the European connection, a health monitoring

programme has also been developed for the European regions. This programme, Health

Indicators in the European Regions (ISARE) follows through on the work of the ECH and

ECHIM projects.

With the creation of the Focal Point WHO, OECD and EUROSTAT a first step was

taken towards the development of a network organization model (Van de Sande et al.,

2006). The fact that this Focal Point acts as a steering group for the present research and

implementation assignment may facilitate the harmonization of Belgian data collection and

distribution according to the ECHIM guidelines.


Objective 5. Examining the feasibility of collection of indicators

As final objective of this research and implementation assignment we studied the feasibility

of Belgian data collection in the framework of the development by ECHIM of a sustainable

European health monitoring system. This report goes on to outline action points of a rather

limited (minor) or a more extensive (major) nature. Here due account was taken of the four

indicators in the group Health promotion. These are developed during an early phase in

the ECHIM project in which no definitions, calculations and sources are yet available (d.d.

02/09/2009). The further operationalization of these indicators will of course have to beclosely followed by the Focal Point WHO, OECD and EUROSTAT.

The action points of a limited nature mainly concern calculation of the indicators. In

Belgium other age intervals are often used for the calculation. The MKG / RCM and MPG /

RPM data must also be assembled for a number of indicators. For one thing the difference in

codification (ICD-9-CM versus DSM-IV) must be reconciled. However, these adaptations do

not require any extensive resources and can generally be executed within a short period of

time.

The action points of a more extensive nature concern (a) the optimization of theexisting data processing (cf. the birth and death certificates) and (b) the development of asustainable exchange of data. We referred earlier to the harmonization of breastfeeding

registration by the competent regional institutions. Besides such harmonization an exchange

must also be organized at national level. A coordinating role is here set aside for the WIV OD

Volksgezondheid / ISP DO Santé Publique of the Federal Breastfeeding Committee (FBFC).

One action point requiring more substantial resources is data collection for “Smoking

during pregnancy” (Ind. 51). An extension of existing surveillances (HIS-Belgium, national

food consumption survey,…) with a population of pregnant women appears to be a solution

with a high degree of cost-efficiency. One alternative that calls for further attention is the

inclusion of a validated item in Section C of Form I (Certificate of birth of a live child) and

Form III D (Certificate of death of a child younger than one year or of a stillborn child). This

data could be made available via the Federal Birth Register. If reliable and valid this

alternative would have a scale advantage (total population of pregnant women), a periodic

advantage (available annually) and an important financial advantage (in comparison with the

cost of a surveillance).

In the implementation of this indicator efforts can also be made towards a further

harmonization with the EURO-PERISTAT project (EURO-PERISTAT Group, 2008).


With the realization of the abovementioned action points Belgium satisfies the current

ECHIM guidelines in the matter of collection of health data. However, as mentioned earlier,

given the sustained character of international data collection, a structural framework must be

developed for data collection. The major areas of concern here have already been

formulated by Van de Sande et al. (2006) and Bossuyt & Van Casteren (1998). One such

area of concern has to do with an integrated legal framework. The present study likewise

shows that not all databases, necessary for the transfer of data for the ECHIM indicators,

have a legal framework that structurally guarantees and facilitates data collection. The

realization of such a coordinating legal framework that takes into account the different (types)

of end-users is therefore also an important priority (Bossuyt & Van Casteren 1998; Van de

Sande et al., 2006).

The present study confirms the necessity mentioned earlier of a better documentation ofthe (collection and calculation) methods used by the managers of the databases and the

centralization of the metadata in Belgium (Van de Sande et al., 2006). This must make the

scientific monitoring of the quality of data and data collection possible. Validation

research of the databases by the managers and by external researchers should be

encouraged in this connection.

Following on, the standardization of these indicators in sources other than theprimary source mentioned in this report must be promoted, not only at national but also at

regional level. In the framework of, for example, research on the impact of social inequality

on access to health services, the systematic use in the health registers of the definitions and

calculations of the socio-demographic indicators formulated in this report offers an important

methodological surplus value. The same surplus value can be obtained by applying the

methodology, for example, to measure morbidity (such as in HIS Belgium) in research or

registers in which health is not a primary variable. The authorities could facilitate thisstandardization by including the ECHIM indicators in the research and surveillanceassignments financed by them.

Why collect Belgian data on health, health determinants and healthcare?

