Financial accessibility

An effective health system should be financially accessible to as many people as possible. If people have to restrict or postpone necessary care or treatments due to cost or have to give up on other basic needs to pay for healthcare, the healthcare system can be said to be financially inaccessible. This issue is all the more problematic because interrupting or delaying a treatment can cause the patient’s health to deteriorate further, resulting in higher costs for the individual and for the system down the line. Households with low incomes are most likely to struggle with affordable access to healthcare

In this section, we will focus on the following indicators of financial accessibility:

• Coverage by the compulsory health insurance (A-1)
• Households’ out-of-pocket payments (A-2 to A-5)
• Postponing of medical/dental care for financial reasons (A-6, A-7)
• Access to conventioned healthcare professionals working at negotiated official fees (A-8, A-9)

Indicators on financial accessibility

ID	Indicator	Score	BE	EU-14	EU-27	Year
A-1	Compulsory health insurance coverage (% of the population entitled to compulsory insurance)		99.1%	99.9%	98.4%	2022
A-2	Out-of-pocket (OOP) payments (% of current expenditure on health)		17.9%	16.5%	18.2%	2021
A-3 (ex A-10)	Out-of-pocket (OOP) medical spending (% of final household consumption)		3.7%	2.9%	2.9%	2021
A-4 (ex EQ-5)	Households facing catastrophic out-of-pocket payments (% of respondents, HBS)		5.2%	4.3% (2018) [BE: 3.8%]	6.5% (2018) [BE: 3.8%]	2020
A-5 Nieuw	Out-of-pocket (OOP) payments for hospital care (% of total hospital care expenditures (excluding budgetary twelfths))		17.6%			2021
A-6 (ex-A-4)	People with self-reported unmet needs for medical examination due to financial reasons (% of respondents, EU-SILC)		0.9%	1.2%	0.9%	2022
A-7 (ex-A-4)	People with self-reported unmet needs for dental examination due to financial reasons (% of respondents, EU-SILC)		2.5%	3.3%	2.6%	2022
A-8 Nieuw	Volume of outpatient activity done by “conventioned” physicians (i.e. physicians acceding to the agreement on national tariffs) (% of outpatient consultations/contacts with practicing physicians)	GP: Specialist:	87.3% 44.0%			2021 2021
A-9 Nieuw	Volume of outpatient activity done by “conventioned” dentists (i.e. dentists acceding to the agreement on national tariffs) (% of outpatient consultations/contacts with practicing dentists)		26.3%			2021

 

Link to the full synoptic table and the report

Healthcare insurance status of the population (A-1)

Belgium has a compulsory health insurance system which, in theory, covers all individuals who have their legal residence in the country (“universal coverage”) regardless of their status: employees, self-employed workers, civil servants, unemployed or disabled people, pensioners, students and foreign nationals who have their legal residence in Belgium are all eligible, as well as all their dependents (e.g. children). To benefit from it, they need to be registered with a sickness fund of their choice. People with sufficient professional income (and some people with a replacement income, e.g. pensioners) are required to contribute to the health insurance system through social security payments.

Some specific vulnerable groups are not covered by the compulsory health insurance (undocumented migrants, asylum seekers in certain circumstances, homeless persons in certain circumstances, …), but have access to a more restricted set of health services (known as “urgent medical assistance”). No good data exist to capture the size of the population groups without coverage and they are not included in the analysis.

This indicator measures the percentage of the population that is fully compliant with administrative and financial requirements (and thus covered by the compulsory insurance) among those affiliated with a sickness fund.

Results

• In 2022, the compulsory health insurance covered nearly all of the Belgian population (99.1%). A small share of the population still struggles to comply with all administrative hurdles. It has remained stable between 2010 and 2022.
• Differences between population subgroups are limited, with slightly lower coverage among males (98.8% in 2022), younger adults (age group 20-39, 98.0%), and people living in Brussels (98.7%).
• Most EU countries, including Belgium, report (near) universal population coverage, although it is unclear how reliable and comparable these data are.

