Devolution, Nationalism, and the Limits of Social Solidarity: The Federalization of Health Policy in Belgium

Abstract

Observers who attempt to situate Belgium in typologies of European healthcare systems inevitably conclude that Belgium is a hybrid, possessing characteristics of different types in a unique “ecosystem” of health care. The Belgian system in part resembles NHS-style systems with their reliance on tax revenues to finance health care; but Belgium also relies, perhaps to a surprising extent in Western Europe, on private expenditure. Belgium has strong elements of so-called mutual aid systems in which government’s role largely entails subsidizing and regulating the private organizations that serve as insurers (Immergut 1992). However, the Belgian system goes beyond the limited intervention understood by this model: government spending in Belgium is considerable and insurance coverage is extensive and compulsory. As in the Dutch and German systems, insurers in Belgium act as intermediaries between patients and providers, with extensive market freedom for doctors, hospitals, and patients. Yet compared with its neighbors, Belgium exhibits distinctive traits, for example, being less enthusiastic than the Netherlands about embracing market-based reforms to achieve efficiencies (Schokkaert and Van de Voorde 2010;van Doorslaer and Schut 2000). Overall, Belgium belongs on the spectrum of national insurance healthcare systems, in which the state plays the role of the administrator or “steward” of the health system, not the owner, with a focus on enabling the system to achieve social goals such as redistributive or equity-promoting outcomes (Saltman 2004: 5–6).