The objectives of this research and implementation assignment concerned the availability and

utility of the present Belgian health data for transfer to ECHIM and the databases of the WHO,

OECD and EUROSTAT. The impression may be formed that data are collected because they

have to be collected (measuring for measuring’s sake) and this to compare and be compared


Figure 7: Portaalwebsites van het Nationaal KompasVolksgezondheid (RIVM) en het Health Indicators Report(CIHI)

(measuring to be measured) (Berings, 2008). In closing this report we therefore wish to set thenational use of data collection as a priority. The collection of Belgian health data, following

the ECHIM guidelines, a “measuring in order to evaluate, improve and justify oneself”(Berings, 2008).Figure 7. Portaalwe bsites van het Nationaal Kompas Volksge zondheid (RIVM) en het Health Indicators Report (CIHI).

Specialized reports appear in

Belgium on a regular basis on, for example,

the number of (new) cancer patients, the

number of infectious diseases or the

number of active doctors. However,

publications that offer a broad overview of

the health data from a conceptual health

model are not available in Belgium. The

permanent compilation of health data in a

sustained integrative health monitoring

system offers the authorities a manageable

up-to-the-minute evaluation of the health

status, the health determinants and health

services in Belgium. Such an evaluation

would also offer the possibility of identifying

needs and formulating policy objectives for

improvement that go beyond the individual

domains of health (state, determinants,

care and promotion). Such a health monitor

would also offer the possibility of

justification to the outside world. (“The

means are made available, are deployed

effectively” Berings, 2008).

An international comparative

analysis of the Belgian health data may yield valuable recommendations for improvement

of policy and, consequently, of public health. However, such analysis always sets out from

comparability with other EU Member States whereby data specific and essential to

Belgium often cannot be taken into account. This underlines the importance of a national

analysis of the ECHIM indicators.

Countries with a tradition of integrative monitoring of health data are Canada and the

Netherlands. The RIVM developed the “Nationaal Kompas Volkgezondheid”, a website on

which quantitative data on health, disease, risk factors, care and prevention in the Netherlands


are presented and explained at length. This instrument is also the basis of the four-yearly

policy-supporting reports “Volksgezondheid Toekomst Verkenningen” (Harteloh et al., 1995;

Ruwaard and Kramers, 1997; van Oers 2002; Hollander et al., 2007) in which the indicators of

the National Public Health Compass are analyzed in an integrative manner and whereby policy

recommendations can be formulated. On the basis of the Belgian data collection for the

ECHIM indicators a policy-supporting instrument of that kind could also be developed forBelgium. Because disaggregations to regional, provincial and often also district level are

available for many of the indicators, these instruments could also be policy-supporting forthe local authorities.


Conclusion

The availability of the Belgian data in the international databases of the WHO

(WHO/European Health for All database), the OECD (OECD Health Data) and EUROSTAT

(EUROSTAT Public Health Database) is high. The correspondence between ECHIM and

ECHIM.be on the definitions, calculations, dimensions, data collection method and sources of

indicators is also high, and this in each group of indicators. These results can be explained by

the high degree of participation in European projects and the use of international calculations

and classifications.

The international databases work towards a progressive increase in the number of

indicators for which they collect data via the so-called Joint Questionnaires. The ECHIM project

offers the conceptual framework and the scientific methodologies for Europe and for the

European sustainable system of health monitoring What is important here is that these

methodologies are not static but a dynamic given. For Belgium the implementation of this

framework and these methodologies therefore requires a number of necessary short-term

actions and a number of important structural conditions.

In the short term a limited number of indicators regarding calculation and data collection

must be adapted. Regarding the calculations no substantial resources need be provided.

These adaptations may also be executed direct. However, the action points regarding data

collection (processing of birth and death certificates; national breastfeeding register, extension

of existing surveillances with sampling of pregnant women,…) will require more substantial

resources.

With the execution of the above actions Belgium satisfies the present sate of the art in

the ECHIM-project. However, no (final) guidelines for operationalization are yet available for

more than one third of the ECHIM shortlist indicators. Structural actions are therefore also

necessary in order to follow these contents-specific scientific developments in a continuous

manner. Furthermore a coordinating concept and strategy for data collection must be mapped

out and executed with the managers of the databases. A structured consultation with the

concerned authorities and institutions, such as the Focal Point WHO OECD EUROSTAT, and

an integrated legal framework are necessary to that end. An increase of the scientificpersonnel is necessary for the monitoring and support of these structural actions.

In closing it is emphasized that transfer to the international databases should not be the

only priority of Belgian data collection. Indeed, data collection also serves the purpose of

evaluation and improvement of Public health in Belgium and its Communities and Regions and

the justification of the resources deployed to that end.


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