Link to technical datasheet and detailed results

Households’ out-of-pocket expenses (A-2 to A-5)

The Belgian compulsory public health insurance system covers a wide range of services with the costs of these services shared between the patient, the compulsory public health insurance and sometimes an additional voluntary health insurance. Out-of-pocket (OOP) payments are the expenditures borne directly by a patient when using healthcare because public or voluntary health insurance does not cover the (full) cost of the healthcare good or service. They consist of co-payments, supplements (balance/extra billing) and direct payments for non-covered goods and services.

OOP payments affect some population groups more than others because they have more health costs and/or less resources and can therefore be a barrier to accessing health services. Several protection mechanisms have been put in place to reduce (increased reimbursement) or cap (maximum billing, known as maximumfactuur/maximum à facturer) co payments for low income households, chronic care users and individuals with high healthcare expenditures.

This set of indicators measures the share of healthcare costs which is not covered by the compulsory health insurance and is, therefore, directly charged to patients as well as its financial impact on household resources. It includes:

• OOP payments, as a percentage of current expenditure on health (A-2)
• OOP payments, as a percentage of final household consumption (A-3)
• Share of households facing catastrophic OOP payments (A-4)
• OOP payments for hospital care, as a percentage of hospital care expenditure (A-5)

Results

Out-of-pocket (OOP) payments, as a percentage of current expenditure on health (A-2) and as a percentage of final household consumption (A-3)

• Total OOP payments increased by 40% between 2010 and 2019, before dropping strongly in 2020 due to lockdowns and to the postponement of non-urgent care during the COVID 19 pandemic. They rebounded in 2021, but remained below the level of 2019.
• Official co-payments also increased, but not as fast as OOP payments. In 2021, they made up one fifth of OOP payments.
• Overall, the share of OOP payments in total health expenditure has been slightly declining over time, from just under 20% in 2010 to just under 18% in 2021. This percentage is higher than in neighbouring countries.
• The share of OOP payments in total health expenditure varies considerably by type of health care. It is particularly high for dental care and medical products (e.g. glasses, hearing aids, etc.).
• After remaining fairly stable around 3.9% between 2010 and 2019, the share of OOP payments in final household consumption fell to 3.6% in 2020. For this whole period, figures remained above EU averages and twice to three times as high as in neighbouring countries.

Link to technical datasheet and detailed results

Households facing catastrophic OOP payments (% of respondents, house budget survey) (A-4)

Households’ resources typically go first to basic needs such as food, housing and utilities, especially when money is tight. The amount that remains after those basic needs are covered is known as the “capacity to pay” (for healthcare). By charging costs directly to households, OOP payments may lead to financial hardship for people using healthcare.

Financial hardship linked to care use is measured by two indicators: catastrophic health spending and impoverishing health spending. OOP payments are considered catastrophic when they exceed 40% of the capacity to pay, and impoverishing when they exceed the capacity to pay.

• In 2020, 5.2% of Belgian households faced catastrophic OOP payments, of which 1.1% were impoverished.
• Catastrophic OOP payments more frequently affected poor households and households with a low-educated, inactive or unemployed head. They were also more common in Brussels (6.7%) than in Wallonia (5.3%) or Flanders (4.8%).
• Medical products, physiotherapy/rehabilitation and dental care were important drivers of catastrophic spending in 2020, while spending on inpatient and outpatient care was lower than usual due to lockdowns and the postponement of non-urgent care during the COVID-19 pandemic.
• Before the pandemic, the percentage of households facing catastrophic OOP payments in Belgium (3.8% in 2018) was below the EU-averages, but higher than in neighbouring countries.

Link to technical datasheet and detailed results

Out-of-pocket (OOP) payments for hospital care, expressed as a percentage of total hospital care expenditure (A-5)

In hospital, OOP payments consist of co-payments, supplements charged on top of official fees, and direct payments for non-covered services, equipment, medications, etc. Supplements and direct payments can be set freely by hospitals and may represent a much greater financial burden than official co-payments; they can considerably increase the cost of a hospital stay. Moreover, normal financial protection mechanisms like increased reimbursements or maximum billing do not apply to these additional costs, which increases the risk that vulnerable patients might not be able to afford the care they need. Those costs are, however, often covered in part or in full by voluntary health insurance… for those who can afford this additional coverage.

