Preventive care refers to healthcare interventions which aim either to avoid the occurrence of a disease (primary prevention, e.g. vaccination) or to identify it as early as possible in order to take action to mitigate its negative effects (secondary prevention, e.g. cancer screening). As opposed to curative care, which is implemented once a disease is present, preventive care typically targets non-symptomatic and often healthy individuals with the purpose of keeping them as healthy as possible.
Preventive measures can be undertaken both by individuals (keeping a healthy diet, exercising, avoiding harmful behaviours like smoking, etc.) and by public authorities (organising screening campaigns, vaccinations, health education, etc.). We will focus solely on this second aspect, as individual behaviours go beyond the scope of this report on the performance of the healthcare system; however, a number of them are addressed in the “Determinants of Health” section of the Health Status report.
In Belgium, preventive care is mostly organised at the level of the federated entities, with some elements remaining under the responsibility of the Federal State. Cancer screening programmes, for instance, are set up by the regions, but the actual tests (cervical smear test, mammograms…) are reimbursed by the national health insurance (NIHDI).
This section includes a number of indicators on primary prevention and more specifically on vaccination (P-1, P-12, P-2, P-3, P-14, P-4, P-5) and dental care (P-11); other indicators relating to primary prevention can be found in the sections on Equity (EQ-7, preventive contact with a dentist) and Resilience (R-10 and R-11, Covid-19 vaccination). We will also examine preventable mortality, i.e. deaths that can be avoided through public health and primary prevention interventions (P-13). Secondary prevention will be addressed through a number of indicators on cancer screening (P-6 to P-9).
a Excluding population residing in homes for the older people and nursing homes (no reliable data). b Measles cases have been strongly influenced by the pandemic and the control measures; there is still a risk of measles outbreaks in Belgium. c Within the last two years for breast and colorectal cancer screening, within the last three years for cervical cancer screening. d Regular contacts is defined as patients who have at least two contacts in two different years during the last three years.
Vaccination in children and teenagers (P-1, P-12, P-2, P-3, P-14)
Vaccination is one of our most powerful and cost-effective tools for primary prevention. Beyond the individual protection it confers, it can also limit or prevent the circulation of infectious diseases as long as coverage (i.e. the percentage of the population that is vaccinated) is sufficient, which means even people who have not been vaccinated themselves have a much lower likelihood of getting ill. This is known as group immunity. Critical thresholds and target rates for various vaccinations have been defined both at a Belgian and at an international level.
Like most countries, Belgium has officially recommended immunisation schedules for infants, children and teenagers, though only polio vaccination is currently compulsory. The vaccination programmes are organised by the federated entities (regions/communities); most vaccines are offered free of charge.
Its importance for group immunity makes vaccination coverage for recommended vaccines a highly relevant indicator within preventive care. This section includes indicators on the following vaccinations:
- Complete 4-dose poliomyelitis vaccination in infants (P-1)
- Complete 4-dose diphtheria, tetanus and pertussis (DTP) vaccination in infants (P-12)
- Measles (MMR) vaccination in infants (1st dose) (P-2a) and teenagers (2nd dose) (P-2b)
- Complete 3-dose pneumococcus vaccination in infants (P-3)
- Human papillomavirus (HPV) vaccination in teenagers (P-14)
Results
Source: Official national estimates (Institute of Public Health), computed from the weighted average of the regional survey results
| Vaccine and dose | Flanders 2016 | Brussels 2015 | Wallonia 2015 | Flanders 2020 | Brussels 2019 | Wallonia 2019 |
| Polio 4 | 93.60% | - | 92.90% | 94.20% | 92.80% | 94.30% |
| DTP 4 | 93.00% | - | 92.90% | 94.20% | 92.60% | 94.00% |
| Pneumococcus (PCV) 3 | 94.90% | - | 92.90% | 95.40% | 91.70% | 92.00 |
| MMR 1 | 96.20% | - | 95.60% | 96.10% | 94.80% | 96.50% |
| MRR 2* | 87.40% | 75.00% (2015-2016) |
75.00% (2015-2016) |
89.20% | 51.1%** (2020-2021) |
51.1%** (2020-2021) |
| HPV 2* (girls) | 89.50% | 36.10% (2016-2017) |
36.10% (2016-2017) |
84.30% | 50.20% (2019-2020) |
50.20% (2019-2020) |
| HPV 2 (boys) | - | - | - | 77.30% | 0.45 | 45.40% |
| HPV 2* (girls and boys) | - | - | - | 80.70% | 0.48 | 47.60% |
Green: reaching the critical threshold and national target; Yellow: reaching critical threshold but not national target, or very close to critical threshold; Red: far from the target/threshold
*the method differs by region (school survey for Wallonia and Brussels, survey in general population for Flanders)
**this study was done with another sample and methodology than the previous years in the context of change of vaccination schedule and pandemic; results are not representative
- Vaccination coverages for all vaccines included in the basic infant vaccination schedule keep improving and are now well above 90% throughout Belgium.
