8 Soignon'Sympa Coopérative SCRL. 2014. Website. Retrieved August 25, 2014 ... (http://www.vivalia.info/WEBSITE/BEFR/01
BETTER HEALTH & SOCIAL CARE
National Case
An excerpt from: Better Health & Social Care: How are Co-ops & Mutuals Boosting Innovation & Access Worldwide? An International survey of co-ops and mutuals at work in the health and social care sector (CMHSC14) Volume 2: National Cases Copyright © 2014 LPS Productions Montréal, Québec, Canada For the research framework, the analysis of the national cases, and other research components, including a description of the research team members, refer to Volume 1: Report. For information regarding reproduction and distribution of the contents contact the editor and research leader: Jean-Pierre Girard LPS Productions 205 Chemin de la Côte Sainte-Catherine, #902 Montréal, Québec H2V 2A9 Canada
[email protected] URL http://www.productionslps.com
BELGIUM
2014
HEALTH SYSTEM1
T
he Belgian health system is mainly organized on two levels, federal and regional. Population (in thousands): 11,060 Since 1980, part of the responsibility for health care policy has been devolved from the federal government to the regional governments. The federal government is Population median age (years): 41.41 responsible for the regulating and financing of the compulsory health insurance. The regional governments are responsible for health promotion. Population under 15 (%): 16.88 The Belgian health system is based on the principles of equal access and freedom of choice, with a Bismarckian type of compulsory national health insurance. It covers the Population over 60 (%): 23.81 whole population and has a very broad benefits package. Compulsory health insurance is combined with a private system of health care delivery, based on independent medical Total expenditure on health as a $ of Gross practice, free choice of service provider, and predominantly fee-for-service payment. All Domestic Product: 10.8 individuals entitled to health insurance must join or register with a sickness fund. Patients in Belgium participate in health care financing 1) via co-payments, for which General government expenditure on the patient pays a fixed amount of the cost of a service, with the third-party payer health as a % of total government covering the balance of the amount; and 2) via co-insurance, for which the patient pays a expenditure: 15.0 fixed proportion of the cost of a service and the third-party payer covers the remaining proportion. There are two systems of payment: 1) a reimbursement system, for which the Private expenditure on health as a % of patient pays the full costs of services and then obtains a refund for part of the expense total expenditure: 24.1 from the sickness fund, which covers ambulatory care; and 2) a third-party payer system, for which the sickness fund directly pays the provider while the patient only pays the coinsurance or co-payment, which covers inpatient care and pharmaceuticals. Health care in Belgium is sponsored by competing mutual health associations and is provided by a mixture of public and non-profit hospitals. The government pays each mutual health association depending upon the number of registered members. Most of the mutuals are historically affiliated to a political institution. However, there is no substantive difference between them as reimbursement rates are fixed by the Belgian government. Insurance funds do not cover 100% of the patient’s bills. The typical reimbursement is between half to three-quarters of a typical doctor or specialist fee. Insured citizens have a standardized credit-cart style “SIS” card, which is mandatory in pharmacies and hospitals.
