The share of households with catastrophic health spending in Belgium is currently among the highest in western Europe, according to a new report launched today by the WHO Regional Office for Europe. However, concrete steps are being taken to address this challenge – one that is shared by many other countries in the WHO European Region.

Catastrophic health spending means a household can no longer afford to meet basic needs – food, housing and heating – because of having to pay out of pocket for health care.

According to the report, nearly 260 000 households in Belgium experienced catastrophic health spending in 2020, the latest year of data available. This corresponds to 5.2% of all households, but the number goes up to 8% for households headed by unemployed people and 12% for households in the poorest fifth of the population.

Produced in collaboration with the Belgian Health Care Knowledge Center (KCE), and with funding from the European Union (EU), the new analysis shows that catastrophic health spending in Belgium is more heavily driven by out-of-pocket payments for medical products ( for example, hearing aids, glasses, dentures and prostheses) than in many other countries. For poorer households, it is mainly driven by outpatient medicines, diagnostic tests and outpatient care.

“The numbers from 2020 show that 1 in 20 Belgian households experienced financial hardship due to out-of-pocket payments for health care. That’s a serious concern. “The Government of Belgium has recently taken significant steps to strengthen financial protection, but reducing out-of-pocket payments even further – especially for people with low incomes – should continue to be a priority,” said WHO Regional Director for Europe, Dr Hans Henri P. Kluge. “Continuing with efforts to protect people from the cost-of-living crisis affecting many households in Belgium, and more widely Europe as a whole, will improve people’s health and strengthen the health system.”

Gaps in affordable access to health care

Many of the factors that undermine affordable access to health care – and have a disproportionate impact on poorer households – reflect the complexity of coverage policy in Belgium. For example:

• A complex system of user charges (co-payments) applies to all health services.
• Although there are several mechanisms in place to protect people from co-payments, some of these mechanisms are not applied automatically and thus are not as effective as they should be. In addition, there is no general exemption from co-payments targeting households with low incomes.
• Some outpatient care is still subject to retrospective reimbursement (when people pay the full price at the point of use and receive partial reimbursement from their sickness fund), which is unusual among EU health systems.
• Publicly financed coverage of dental care, medical products and over-the-counter medicines is still insufficient.
• At least 1% of the population (about 115 000 people) lacks social health insurance coverage, rising to around 2% in the Brussels region and among younger adults.

The new report finds that the government recognizes these issues and has taken important steps to address them – for example:

• replacing percentage co-payments (when the user pays a share of the service price) with fixed co-payments for visits to a family doctor or medical specialist;
• limiting balance billing (when health-care providers are allowed to charge people more than the price set by the social health insurance scheme) in hospitals;
• abolishing retrospective reimbursement for family doctor services for people with low incomes and allowing all outpatient care providers to offer benefits in kind on a voluntary basis;
• strengthening the annual cap on co-payments by lowering the maximum amount a person with a low income must pay out of pocket.

More recently, the government has taken additional steps to protect people – especially those in vulnerable situations – from out-of-pocket payments. The annual cap on co-payments has been frozen, rather than rising with inflation; coverage of dental care and first-line mental health services has been expanded; and measures are being taken to limit balance billing in outpatient care.

Simplify coverage policy to protect the poorest households

The WHO Regional Office for Europe welcomes these changes and puts forward recommendations to overcome remaining challenges, including:

• abolishing retrospective reimbursement for all health services;
• further limiting balance billing in all settings;
• expanding the annual cap on co-payments to all health services and lowering it even more for people with low incomes;
• granting automatic entitlement to everyone eligible for increased reimbursement (reduced co-payments) to eliminate administrative barriers to take-up; research finds that take up of reduced co-payments is close to universal when granted automatically but very low when people have to apply for them;
• exempting low-income households from all co-payments;
• strengthening regulation of the price of medical products not covered by the social health insurance scheme;
• ensuring that the social health insurance scheme covers the whole population.

“In addition to reducing unmet need and financial hardship for low-income households, these measures would make the health system fairer and less complex for people using health services,” said Dr Natasha Azzopardi-Muscat, Director of the Division of Country Health Policies and Systems, WHO Regional Office for Europe. “The lessons learned in Belgium are useful for other countries in our region working to address their own challenges with catastrophic health spending and to improve everyone’s access to health care.”

About the report

The report assesses the extent to which people in Belgium experience financial hardship when they use health services (including medicines) and unmet need caused by financial barriers to access. It draws on microdata from household budget surveys carried out by Statistics Belgium every two years from 2012 to 2020 (the latest year of data available); data on unmet need for health care and dental care from EU Statistics on Income and Living Conditions up to 2021 (the latest year of data available); and detailed information on coverage policy (the way in which health coverage is designed and implemented) up to 2022. The focus is on three key dimensions of coverage policy: population coverage, service coverage and user charges (co-payments).

About the WHO Regional Office for Europe

Financial protection is central to universal health coverage, which is at the heart of the European Program of Work, the Regional Office’s strategic framework, endorsed by all 53 Member States encompassing Europe and central Asia. It is an indicator of the Sustainable Development Goals and part of the European Pillar of Social Rights.

The Regional Office monitors financial protection through the WHO Barcelona Office for Health Systems Financing. The WHO Barcelona Office provides tailored technical assistance to countries to reduce unmet need and financial hardship by identifying and addressing gaps in coverage.

The report on Belgium was produced by the WHO Barcelona Office in collaboration with national experts from KCE, with financial assistance from the EU. The contents of the report are the sole responsibility of WHO and can in no way be taken to reflect the views of the EU.

In June 2023, the Regional Office will release a regional report on financial protection, comparing affordable access to health care in over 40 countries in the European Region.

About KCE

KCE is an independent research center that provides scientific advice on topics related to health care. KCE’s mission is to advise policy-makers on decisions relating to health care and health insurance on the basis of scientific and objective research. It is an advisory body and is not involved in the decision-making or implementation process.