- For measles vaccination, however, coverage for the second dose remains well under the 95% target in all three regions. Flanders is closest to this threshold with 89.2%; the latest figures for Brussels and Wallonia seem alarmingly low (51.1%), but are probably not representative due to various changes and external factors.
- HPV vaccination in girls remains too low across Belgium, particularly in Brussels and Wallonia where it is still barely above 50% (but increasing steadily). HPV vaccination in boys was launched in 2019 with encouraging rates of 77.3% in Flanders and 45.4% in Wallonia and Brussels.
Link to the technical sheet and detailed results
Incidence of measles (P-5)
Measles is a highly communicable viral disease, which causes complications in roughly 30% of patients and very severe complications (resulting in death or permanent brain damage) in 4/1000 cases in developed countries. European countries have committed to lower its incidence rate to less than 1 case per million inhabitants.
Incidence rates have indeed plummeted across Europe following the introduction of vaccination in the official schedule (which, in Belgium, occurred in 1985). Nonetheless, outbreaks are still regularly reported in population subgroups with lower levels of immunity, highlighting the need to continue improving vaccination coverage. In recent years, Belgium has experienced fairly substantial epidemics in 2011, 2017 and 2019.
The Belgian Superior Health Council currently recommends a 95% coverage for both doses of the measles vaccine. As mentioned above in the section on vaccination in children and teenagers, his target is reached for the first dose (administered in infancy); but not for the second dose (initially given at 10-12 years old, currently around 7-9 years old).
Results
- 47 cases of measles were reported in Belgium in 2020 and only 7 in 2021, compared to 480 cases in 2019. As a result, the disease was declared eliminated in our country in 2020. There is little doubt, however, that the restrictions linked to the Covid-19 pandemic greatly contributed to this spectacular improvement, and reaching vaccination coverage targets for both doses remains crucial to prevent new outbreaks.
- The target incidence rate of less than 1 case per million inhabitants was reached in all EU countries in 2020 (with the exception of Cyprus). Again, this is probably closely linked to the pandemic.
Link to the technical sheet and detailed results
Influenza vaccination in people aged 65 years and older (P-4)
Immunisation against seasonal influenza is considered the most effective preventive measure to reduce the number and severity of influenza virus infections. In Belgium, it is currently highly recommended in a number of population groups with an increased risk of developing a severe infection (“priority groups”), including all individuals aged 65 years and older as well as those living in care facilities.
The WHO recommends aiming for a 75% vaccination rate in older people, which has become even more crucial in the Covid-19 era not only to avoid a flu epidemic on top of the coronavirus pandemic, but also because it is thought that influenza vaccination might offer some degree of protection against Covid-19.
The proportion of people aged 65 years and older who were vaccinated against influenza over the past year is an important indicator of the accessibility of preventive care. Please note this indicator is based on NIHDI reimbursement data and excludes older people residing in care facilities, which means it might underestimate the coverage rate.
Results
- In Belgium, vaccination rates against influenza among individuals aged 65 years and older living at home have slightly decreased between 2010 and 2019 (from 57.7% to 52.9%), remaining well under the 75% target set by the WHO but above both EU-14 and EU-27 averages.
- During the Covid-19 pandemic, there was a sharp increase (+17%) in 2020, but the vaccination rate fell back to 57% in 2021. This last figure was lower than the EU-14 average (62.8%), but higher than the EU-27 average (43.2%).
- In 2021, influenza vaccination rates for people aged 65 years or older were higher in Flanders (65%) than in Wallonia (49%) and Brussels (46%).
- Overall, influenza vaccination rates in older people are slightly higher in women and tend to increase with age, except in the oldest age group (90 years or older).
- In this population, the vaccination rate is slightly lower among people entitled to increased healthcare reimbursements, which might reflect an accessibility problem.
Link to the technical sheet and detailed results
Data source: IMA - AIM data, KCE calculation
Note: People residing in institution are excluded from the analysis (see section limitation in technical fiche for details).