HEALTH CO-OPS
(healthcare and welfare). (See Table 1, next page.) Even if SFSs are not registered under co-op law, the medical clinics (“maisons médicales”) have a lot of similarities to co-ops.2 In Flanders, “the healthcare sector from a cooperative perspective is a virtually untapped market niche.”3 Private companies are the main actors in this area, where health care cooperatives are held in deep “suspicion.”4
In Belgium, there is a strong cooperative movement. In 2011, the country had more than 26,000 cooperatives representing 5% of GDP. Most of the cooperative societies are found in the Walloon region. The province of Liege tops all Belgian provinces in terms of the number of cooperatives. Since the 1991 reform, the “cooperative society” legal form has variants: SCRL (limited liability) and SCRI (unlimited liability). Belgium has many cooperative professions including doctors, specialists, dentists, etc. The cooperative form offers more flexibility on how to join and exit. Companies with a social purpose (SFS) also appeared in 1995. There were 31 SFSs in 2011. Three-quarters of SFSs are cooperatives. In the health sector the SFS are also present, as the example of the Entente Jolimontoise demonstrates Better Health & Social Care. Vol. 2: National Cases
SOCIAL CARE CO-OPS
Social care cooperatives have emerged in the past years in Belgium, although few examples were found during this study. A nurse cooperative, “Soignon’Sympa,” was identified. It provides care and domiciliary services and is a producer-based cooperative. (See Table 1, next page.) 9
BELGIUM
2014 convalescent patients. The Association Intercommunale de Santé de la Basse-Sambre operates a hospital, a clinic, two long-term centres, a centre for drug addicts, and a social care centre. It also offers domiciliary and therapy services. The Intercommunale de Soins Spécialisés de Liège operates psychiatric and geriatric centres as well as centres for the elderly (long-term and retirement). The CHU Ambroise Paré operates four hospitals. Two cooperatives in Flanders were also identified: Inclusie Invest and Biloba huis. Inclusie Invest is a cooperative that builds “custom living arrangements for people with disabilities.”5 Biloba huis is a cooperative project whose goal is to provide “housing for seniors and a caring living space for the residents”6 and to prevent financial insecurity.7
Social care cooperatives are also found in the form of “intercommunals” (intercommunales). In Belgium, intercommunal organizations are cooperatives created by cities or institutions that collaborate in the management of public social services (e.g., water management). Ten intercommunal health and social care organizations were identified. All are multistakeholder cooperatives; both public and private entities sit on their boards. They manage hospitals and/or social and medical services. For example, the Intercommunale de Santé Publique du Pays de Charleroi manages a public hospital, three clinics, a daycare centre, a nursery, and a youth centre. The Intercommunale Centre d’Accueil “Les Heures Claires” offers rehabilitation and social care services for elderly and handicapped people as well as for long-term and
Table 1: Health & Social Care Cooperatives Members
Employees
Types of service
N/A
N/A
X
N/A
N/A
X
X
X
X
N/A
N/A
X
X
X
N/A
N/A
X
X
N/A
N/A
X
N/A
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
1,810
260
X
X
X
X
X
X
X
N/A
N/A
X
X
X
X
X
X
X
X
X
N/A
N/A
X
X
X
X
X
X
X
X
Association Intercommunale Hospitalière du Sud-Hainaut et du Sud-Namurois16
X
N/A
N/A
X
X
X
X
X
X
X
X
Vivalia17
X
N/A
3,600
400
X
X
X
X
X
X
X
Intercommunale d’œuvres médico-sociales des arrondissements de Tournai-ATHMouscron
X
N/A
N/A
x
x
x
x
x
x
X
Inclusie Invest
X
N/A
N/A
Biloba huis
x
N/A
N/A
Better Health & Social Care. Vol. 2: National Cases
NB
10
x
Wellness & health promotion
X
X
Illness & accident prevention
X
Others
X
Other health prof
X
Nurses
X
X
Doctors
X
Multistakeholder
X
Soignon’Sympa8 Intercommunale de Santé Publique du Pays de Charleroi9 Entraide Jolimontoise10 Intercommunale Centre d’Accueil “Les Heures Claires”11 Association Intercommunale de Santé de la Basse-Sambre12 Centre Intercommunal Universitaire Ambroise Paré (Société Intercommunale)13 Intercommunale de Soins Spécialisés de Liège (Société Intercommunale)14 Centre Hospitalier Régional de Huy15
Producer
X
User
Rehabilitation
Type
Treatment and cure
Name of cooperative
X
x
x
x
BELGIUM
2014
PHARMACY CO-OPS
Security Institution (l’Institut National d’Assurance MaladieInvalidité, INAMI) and citizens.18 They also offer complementary health plans and social services like domiciliary care. Health mutuals are organized in five national networks.19 These networks operate multiple regional offices (from 6 to 19 regional mutuals in some cases). Collectively they have 12,864 employees20 and 10,834,186 users. In addition to providing reimbursement, they offer complementary health plans as well as domiciliary and other care services. Some of them also offer social services, such as legal aid or support groups for youth. One mutual, Mutualité Socialiste du Brabant, also operates 14 medical clinics. These clinics served 609,465 users in 2013.21
Distribution of drugs is one of the pillars of the cooperative movement in Belgium. According to the federation OPHACO, cooperative pharmacies have a market share of about 20% in Belgium. Many of these cooperatives opted for the cooperative form, either under the legal framework of limited liability or Cooperative Society (SC). Febelco is the largest wholesale distributor of drugs in Belgium with a market share of over 35%. It has more than 2,500 clients.
