Healthcare Finance and Organization in Belgium

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Belgium has a mixed private/public health care system, based on the system which was developed by Otto von Bismarck (1815-1898 CE) in Germany (e.g. The Prussian Health Insurance Act of 1883 entitled workers to health insurance). The Belgian system comprises both government at different levels (federal, regional and local) as well as private participants (e.g.: insurance companies, healthcare providers). The foundations of Belgian healthcare insurance were laid in the nineteenth century, when workers organizations created Health Insurance Associations (HIAs or mutualities) to protect affiliated members against the risk of disease and incapacity to work. With the Law of 3 April 1851 the Belgian state officially recognized these mutualities, and with the Law of 23 June 1894 it passed more important legislation which served as the legal foundation for the mutualities until its replacement by the Law of 6 August 1990 regarding HIAs and National Unions of HIAs.

With a decree of 28 December 1944 social security for salaried workers was established, which had been voluntarily until then. This decree advocated universal access to social security, and made health insurance compulsory for all salaried employees. The new law also created the National Office of Social Security (NOSS) (Dutch: Rijksdienst voor Sociale Zekerheid : RSZ; French : Office National de Sécurité Sociale: ONSS), to collect contributions for all social security sectors, and a National Fund for Sickness and Invalidity to manage the health insurance in particular.

The Law of 9 August 1963 (Edmond Leburton, Socialist) created the National Institute for Sickness and Invalidity Insurance (Dutch: Rijksinstituut voor ziekte- en invaliditeitsverzekering: RIZIV; French: Institut National d'Assurance Maladie-invalidité: INAMI) which replaced the National Fund for Sickness and Invalidity and exists to this day. The Leburton-law was modified on 25 June 1964. The Leburton reform of the compulsory health insurance also formed the basis for legislation on hospitals dated 23 December 1963 (known as Joseph Custers's Law, Christian Democrat) when the Belgian government for the first time regulated the hospital system with specific legislation.

By 1969 healthcare insurance was expanded to the entire population, with a distinction being made between major and minor risks. Belgian health insurance nowadays consists of two distinct schemes: the general scheme which covers major risks and minor risks for the whole population except for the self-employed, and the scheme for the self-employed (and their dependants) which only covers the major risks.

In recent years cost control and cost reduction became more important, which started a process of financial responsabilization for healthcare providers. Since 1995, in accordance with a Royal Decree of 12 August 1994, the mutualities were granted more direct financial responsibility for health expenditure. There is a growing tendency to accomplish a shift from in-patient care (intramural, second and third line) towards out-patient care (extramural, first line). Registration of Key Performance Indicators (KPIs) was introduced in the nineties of the twentieth century, together with intra- and transmural clinical pathways.


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First version published on 21 September 2009. Last modified on 16 December 2017.

The author of this Webpage is Peter Van Osta.

Email: pvosta{at}gmail{dot}com