Data source: IMA - AIM data, KCE calculation.
Note: People residing in institution are excluded from the analysis (see section limitation in technical fiche for details).
Data source: OECD health data 2023
Data source: OECD health data 2023
Cancer screening (P-6 to P-9)
Screening is a typical example of secondary prevention. It aims to identify a disease at a very early stage, when curative treatment is likely to achieve its best results – ideally a full recovery or, if this is impossible, a slower decline ensuring a longer and better life with less symptoms and complications. Screening can target various types of diseases in individual patients (e.g. close relatives of patients with a disease known to run in families, people with specific risk factors linked to lifestyle or exposure…) or in population groups (e.g. all people within a certain age range). Official screening campaigns often focus on cancers for which an early diagnosis is available and can make a substantial difference, and will typically target specific population groups. The indicators in this section all relate to cancers for which an official screening initiative exists, though some people also choose to be screened outside of these organised campaign (this is known as “opportunistic screening”): breast cancer, cervical cancer and colorectal cancer (see text box for more information).
Cancer of the cervix (the canal connecting the vagina to the uterus) is a relatively uncommon cancer which tends to affect younger women. Its main cause is a lingering infection by a sexually transmitted virus, known as human papillomavirus (HPV). While its overall prognosis is medium to poor, an accessible and completely harmless test (smear test) is available to detect cervical cancer at an early stage where it can still be cured. This smear test is reimbursed once every three years since 2013. In Flanders, an official screening program has been introduced that same year. Wallonia has no official screening programme yet, but a pilot project is currently running. However, in December 2022, the Minister of Health announced that women aged 30 to 64 years would soon be invited for a HPV test every five years instead of a smear test every three years for early detection of cervical cancer.
In Belgium, colorectal cancer (which affects the large intestine and/or the rectum) is currently the third most frequent cancer in both men and women. It is often lethal when detected at an advanced stage, but an effective screening test (faecal occult blood test or FOBT) is available and recommended by European guidelines in all individuals aged 50 to 74 years. A screening programme in this age group (with a test every other year) has been launched in Brussels and Wallonia in 2009 and in Flanders in 2013
Results
Participation in breast cancer screening (% of women aged 50-69) (P-6, P-7)
The indicators in this section measure the percentage of women 50 to 69 years old who take part in the organised screening (P-6) and the total percentage of women 50 to 69 years old who undergo a mammography, whether through the official programme or not (P-7); this way, we measure both the success of the organised programme and the coverage of mammographic screening in Belgium.
- In 2021, Belgium had a total coverage of 59% for breast cancer screening, well below the generally recommended target of 75%. This rate was highest in Flanders (65.8%), followed by Wallonia (49.2%) and Brussels (48.0%).
- Participation in organised breast cancer screening varies wildly between regions, with rates of 49.2% in Flanders, 9% in Brussels and a mere 4% in Wallonia in 2021 (national average 31.5%).
- Aside from a slight dip during the COVID-19 pandemic, participation rates have varied very little since 2010 both for organised campaigns and overall breast cancer screening coverage.
- Although organised screening is offered free of charge, participation in breast cancer screening is lower in women with a lower socio-economic status (i.e. those entitled to increased reimbursement).
- In 2021, breast cancer screening coverage in Belgium remained just under the EU-14 average of 61.4%, but above the EU-27 average of 54.5%. In Flanders, however, coverage was higher than both EU-14 and EU-27 averages.
Link to the technical sheet and detailed results
Data source: IMA - AIM data
Data source: IMA - AIM data
Data source: OECD health data
Data source: OECD health data, for Belgium IMA-AIM atlas.
Data source: IMA - AIM atlas (2010-2015)
Note: mammogram = organised + opportunistic screening + diagnostic test
Data source: IMA - AIM data (2016-2021); IMA - AIM atlas (2010-2015)
Note: mammogram = organised + opportunistic screening + diagnostic test
Participation in cervical cancer screening (% of women aged 20-69 years) (P8)
- In 2021, Belgium had a coverage rate just under 54% for cervical cancer screening among women aged 20 to 69 years (57% after excluding the women who could not be tested for medical reasons from the calculation). This percentage was similar across regions (52%).
- In Flanders, the coverage rate in the group targeted by the organised screening programme (women aged 25 to 64 years, rather than 20 to 69 years) was 63% in 2021.