HEALTH MUTUALS
Health mutuals are a key component of Belgium’s health care system. They act as an interface between the National Social
Table 2: Top 10 Pharmacy Co-ops in Belgium22 Rank 2 12 29 32 77 84 95 100 102 118
Name Febelco Multipharma L’Economie Populaire (E.P.C) ESCAPO SCRL Royale des Pharmacies Populaires de Verviers et Arrondissement MSF Supply23 Vooruit Nr 1 Pharmacies du Peuple Réseau Solidaris Pharma Santé-Réseau Solidaris De Voorzorg
Legal status SCRL SCRL SCRL SCRL SC SC SCRL SCRL SCRL SCRL
Region Flanders Capital Brussels Walloon Flanders Walloon Capital Brussels Flanders Walloon Walloon Flanders
Table 3: Health Mutual Organizations Name of cooperative
Number of mutuals24
Number of members (2013)
Number of employees
Alliance nationale des mutualités chrétiennes/ Landsbond der christelijke mutualiteiten25
19 regional mutuals
4.543.81926
6,178
Provides complementary health plans and offers domiciliary services and health-related workshops.
Union nationale des mutualités neutres/ Landsbond van de neutrale ziekenfondsen27
7 regional mutuals
497.925
748
Provides complementary health plans and social and medical services (e.g., legal aid).
Brief description
Union nationale des mutualités socialistes/ Nationaal verbond van socialistische mutualiteiten
11 regional mutuals28
3,111,616
N/A
Provides complementary health plans, domiciliary services, and social and legal services. One mutual (Mutualité Socialiste du Brabant) operates 14 medical clinics with different health professionals (general practitioner, ophthalmologist, dentist, etc.).29
Union nationale des mutualités libérales/ Landsbond van liberale mutualiteiten30
10 regional mutuals
575,798
N/A
Provides complementary health plans and offers domiciliary services, health-related workshops, and social services.
Union nationale des mutualités libres/ Landsbond van de onafhankelijke ziekenfondsen31
6 regional mutuals
2,105,028
N/A
Provides complementary health plans and offers care services and health-related workshops/support.
Better Health & Social Care. Vol. 2: National Cases
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BELGIUM
2014
SOURCES
18
1
Defourny, Jacques. 2014. “Économie sociale.” Centre d’économie sociale. Université de Liège. Webpage. Retrieved August 24, 2014 (http://www.ces.ulg.ac.be/fr_FR/services/cles/dictionnaire/e/economie-sociale3). 19 The five networks are the Alliance nationale des mutualités chrétiennes/ Landsbond der christelijke mutualiteiten, Union nationale des mutualités neutres/Landsbond van de neutrale ziekenfondsen, Union nationale des mutualités socialistes/Nationaal verbond van socialistische mutualiteiten, Union nationale des mutualités libérales/Landsbond van liberale mutualiteiten, and Union nationale des mutualités libres/Landsbond van de onafhankelijke ziekenfondsen. 20 Defourny 2014. 21 Mutualité socialiste du Brabant. 2013. Rapport moral 2013. Retrieved August 24, 2014 (https://www.fmsb.be/doc-issuu/rapport_moral_2013batbd). 22 Van Opstal, W. 2013, “Les coopératives en Belgique. Top 100 des sociétés coopératives en Belgique en 2011.” Leuven: CESOC-KhLeuven & Coopburo and the VKBO (verrijkte kruispuntbank voor ondernemingen / Registry of companies in Flanders and Belgium). 23 Centre responsible for the purchase of supplies and equipment missions to Médecins Sans Frontières. 24 INAMI-RIZIV. 2014. “Répertoire des unions nationales de mutualités.” Webpage. Brussels: Alliance nationale des mutualités chrétienne. Retrieved August 25, 2014 (http://www.riziv.be/citizen/nl/insurers/contacts/pdf/Repertoire_1.pdf). 25 Alliance nationale des mutualités chrétiennes. 2012. “2012 Annual report.” Brussels: Alliance nationale des mutualités chrétiennes. Retrieved August 25, 2014 (http://www.mc.be/binaries/rapport_annuel_2012_FR_tcm377-130989.pdf). 26 Union Nationale des Mutualités Neutres. 2013. “2013 Rapport annuel.” Brussels. Retrieved August 25, 2014 (http://www.mutualitesneutres.be/doc/public?set_language=fr). 27 Union Nationale des Mutualités Neutres 2013. 28 INAMI. 2014. “Contactez les mutualités.” RIZIV-INAMI. Webpage. Retrieved August 25, 2014 (http://www.riziv.be/citizen/fr/insurers/contacts/index.htm). 29 Mutualité socialiste du Brabant 2013. 30 Union Nationale des Mutualités Neutres 2013:47. 31 Union Nationale des Mutualités Libres. 2013. “2013 Rapport annuel.” Retrieved August 25, 2014 (http://digibook.digiwork.com/Digibooks.aspx/Get/MLOZ/1192/04072014_ra13pdf).