Since 2010, several laws have been passed to limit supplements or even prohibit them altogether in specific situations. Currently, they can only be charged to patients who explicitly request a single-occupancy room.

• The share of OOP payments in total hospital care expenditures declined from 19.0% in 2018 to 17.6% in 2021. To a large extent, this is related to a shift from inpatient care with higher OOP payments to one-day admissions (where patients don’t stay overnight) with lower OOP payments. For one-day admissions, the share of OOP payments also decreased over time.
• The share of supplements in total OOP payments increased from 67% in 2018 to 69% in 2021. More than 70% of those supplements were fee supplements; this category accounted for nearly half of all OOP payments and was the only one that increased over time.
• Hospital OOP payments were higher in Brussels both for inpatient care and one-day hospitalisations, and somewhat lower in Flanders.
• In 2021, OOP payments for inpatient stays amounted to €660 on average (€206 for co-payments and €454 for supplements and direct payments). For one-day admissions, this amount was €110 on average (€33 for co-payments and €78 for supplements). There was, however, considerable variation depending on e.g. the hospital, the type of room (single-occupancy or not), the right to increased reimbursement, etc.
• During the COVID-19 pandemic, public spending on hospital care dropped by 6% and OOP payments by 16%, which reduced the share of OOP payments in total hospital expenditure from 18.6% in 2019 to 17.1% in 2020. This was followed by a rebound to 17.6% in 2021.

Link to technical datasheet and detailed results

People with self-reported unmet needs for medical (A-6) or dental care (A-7) due to financial reasons (% of respondents, EU-SILC)

When confronted with high OOP payments, some low-income households may choose to use the care they need and manage to cover catastrophic expenses, while others may choose to delay or forego care. There is only limited information on care that is needed but not used, so we have to rely on survey data to give us an idea of the number of people who actually experience the cost of healthcare as problematic to the point of giving up on necessary examinations or procedures.

In EU-SILC, the main source of data for these two indicators, an unmet need for medical/dental care is defined as the occurrence of at least one situation when the person did not receive a medical/dental examination or treatment for a health problem when s/he really needed it.

Results

People with self-reported unmet needs for medical care due to financial reasons (A-6)

• The percentage of respondents reporting unmet needs for medical care increased from 1.4% in 2011 to 2.2% in 2014-2016, then decreased gradually to 0.9% in 2022.
• The likelihood of experiencing unmet healthcare needs due to financial reasons was higher in low-income households (4.1% in 2011, 7.7% in 2016 and 2.6% in 2022), in people with lower educational attainment and in working-age people who did not work due to unemployment or other reasons, while retired individuals had lower rates of unmet needs. No unmet needs were found in the richest income quintile
• There were regional differences in the rate of unmet needs (1.9% in Brussels, 2.0% in Wallonia and 0.2% in Flanders in 2022), which can be (partly) explained by differences in income, education, age, etc. of the population.
• Up until 2021, the rate of unmet medical needs for financial reasons in Belgium was above the European average. It plunged below EU-14 and EU-27 averages in 2022, but there is still room for improvement.

Link to technical datasheet and detailed results

People with self-reported unmet needs for dental care due to financial reasons (A-7)

• The percentage of respondents reporting unmet needs for dental care increased from 2.9% in 2011 to 3.8% in 2014 and 3.7% in 2016, then gradually fell to 2.5% by 2022.
• The likelihood of experiencing unmet needs for dental care due to financial reasons was higher in low-income households (7.6% in 2011, 11.5% in 2014 and 2016 and 6.6% in 2022), and almost non-existent in the most affluent. It was particularly high in working-age people who were unemployed (8.6% in 2022) and, to a lesser extent, in those who did not work for other reasons (e.g. people with a disability or incapacity, stay-at-home parents, etc. – 4.9% in 2022). Rates were somewhat higher in people with lower educational attainment and somewhat lower among retired individuals.
• In 2021, the rate of unmet needs for dental care was 2.7% in Brussels, 3.8% in Wallonia and 1.3% in Flanders, possibly due to differences in income, education, age, etc. of the population.
• The rate of unmet dental care needs for financial reasons in Belgium has been in line with the European average since 2016. Despite an improving trend in recent years, a wide gap remains between the poorest and richest household.

