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ITINERA INSTITUTEMEMO
Breaking the deadlock o budgetary autism: what paradigmsor uture healthcare organisation in Belgium?
 
Pro. dr. Marc De Vos and Brieuc Van Damme(1)IntroductionAt the beginning o the 21st century demographic, scientic and technological evolutionsare increasingly putting nancial strain on healthcare systems all over Europe, indeed inalmost all developed countries. These evolutions are destined to increase as the centuryprogresses, orcing governments, administrators, and healthcare proessionals to think anew about the oundations o healthcare organisation. In Belgium, the elementary pillarso our healthcare philosophy – quality combined with accessibility and ree choice – arealready eroding. A proactive and ambitious reorm involving patients, providers, payers,the industries, policymakers, and academics will be needed to prevent urther gradualdecline(2).Healthcare reorm is not on the cards in Belgium today. The policy emphasis has beenand still remains essentially budgetary. Thereore, or a coherent policy approach to bedeveloped, we must identiy trends and challenges rst. Based on these a suggestion o possible policy options will be made. A pragmatic and realistic approach – we do nothave the luxury o ideology or romanticism – can be taken seriously only i the prioritiesand limits o promising solutions are dened. The purpose o this article is to oer someood or thought on real healthcare policy reorm in Belgium, based on the stated necessityo such reorm. Our purpose is not to provide a comprehensive or academic analysis, butrather to indicate – with a bird’s eye view or the big picture – the unmistakable trends anduture challenges that are upon us and to draw the plain conclusions they suggest.
2009/8 27 03 2009
Marc De VosDirecteurItinera Institute
Brieuc Van Damme
Junior Fellow
 
Breaking the deadlock o budgetaryautism: what paradigms or uturehealthcare organisation in Belgium?
1. Major trends in Belgian healthcare provision1.1. Budgetary explosion combined with budgetary austerityIn healthcare organisation – contrary to perhaps some popular and naïve belie about ‘ree’ andaccessible healthcare – everything comes down to numbers. And the numbers are impressivewhen you take a look at the evolution o the budget or public health care in Belgium. In1970, public healthcare expenditures were still under the billion euro mark. Ten years later,they accounted or more than € 3 billion. By the end o the millennium, public health careexpenditures had reached € 12 billion and it is very likely this gure will again be doubled by2010. In 2005, the public healthcare budget already equalled €17 250 358 000, in 2006 €17 735292 000 and in 2007 €18 873 404 000. The objective is to spend approximately €21,5 billionin 2008(3) and €23 billion in 2009. Compare this gure with the € 850 million in 1970 and themetaphor with the universe seems straightorward: always expanding and expanding. O course, these are absolute gures. We have seen in over 30 years an average annual growth o close to 5 percent in real terms, i.e. on top o ination. This is way aster than average economicgrowth in this country. From the perspective o public budget control, thereore, the growth o healthcare spending is simply unsustainable.We have nonetheless managed to survive such an expenditure explosion by giving everincreased weight to the relative importance o healthcare in the total social security budget.In 2008, the share o public health care expenditures in the total social security budget willbe close to 32%(4). In 1980, it was a mere 22%. It is thereore air to say that healthcareis gradually cannibalizing social security(5). The victims o this budgetary evolution are therst pillar pensions, the unemployment insurance benets and child allowances, all o whichhave seen their relative levels reduced because o increased healthcare expenditure. Thissituation is untenable in the long run and has already led to a series o healthcare policiesthat are perhaps necessary or inevitable, but that share a common characteristic in that theyrestrict the oer o, or access to healthcare in this country.1.2. Healthcare policy vs. budgetary policyGiven the enormous and ever increasing budgetary importance o healthcare, it is normaland predictable that government should impose a budgetary discipline to avoid decitspending. This necessary awareness, however, has turned into somewhat o an obsession.Since about a quarter o a century, Belgium’s governmental policies in healthcare haveindeed been dominated by budgetary concerns, rather than by public health concerns(6).When one looks at the picture rom a distance, one can easily come to the conclusion thathealthcare policy in Belgium has essentially become budgetary policy. On the one hand,a lot o time and eort is spent on an almost yearly basis in determining growth norms orthe public healthcare budget. On the other hand a number o reorm measures, althoughnot directly o a budgetary nature, have been developed under the growing pressure o budgetary austerity. In just the past couple o years, we have observed tightened budgets orhospitals and new technology, mergers o hospitals, and the concentration o some medicalservices in certain hospitals. The doctors and other healthcare providers have seen theirtherapeutic reedom restricted or the sake o eciency. The reedom o choice in accessto doctors is partially eroding and the doctors have seen the prescription o generic drugsimposed. More bureaucratic rules streamline the medical proession, the inow o newmedicines has been more strictly managed, reimbursed care is increasingly controlled, theinow o doctors managed, etc.
MEMO
2
“The objective is to spend approxi- mately €21,5 bil- lion on healthcare in 2008 and €23 billion in 2009.Compare this g- ure with the € 850 million in 1970 and the metaphor with the universe seems straightorward: always expanding and expanding.” 
 
Breaking the deadlock o budgetaryautism: what paradigms or uturehealthcare organisation in Belgium?
What the neutral observer notices, thereore, is a gradual streamlining and sot restriction onhealthcare supply, and a gradual streamlining and sot restriction on healthcare demand.Some o these evolutions are highly contentious and debated. Many, indeed perhaps even all,may be necessary or desirable rom a pubic governance perspective. But it goes without sayingthat they all have tradeos. Our oten trumpeted model o reely available and accessiblehealthcare in an open market that guarantees competition and choice is gradually eroding.What are widely considered as key components o the Belgian healthcare ‘model’ are thusbegin gradually undermined. We can illustrate this trend by ocussing on two key parties: themedical proession and the patients/citizens.1.3. The medical and paramedical proession under pressureAs almost any practitioner will tell you when questioned upon the state o his/her proession,doctors are acing less therapeutic reedom and more bureaucracy. Moreover, as hospitalshave been rationalized, ewer have remained in the non-private sector, thereby decreasing thepersonal social security o the aliated medical corps as compared to the previous generationdoctors with public servant status. Furthermore, the income growth o the medical proessionhas diminished in relative size: between 1996 and 2008, the share o the doctors’ honorariain the public budget went rom 33,6% to 28,4% - a 5 points decline(7). This trend is urtherexacerbated by the systematic underunding o hospitals, which has led hospitals to increasethe overhead deducted rom the doctors’ ees. The growing pressures on the medical proession and its correspondingly diminishedattractiveness should be a source o grave concern. For at the end o the day, the quality o a healthcare system depends on the quality o its human capital. This goes or the medicalproession as it goes or the paramedical proession. Human resources will be a key challengeor the uture wellbeing o Belgium’s healthcare system. I we are to continue to thrive, weneed to be able to attract and motivate the requisite human capital at home and, increasingly,abroad as well.1.4. Private expenditures are on the riseAlthough our healthcare expenditures are nanced by an ever expanding public budget,the patients themselves have to carry some o the burden. The OECD computed that 27,7%o the total healthcare expenditures in Belgium are paid by the patient-citizen (or his/heremployer), either as out o the pocket expenses or through private insurance(8). Only ourOECD countries have an even more important share o private expenditure: the US, Canada,Spain and Switzerland (Figure 1).
MEMO
3
“Belgium’s gov- ernmental poli- cies in healthcare have indeed been dominated by budgetary con- cerns, rather than by public health concerns.” 
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