Corens, Dirk. 2007. Belgium Health System Review. Health Systems in Transition, 9(2):1-172. European Observatory on Health System and Policies. Retrieved August 24, 2014 (http://www.euro.who.int/__data/assets/pdf_file/0007/96442/E90059.pdf). 2 Today there are nearly 100 medical centres in French-speaking Belgium representing in total 220,000 patients treated annually by 1,600 professionals. This is an evolving model. Six new medical centres are created every year on average. Fédération des maisons médicales et des collectifs de santé francophone. 2014. Website. Retrieved August 24, 2014 (http://www.maisonmedicale.org). 3 Van Opstal, Wim. 2011. “Coöperatie in Zorg: Een verkenning van vraagstukken en goede praktijken in binnen-en buitenland.” Europees Fonds voor Regionale Ontwikkeling (EFRO) project 563 02.04. Retrieved August 24, 2014 (https://lirias.kuleuven.be/bitstream/123456789/393221/1/Rapport.pdf). 4 Van Opstal 2011. 5 Inclusie Invest. 2014. Website. Retrieved August 25, 2014 (http://www.inclusieinvest.be). 6 Van Opsal 2011. 7 EVA vzw. 2014. Website. Retrieved August 25, 2014 (http://www.evavzw.net). 8 Soignon’Sympa Coopérative SCRL. 2014. Website. Retrieved August 25, 2014 (http://www.soignonsympa.eu/fr/infirmiere-a-domicile). 9 ISPPC: Intercommunale de Santé Publique du Pays de Charleroi. 2014. Website. Retrieved August 25, 2014 (http://www.isppc.be/isppc). 10 INDC-Entité Jolimontoise. 2014. Website. Retrieved August 25, 2014 (http://www.entite-jolimontoise.be). 11 Intercommunale du Centre d’Accueil “les Heures Claires” SRCL. 2014. “Accueil.” Webpage. Retrieved August 25, 2014 (http://www.cahc.be). 12 Association Intercommunale de Santé de la Basse-Sambre. 2014. Website. Retrieved August 25, 2014 (http://www.sambreville.be/social-et-sante/lesquartiers/pfcq/linventaire/inventaire_db/aisbs). 13 CHU Ambroise Paré. 2014. “Son profil”. Website. Retrieved August 25, 2014 (http://www.hap.be/Public/menu.php?ID=675&IDm=719&i=1&j=0). 14 Intercommunale de Soins Spécialisés de Liège. 2014. Website. Retrieved August 25, 2014 (http://www.isosl.be/index.php/left-menu-1-intercomunale). 15 Centre Hospitalier Régional de Huy. 2014. Website. Retrieved August 25, 2014 (http://www.chrh.be). 16 Centre de Santé des Fagnes. 2014. “Hôpital de jour.” Webpage. Retrieved August 25, 2014 (http://www.csf.be/Hopital-de-jour_493.html). 17 Vivalia. 2014. Website. Retrieved August 25, 2014 (http://www.vivalia.info/WEBSITE/BEFR/01/Homepage01.php).
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