July 2020 Inequalities in access to healthcare in Belgium Sophie Cès Rita Baeten © Observatoire social européen Inequalities in access to healthcare in Belgium Sophie Cès and Rita Baeten European Social Observatory This report was produced as part of the research agreement (2020-2021) between the European Social Observatory (OSE asbl) and the National Institute for Health and Disability Insurance (NIHDI), financed via article 56 (1) of the law on compulsory health and disability insurance (la loi relative à l’assurance obligatoire soins de santé et indemnités), coordinated on 14 July 1994. The facts and views expressed in this publication and any errors that remain are the sole responsibility of the authors. Referring to this publication: Cès, S. and Baeten, R. (2020), Inequalities in access to healthcare in Belgium. Brussels: European Social Observatory, July 2020, 184 p. 2 © Observatoire social européen Table of contents Executive summary ..................................................................................................... 7 Introduction: ambitions and scope .......................................................................... 11 Chapter 1. Theoretical background on access to healthcare ..................................... 14 1.1 Universality and equity ................................................................................................ 14 1.2 Factors influencing access to healthcare ........................................................................ 14 1.3 Definition of healthcare need ....................................................................................... 18 Chapter 2. Methodology ............................................................................................ 21 2.1 Statistical analysis of data on self-reported unmet needs for healthcare ........................... 21 2.1.1 The EU-Statistics on Income and Living Conditions (SILC) .................................... 21 2.1.2 The question on unmet needs for medical and dental care in the EU-SILC survey .. 22 2.1.3 Variables used in the quantitative analysis .......................................................... 24 2.1.4 Statistical analysis ............................................................................................ 24 2.2 Semi-structured interviews ........................................................................................... 25 2.2.1 Selection of interviewees ................................................................................... 25 2.2.2 Semi-structured interviews ................................................................................ 26 2.2.3 Thematic analysis ............................................................................................. 26 Chapter 3. Access to healthcare in Belgium: a review of literature ........................... 27 3.1 Self-reported unmet needs for healthcare ..................................................................... 27 3.1.1 Belgium compared to other EU countries ............................................................ 27 3.1.2 National surveys ............................................................................................... 33 3.2 Out-of-pocket expenses: Belgium compared to other European countries ........................ 35 3.2.1 Population coverage ......................................................................................... 36 3.2.2 The importance of out-of-pocket expenses ......................................................... 38 3.2.3 Self-reported financial burden of out-of-pocket expenditure ................................. 43 Chapter 4. Self-reported unmet needs for medical and dental care in Belgium: an in-depth analysis of the EU-SILC micro data ........................................................ 49 4.1 Self-reported unmet needs for medical care .................................................................. 49 4.1.1 Profile of persons with unmet needs in 2011 and 2017 ........................................ 49 4.1.2 Identifying the determinants of unmet medical needs in 2011 and 2017 ............... 54 4.2 Self-reported unmet needs for dental care .................................................................... 56 4.2.1 Profile of persons who declared unmet needs in 2011 and 2017 ........................... 56 4.2.2 Identifying the determinants of unmet dental care needs in 2011 and 2017 .......... 59 3 © Observatoire social européen 4.3 Conclusion of the analysis of the EU-SILC micro data on unmet healthcare needs ............. 60 Chapter 5. Hurdles for access to healthcare reported by interviewees ..................... 62 5.1 Who is most at risk of access problems due to costs? ..................................................... 62 5.1.1 People without mandatory health insurance coverage .......................................... 62 5.1.2 People in a precarious situation ......................................................................... 67 5.1.3 People on sickness leave ................................................................................... 68 5.1.4 People with a chronic condition .......................................................................... 69 5.1.5 People with frail mental health ........................................................................... 70 5.2 The financial hurdles identified per type of healthcare .................................................... 70 5.2.1 Primary care .................................................................................................... 73 5.2.2 Dental care ...................................................................................................... 77 5.2.3 Outpatient specialist care .................................................................................. 79 5.2.4 On-call services and emergency care .................................................................. 82 5.2.5 Medical-technical acts ....................................................................................... 83 5.2.6 Prescribed medicines ........................................................................................ 84 5.2.7 Medical devices ................................................................................................ 87 5.2.8 Outpatient mental health services ...................................................................... 88 5.2.9 Hospital care .................................................................................................... 89 5.2.10 Post-treatment after hospital discharge .............................................................. 94 5.3 Other hurdles ............................................................................................................. 96 5.3.1 Hurdles related to availability ............................................................................. 96 5.3.2 Hurdles related to acceptability .......................................................................... 98 5.4 Strengths and weaknesses of provisions to improve financial access to healthcare for vulnerable groups ................................................................................ 101 5.4.1 The increased reimbursement status ................................................................ 101 5.4.2 Measures for chronically ill patients .................................................................. 104 5.4.3 Interventions of the Public Centres for Social Welfare ........................................ 105 5.4.4 Interventions from other social services ............................................................ 110 5.4.5 Services provided by sickness funds and complementary health insurance........... 113 5.5 Potential explanations for the deterioration in access to healthcare ............................... 113 5.5.1 Shift from inpatient to outpatient care .............................................................. 114 5.5.2 Reduction in transportation services provided by non-profit associations ............. 114 5.5.3 Increased cost of pharmaceuticals ................................................................... 114 5.5.4 Hospitalisation insurance advertising ................................................................ 115 5.5.5 Hospital policies to avoid unpaid bills ................................................................ 115 4 © Observatoire social européen 5.5.6 Policies of the CPAS/OCMW ............................................................................. 115 5.5.7 Reduced assistance from social services ........................................................... 117 5.6 Conclusion on the analysis of the interviews ................................................................ 117 Chapter 6. Discussion of the findings ...................................................................... 119 6.1 Who is most at risk of unmet needs and of experiencing healthcare as a financial burden?....................................................................................................... 119 6.1.1 Individual characteristics of people who self-reported unmet needs .................... 119 6.1.2 Determinants of unmet needs for medical and dental care ................................. 121 6.1.3 Regional differences ....................................................................................... 124 6.1.4 Financial hardship leading to unmet healthcare needs ....................................... 124 6.1.5 People without mandatory health insurance coverage