- In 2021, the cervical cancer screening rate in Belgium was similar to the EU-27 average (53%), but lower than the EU-14 average (60%). This is below the 70% rate considered acceptable in European guidelines, and well below the 85% rate considered desirable.
Link to the technical sheet and detailed results
Data source: CvKO
Participation in colorectal cancer screening (% of people aged 50-74) (P9)
- In 2021, the total colorectal cancer screening rate in Belgium was just under 54%, which is above the 45% rate considered acceptable in European guidelines. Organised programmes accounted for 32.6% of the total, opportunistic screening for just over 21%.
- This coverage rate was twice as high in Flanders (66%, which exceeds the 65% coverage rate considered desirable in European guidelines) as in Brussels and Wallonia (33%).
- In 2021, the Belgian coverage rate was lower than the EU-14 average of 54.6%, but higher than the EU-27 average of 45.7%.
Link to the technical sheet and detailed results
Data source: OECD health data 2023
Regular contacts with a dentist (P-11)
Oral health issues like bad teeth, gum disease or less common problems like oral cancers and birth defects can greatly complicate daily activities like eating, talking and social interactions by causing pain, discomfort or even simply embarrassment. While this is of course important in itself, some oral issues have also been shown to influence other aspects of health – severe gum disease, for instance, is linked to a higher risk of cardiovascular and respiratory issues.
Fortunately, most common oral disorders can easily be treated or even prevented through simple oral hygiene measures like teeth brushing and flossing. Regular dental check-ups provide an opportunity to diagnose and treat any problems that arise before they become too serious, to perform preventive procedures like plaque and tartar removal and to educate and advise patients on dietary matters and proper oral hygiene.
Socio-economically disadvantaged groups struggle more than others with access to oral healthcare and maintaining oral health. This makes regular contacts with a dentist (defined as at least two contacts in two different years over the last three years) a valuable indicator of the accessibility of preventive care.
Results
- The share of the Belgian population aged 3 years or older who had regular contacts with a dentist increased from 48.5% in 2010 to 55.7% in 2019. There was a slight decrease in 2020 (54.4%) and 2021 (53.8%), probably as a result of dental services disruption during the Covid-19 pandemic.
- In 2021, the highest attendance rates were observed in the 5-14 (67%) and 15-17 age groups (71%), where most preventive and restorative procedures are free. The lowest rates were observed in children under 4 years old (16%) and people aged 75 years or older (39%).
- In 2021, the regular dental attendance rate was higher in Flanders (58%) than in Wallonia (49%) and Brussels (47%). This is in line with the results of the previous years.
- In 2021, the regular dental attendance rate was considerably lower in people entitled to increased healthcare reimbursements (42%, vs 57% for people without increased reimbursements).
Link to the technical sheet and detailed results
Data source: IMA-AIM Atlas
Data source: IMA-AIM Atlas
Preventable mortality (P-13)
The term “preventable mortality” refers to premature (untimely) deaths that could have been avoided through effective public health and primary prevention interventions – i.e. by acting on factors that are known to influence the risk of developing health issues (like smoking, pollution, living conditions, excessive drinking, diet, etc.) or by taking preventive measures against infectious diseases (e.g. vaccination, promoting measures to avoid spreading disease, etc.). This indicator gives us an idea of how effective our health care system and health policies are at keeping people healthy.
To assess this, we have examined how many people (per 100 000 population) have died before the age of 75 from a cause that could have been prevented (according to a list of preventable death causes defined by Eurostat/OECD).
A closely related indicator on treatable mortality (QE-8), i.e. premature mortality that could have been avoided not through prevention but through timely and adequate treatment, can be found in the section on effectiveness of care, a subdimension of quality. It is worth noting there can be a certain degree of overlap between those two types of mortality, as some health issues can be effectively prevented as well as effectively treated and the premature deaths they cause can reflect a failure on both counts. However, those deaths will only be counted once, either as “preventable” or “treatable”; if a given cause is considered to fall under both categories, half of the associated deaths will be attributed to each.
Results
- There are clear regional differences in preventable mortality, with higher rates in Wallonia and Brussels and substantially lower figures in Flanders.
- Preventable mortality is consistently more than twice as high in men as in women, particularly in Brussels.
- An increase in preventable mortality has been registered everywhere in Belgium and for both sexes between 2019 and 2020. This increase is likely to be due entirely to preventable COVID-19 deaths as, before the start of the pandemic, figures had been improving in men and remained stable in women since 2010.
- In 2020, Belgium had the highest preventable mortality rate of all EU-14 countries.