Link to technical datasheet and detailed results

Volume of outpatient activity done by conventioned physicians (A-8) or dentists (A-9) (% of outpatient consultations/contacts with practising physicians)

Once a year (normally), the representatives of Belgian healthcare providers come to an agreement with the health insurance payers (“mutualities”) around the maximum fees that can be charged for individual health services during a certain timeframe. This gives patients a degree of security by allowing them to know in advance how much their consultations and treatments will cost, with no supplements. However, only healthcare providers who have chosen to accept the agreement are bound by those official prices. They are offered the opportunity to opt out of each new agreement; however, those who accept it receive certain social benefits.

Practitioners who accept the agreement, so-called conventioned practitioners, commit to not to charging fee supplements in the context of their regular practice. Non-conventioned practitioners are allowed to charge fee supplements on top of the official tariff at their discretion. Partially conventioned providers can charge fee supplements at their discretion, but only during a limited, strictly regulated number of time slots (e.g. they might choose to offer evening consultations from 5 to 9 p.m. two days a week, and charge more for those late time slots). In our analysis, partially conventioned and non-conventioned practitioners have been included in the same category.

As the amount paid for/reimbursed by the compulsory health insurance is generally the same irrespective of the convention status of the healthcare practitioner (with a few exceptions, such as physiotherapy), patients who attend partially or non-conventioned practitioners risk to pay more. Hence, the availability of conventioned healthcare professionals improves price transparency, gives the patient price certainty and contributes to affordable access. However, in some regions and for some types of care (e.g. dermatology, dental care...), they are unfortunately in short supply.

Results

Volume of outpatient activity done by conventioned physicians (A-8)

• In 2021, 87.1% of GPs with 500 or more outpatient consultations per year (“active GPs”) were conventioned.
• The share of ambulatory activity done by conventioned GPs was already high and further increased from 83.1% in 2012 to 87.3% in 2021. It was higher in Flanders (90.1%) than in Wallonia (84.4%) and Brussels (71.2%). Even so, 10% of GP consultations for beneficiaries of increased reimbursement were performed by a non-conventioned practitioner.
• Less than half of the consultations of medical specialists are performed by conventioned practitioners (44.0% in 2021), with a slight declining trend over time. In 2021, more than one third of specialist consultations for beneficiaries of increased reimbursement were performed by a non-conventioned practitioner.
• In 2021, 56.4% of specialists with 500 or more outpatient consultations per year (“active practitioners”) were conventioned. However, this group includes more doctors with limited professional activity, which explains why they account for less consultations overall.
• The share of activity done by conventioned specialists varied considerably between medical specialties, ranging from 11.1% for dermatologists to 91.1% for oncologists in 2021.

Link to technical datasheet and detailed results

Volume of outpatient activity done by conventioned dentists (A-9)

• The share of ambulatory activity by conventioned dentists has declined from 34.3% in 2012 to 26.3% in 2021, which means only a little over 1 in 4 patient contacts was performed by a conventioned dentist. It was substantially lower in Flanders (16.6%) than in Wallonia (40.4%) and Brussels (45.5%). In Flanders, non-conventioned dentists totalled almost 4 times as many contacts as conventioned dentists.
• In 2021, the share of ambulatory activity done by conventioned dentists ranged from a mere 1.1% for orthodontists and 1.9% for periodontists to 72.5% for stomatologists, over 29.1% for general dentists.
• In 2021, beneficiaries of increased reimbursement were twice as likely as others to consult a conventioned practitioner (43.6% vs 22.9%). Even in this vulnerable group, however, over one third of contacts with dentists were performed by a non-conventioned practitioner.

Link to technical datasheet and detailed results