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How Equitable Is the Belgian Health System?

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How Equitable Is the Belgian Health System? KCE REPORT 334 HEALTH SYSTEM PERFORMANCE ASSESSMENT: HOW EQUITABLE IS THE BELGIAN HEALTH SYSTEM? EQUALITY EQUITY 2020 www.kce.fgov.be KCE REPORT 334 HEALTH SERVICES RESEARCH HEALTH SYSTEM PERFORMANCE ASSESSMENT: HOW EQUITABLE IS THE BELGIAN HEALTH SYSTEM? NICOLAS BOUCKAERT, CHARLINE MAERTENS DE NOORDHOUT, CARINE VAN DE VOORDE 2020 www.kce.fgov.be COLOPHON Title: Health System Performance Assessment: how equitable is the Belgian health system? Authors: Nicolas Bouckaert (KCE), Charline Maertens de Noordhout (KCE), Carine Van de Voorde (KCE) Project facilitator: Nathalie Swartenbroekx (KCE) External experts: Ri De Ridder (Dokters van de Wereld), Erik Schokkaert (KU Leuven), Niko Speybroeck (UCLouvain), Sigrid Vancoreland (Landsbond der Christelijke Mutualiteiten (LCM)), Toon Vanheukelom (KU Leuven), Rudi Van Dam (FOD Sociale Zekerheid – SPF Sécurité Sociale), Tom Van Ourti (Erasmus University Rotterdam, the Netherlands) Stakeholders: The following administrations and public institutions have been consulted throughout the duration of the project. At the federal level: • RIZIV – INAMI: Pascal Meeus • FOD Volksgezondheid – SPF Santé Publique: Pol Gerits, Veerle Vivet, Harun Yaras • FOD Sociale Zekerheid – SPF Sécurité Sociale: Dirk Moens, Rudi Van Dam • Sciensano: Brecht Devleesschauwer, Françoise Renard At the regional level: • Vlaamse Gemeenschap (Vlaams Agentschap Zorg en Gezondheid): Erik Hendrickx • Région wallonne (Direction générale opérationnelle des Pouvoirs locaux, de l’Action sociale et de la Santé et observatoire wallon de la santé): Anouck Billiet • Communauté Germanophone (Ministerium der Deutschsprachigen Gemeinschaft): Karin Cormann External validators: Hervé Avalosse (Alliance Nationale des Mutualités chrétiennes (ANMC)), Jon Cylus (European Observatory on Health Systems and Policies), Eddy van Doorslaer (Erasmus University Rotterdam, the Netherlands) Acknowledgements: Chris Brijs (Kruispuntbank van de Sociale Zekerheid (KSZ)), Cécile Camberlin (KCE), Danielle Croisiaux (Agence InterMutualiste – InterMutualistisch Agentschap), Brecht Devleesschauwer (Sciensano), Carl Devos (KCE), Stephan Devriese (KCE), Annelies De Schrijver (Statbel), Joeri Guillaume (Nationaal Verbond van Socialistische Mutualiteiten (NVSM)), Mélanie Lefèvre (KCE), Christian Léonard (Sciensano), Pascal Meeus (INAMI – RIZIV), Françoise Renard (Sciensano), Kelly Sabbe (Statbel), Xavier Van Aubel (RIZIV – INAMI) Reported interests: All experts and stakeholders consulted within this report were selected because of their involvement in equity in the Belgian health system. Therefore, by definition, each of them might have a certain degree of conflict of interest to the main topic of this report. Cover picture: Image adapted from Interaction Institute for Social Change (www.interactioninstitute.org). Artist: Angus Maguire (madewithangus.com) Layout: Ine Verhulst Disclaimer: • The external experts were consulted about a (preliminary) version of the scientific report. Their comments were discussed during meetings. They did not co-author the scientific report and did not necessarily agree with its content. • Subsequently, a (final) version was submitted to the validators. The validation of the report results from a consensus or a voting process between the validators. The validators did not co-author the scientific report and did not necessarily all three agree with its content. • Finally, this report has been approved by a majority of votes by the Executive Board. • Only the KCE is responsible for errors or omissions that could persist. The policy recommendations are also under the full responsibility of the KCE. Publication date: 15 December 2020 Domain: Health Services Research (HSR) MeSH: Financing, Personal; Insurance Coverage; Health Services Accessibility; Cost Sharing; Health Expenditures NLM Classification: W74 Language: English Format: Adobe® PDF™ (A4) Legal depot: D/2020/10.273/30 ISSN: 2466-6459 Copyright: KCE reports are published under a “by/nc/nd” Creative Commons Licence http://kce.fgov.be/content/about-copyrights-for-kce-publications. How to refer to this document? Bouckaert N, Maertens de Noordhout C, Van de Voorde C. Health System Performance Assessment: how equitable is the Belgian health system?. Health Services Research (HSR) Brussels: Belgian Health Care Knowledge Centre (KCE). 2020. KCE Reports 334. D/2020/10.273/30. This document is available on the website of the Belgian Health Care Knowledge Centre. KCE Report 334 Equity in the Belgian health system 1 TABLE OF CONTENTS LIST OF FIGURES ............................................................................................................................................... 