Abstract
Globally, health systems have been struggling to cope with the increasing burden of chronic diseases and respond to associated patient needs. Integrated care (IC) for chronic diseases offers solutions, but implementing these new models requires multi-stakeholder action and integrated policies to address social, organisational, and financial barriers. Policy implementation for IC has been little studied, especially through a political lens. This paper examines how IC policies in Belgium were developed over the last decade and how stakeholders have played a role in these policies. We used a case study design. After an exploratory document review, we selected three IC policies. We then interviewed 25 key stakeholders in the field of IC. The stakeholder analysis entailed a detailed mapping of the stakeholders' power, position, and interest related to the three selected policies. Interview participants included policy-makers, civil servants (from ministry of health and health insurance), representatives of health professionals' associations, academics, and patient organisations. Additionally, a processual analysis of IC policy processes (2007-2020) through literature review was used to frame the interviews by means of a chronic care policy timeline. In Belgium, a variety of policy initiatives have been developed in recent years both at central and decentralised levels. The power analysis and policy position maps exposed tensions between federal and federated governments in terms of overlapping competence, as well as the implications of the power shift from federal to federated levels as a consequence of the 2014 state reform. The 2014 partial decentralisation of healthcare has created fragmentation of decisive power which undermines efforts towards IC. This political trend towards fragmentation is at odds with the need for IC. Further research is needed on how public health policy competences and reform durability of IC policies will evolve.
Highlights
The increasing burden of chronic diseases is a public health problem worldwide, including in developed countries.[1]
The broad variety of pilot projects in Belgium supports the belief of several interview participants that much is ‘being done’ in Belgium’s fragmented field of care integration, yet insufficient time is spent on evaluation: “Everyone talks about projects, but in the long run, you don’t know what the difference between one and the other is (...) Integrated care policy is not so great in Belgium
One stakeholder spoke about growing awareness in the field of practice yet hinted at the problem of a policy
Summary
The increasing burden of chronic diseases is a public health problem worldwide, including in developed countries.[1] Across 27 member countries of the Organisation for Economic Cooperation and Development (OECD), almost one-third of people aged 15 years and over reported living with two or more chronic conditions, on average.[2,3,4,5] In Belgium, the country under study, chronic diseases are responsible for at least 90% of the societal burden of disease including disability and substantial mortality.[6] in developing countries, but in wealthy countries as well, health systems are struggling to cope with the overstretch related to chronic diseases and responding to associated patient needs as chronic care is organisationally complex.[7,8,9,10] It requires long-term (often lifelong) and coordinated action from different health, social, and policy actors.[7]. Constructs commonly linked to IC include patient-centred care, care coordination, continuity of care, chronic disease management, and integrated healthcare delivery.[13,14,15,16,17,18,19,20,21,22,23,24,25,26,27] IC leads to better coordination, efficiency, and cost control of care and improves the quality of care and patient outcomes.[7,28,29] The contemporary mission of IC policy is to improve health system performance across the Quadruple Aim.[30,31,32,33,34,35] This entails: (1) improving the quality, safety, and experience of care [individual/patient level], (2) improving population health with a focus on access, equity, the vulnerable and chronically ill [population level], (3) reducing costs of care, whilst creating efficiency and best value for public health system resources [system level], and (4) health worker job satisfaction [individual/caregiver level].30-36 to achieve this, effective health and social policies are needed to support health systems and facilitate the paradigm shift from curative, episodic, hospital-based, and provider-driven care to a more comprehensive, patient-centred, long-term care approach emphasising the integration of health services.[7,37,38,39,40,41,42]
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