Healthcare Finance and Organization in Belgium

Introduction

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.

Primary care

Primary care in Belgium is funded through a combination of public financing, social security contributions, and patient co-payments. The system is centered on universal coverage provided by the country's compulsory health insurance, ensuring accessibility and affordability for everyone.
Overview of the funding mechanisms for primary care:

1. Public Health Insurance (RIZIV/INAMI)
Belgium's primary care is primarily funded through the National Institute for Health and Disability Insurance (RIZIV/INAMI), which manages the compulsory health insurance system. This is financed through: Social Security Contributions: Paid by employees, employers, and self-employed individuals. Government Subsidies: Additional funding is provided by federal and regional governments.
Coverage of Primary Care Services: The system reimburses most costs related to general practitioners (GPs), dentists, physiotherapists, nurses, and other primary care providers. Reimbursement rates vary but are generally high, ensuring most services are affordable.
2. Fee-for-Service Payments
GP Remuneration: GPs are typically paid on a fee-for-service basis, meaning they charge patients for each consultation or procedure performed. Patients pay the GP directly and are reimbursed by their health insurance (sickness fund) for a significant portion of the cost. The remaining co-payment (remgeld / appelée ticket modérateur) is paid by the patient.
Third-Party Payer System (Derde Betalersregeling): For certain vulnerable populations, such as low-income individuals or those with chronic conditions, GPs can use the third-party payer system. Under this system, the patient only pays the co-payment directly, and the GP is reimbursed by the sickness fund for the rest.
3. Global Medical File (Globaal Medisch Dossier / Dossier Médical Global)
Patients are encouraged to register with a specific GP by creating a Global Medical File (GMF). This file allows the GP to coordinate the patient’s care and ensures continuity.
By registering, patients benefit from: Reduced co-payments for GP visits (typically 30% less). Better care coordination.
GPs receive an annual lump-sum payment from RIZIV/INAMI for managing each patient’s GMF, in addition to their fee-for-service payments.
4. Patient Co-Payments (Remgeld / Appelée ticket modérateur)
Patients are required to pay a small co-payment for primary care services. The amount depends on: The type of service. Their insurance status. Whether they benefit from preferential reimbursement schemes (e.g., low-income individuals, those with chronic illnesses).
Preferential reimbursement patients (with verhoogde tegemoetkoming/intervention majorée) pay a reduced or no co-payment.
5. Supplementary Insurance
Many Belgians also opt for private supplementary insurance to cover costs not fully reimbursed by the public system, such as alternative therapies, additional dental care, or non-covered services.
6. Regional and Local Funding
Regional governments and municipalities sometimes fund specific primary care initiatives, such as preventive care programs or health centers in underserved areas.
7. Primary Care Networks
In recent years, Primary Care Zones (Zorgzones/Bassins d'aide et de soins) have been developed to improve coordination among primary care providers and ensure better accessibility.
These networks are supported by government funding and aim to integrate GPs, nurses, social workers, and other professionals to provide holistic care.
8. Community Health Centers (Wijkgezondheidscentra/Maisons Médicales)
Community health centers are an alternative to the fee-for-service model and are funded through capitation payments (a fixed amount per patient per year, regardless of how many services they use).
These centers often cater to low-income or vulnerable populations and provide multidisciplinary care (e.g., GPs, nurses, physiotherapists, and social workers).

Hospitals

In Belgium, hospitals are funded through a combination of mechanisms that include public funding, social security contributions, and patient payments.
How hospital funding works:

1. Public Funding and Social Security
National Health Insurance (RIZIV/INAMI): The core of the funding system comes from Belgium's compulsory health insurance, managed by RIZIV/INAMI (National Institute for Health and Disability Insurance). This is financed through social security contributions paid by employees, employers, and self-employed individuals. Federal and Regional Governments: The federal government plays a key role in allocating budgets for hospital care. Regions also have responsibilities for infrastructure, hospital planning, and specific health services, such as preventive care.
2. Activity-Based Financing
Hospitals receive funding based on the care they provide. This is typically activity-based and depends on: Admissions and Treatments: Hospitals are reimbursed for services, medical procedures, and treatments provided to patients. Diagnosis-Related Groups (DRGs): Payments are sometimes tied to DRGs, which categorize patients based on their diagnosis, procedures, and expected resource use.
3. Patient Contributions
Patients pay a co-payment (known as a remgeld / appelée ticket modérateur) for their hospital stays and services. The amount varies depending on the type of service, patient income, and insurance status. Vulnerable groups, such as low-income individuals or those with chronic illnesses, benefit from reduced co-payments or exemptions through preferential reimbursement schemes (verhoogde tegemoetkoming or intervention majorée).
4. Hospital Financing System (BMF)
The Budget for Financial Means (BMF) is a key mechanism for hospital financing. Hospitals receive a budget based on: Fixed costs (e.g., infrastructure, salaries of certain staff like nurses). Variable costs linked to patient activity and medical interventions.
5. Specialist and Physician Reimbursement
Physicians working in hospitals are typically independent and are paid through a fee-for-service system. They receive a portion of the fees charged for medical procedures and consultations, which are reimbursed through health insurance.
6. Private and Supplementary Insurance
Many Belgians have supplementary private health insurance to cover additional costs, such as private rooms or services not fully reimbursed by public insurance.
7. Capital and Infrastructure Funding
Regional governments are primarily responsible for funding hospital infrastructure and capital investments. This is separate from operational funding and is often allocated through grants or subsidies.

References

• Belgian Social Security Office
• Belgian Health Care Knowledge Centre (KCE)
• Federal Public Service (FPS) Health, Food Chain Safety and Environment (FPS)
• Institut national d'assurance maladie-invalidité (INAMI)
• Banque Nationale de Données Diagnostic médical/Soins & coût

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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.
Private email: pvosta at gmail dot com

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