4 LIST OF TABLES ................................................................................................................................................. 5 LIST OF ABBREVIATIONS ................................................................................................................................. 6 SCIENTIFIC REPORT............................................................................................................................ 8 1 INTRODUCTION .................................................................................................................................... 8 1.1 EQUITY VERSUS EQUALITY IN HEALTH AND HEALTHCARE ......................................................... 8 1.2 SCOPE AND OBJECTIVE OF THE REPORT ..................................................................................... 12 1.2.1 Health System Performance Assessment (HSPA) in Belgium .............................................. 12 1.2.2 Research questions and study approach .............................................................................. 12 1.3 DATA SOURCES ................................................................................................................................. 13 1.3.1 EU-SILC/IMA-AIM data .......................................................................................................... 14 1.3.2 Household Budget Survey data ............................................................................................. 16 1.4 LIMITATIONS ....................................................................................................................................... 16 1.5 OUTLINE OF REPORT ........................................................................................................................ 17 2 (IN)EQUITY IN THE DISTRIBUTION OF HEALTHCARE ................................................................... 17 2.1 WHAT DO WE KNOW ABOUT INEQUALITY AND INEQUITY IN HEALTHCARE USE FOR BELGIUM? SOME LESSONS FROM PREVIOUS RESEARCH ......................................................... 18 2.1.1 General practitioner and specialist services .......................................................................... 18 2.1.2 Dental care services ............................................................................................................... 20 2.1.3 Mental care services .............................................................................................................. 20 2.2 SELECTION OF INDICATORS ............................................................................................................ 20 2.3 DATA SOURCES AND SAMPLE ......................................................................................................... 22 2.4 METHODOLOGY – FROM (IN)EQUALITY TO (IN)EQUITY ............................................................... 25 2 Equity in the Belgian health system KCE Report 334 2.4.1 Poverty makes sick, sickness makes poor ............................................................................ 25 2.4.2 From (in)equality to (in)equity – how to proceed? ................................................................. 28 2.4.3 How to measure healthcare needs? A scenario analysis ...................................................... 30 2.4.4 How to report the results on inequity? ................................................................................... 32 2.4.5 Limitations .............................................................................................................................. 33 2.5 INEQUITY IN HEALTHCARE USE: RESULTS ................................................................................... 34 2.5.1 Increasing number of healthcare contacts and higher use for higher needs groups ............. 34 2.5.2 Needs-adjusted healthcare use by subgroup ........................................................................ 35 2.5.3 Systematic socioeconomic inequity ....................................................................................... 43 2.6 UNMET NEEDS FOR FINANCIAL REASONS .................................................................................... 47 2.6.1 Some lessons from previous research ................................................................................... 47 2.6.2 Self-reported unmet needs for medical and dental care in different subgroups of the population ............................................................................................................................... 49 2.6.3 Affordability of healthcare ...................................................................................................... 55 3 INEQUITY IN THE PAYMENTS FOR HEALTHCARE ........................................................................ 57 3.1 FINANCIAL HARDSHIP WHEN USING CARE ..................................................................................
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