Belgian System Research Articles

Evolutions in both co-payment and generic market share for common medication in the Belgian reference pricing system

Evolutions in both co-payment and generic market share for common medication in the Belgian reference pricing system

The Belgian reimbursement system for prostheses for lower limb amputation in 2013

The Belgian reimbursement system for prostheses for lower limb amputation in 2013

Conclusion: The Future of Belgian Federalism—Between Reform and Swansong?

This article summarizes the main arguments of the special issue. It also probes into the deficiencies of the Belgian federal system and argues that the most recent crisis of Belgian federalism (2007–11) is not the result of rising socio-economic differences between Flanders and Wallonia, but the consequence of building a bipolar federation on to a split party system. The article concludes by identifying some potential roadmaps (federal reform, confederalism, and the referendum) for the future.

Party Strategies, Voter Demands and Territorial Reform in Belgium

This article examines the determinants of the positioning of parties on the question of territorial reform in Belgium. It argues that one cannot explain the high salience assigned to the issue of decentralisation among political parties by looking only at voter demands. Instead, it is the dynamics of party competition that has encouraged parties to adopt an electoral and territorial logic of action. The article shows that the main driver of territorial reform in Belgium has been the continuous relevance of regionalist parties in the Flemish party system, which have compelled mainstream parties to accommodate their demands for territorial autonomy, and, more recently, independence. Regionalist parties have capitalised on a strong sense of Flemish national identity, itself shaped by long-run structural factors. The article also shows that the adoption of an electoral and territorial logic has been strengthened by the split of the Belgian party system and the reinforcement of social cleavages, and, more recently, by the increasing competitiveness of elections and the opening up of party competition at multiple levels.

Belgian Public Accounting: Evolution and Compliance with IPSAS

The Belgian public accounting system is continuously evolving, but efforts must still be made to comply with international standards. Public accounting has been modified several times since the law of 15 May 1846 on state accounting. At first, public accounting only consisted of budgetary accounting, but it then evolved and now consists of two parts: budgetary accounting and double-entry general accounting based on transactions and inspired by the one used by the private sector. So, the law of 15th March 1991 on the reform of accrual state accounting and the provincial accounting (Loi du 15 mars 1991 portant reforme de la comptabilite generale de l’Etat et de la comptabilite provinciale, M.B. 22 mai 1991) as well as the law of 22nd May 2003 on the organization of the budget and the accounting of the federal state (Loi du 22 mai 2003 portant organisation du budget et de la comptabilite de l’Etat federal, M.B. 3 juillet 2003) made it possible to introduce such an accounting system. This system has the advantage of providing more information about the financial and economic situation of public entities and of being more accurate, which enables us to estimate, among other things, public property and public debt. Some external factors induced the reform of 2003. Firstly, we can mention the evolution of the Belgian state organization. Communities and regions are now expected to respect general principles, for instance in terms of accounting disclosure. Secondly, the organizational structure of the federal administration has beenmodified by the Copernicus reform (« Copernicus-Au centre de l’avenir: La reforme de l’Administration federale belge », 1er septembre 2004), which constitutes an opportunity to implement accrual accounting in all federal departments. Thirdly, at the same time as this national evolution, there has also been a modernization of accounting at the international level through the introduction of the International Public Sector Accounting Standards (IPSAS) and at the European level through the implementation of the European System of Accounts (ESA). These national and international reforms tomodernize accounting tally with the concept of Int Adv Econ Res (2013) 19:79–81 DOI 10.1007/s11294-012-9386-8

THE IMPACT OF TREATMENT WITH RISPERIDONE LONG-ACTING INJECTION ON THE BELGIAN HEALTHCARE SYSTEM: RESULTS FROM A BUDGET IMPACT MODEL

Substantial evidence from randomised clinical trials has demonstrated that long-acting risperidone (RLAI) is efficacious and well tolerated in patients with schizophrenia. Recently, a long-term naturalistic study of treatment practices in Belgium, the electronic Schizophrenia Treatment Adherence Registry (e-STAR), reported that treatment with RLAI is associated with improvements in adherence and long-term outcomes. The present report describes the results of a budget impact model that analysed the Belgian e-STAR data, together with other available data, over a 3-year time horizon, in order to establish the potential impact of treatment with RLAI on total healthcare costs in Belgium. The model framework combined medical resource utilisation with costs of the population of interest in order to quantify the costs, and cost offsets, of RLAI treatment. For the purpose of this budget impact model, it was assumed that among patients who would discontinue their previous antipsychotic medication, 6.7% of patients would be switched to RLAI. The overall cost savings to the Belgian healthcare system were calculated to be € 2.3 million in Year 1, € 3.7 million in Year 2 and € 4.4 million in Year 3. The majority of these cost-savings resulted from the substantial reduction in hospitalisation costs associated with RLAI treatment. This report indicates that improvements in adherence and long-term outcomes previously demonstrated for RLAI treatment in Belgium may result in substantial cost benefits to the country’s healthcare system.

The Use of Security Agents Under Belgian Law

This dissertation has as its goal to underline the (un?)important caveat in the Belgian legal system (as opposed to American Common Law) regarding Security Agents (Security Trustees). More specifically it is my wish to address a difference in approach that is of great importance to syndicated financing. Indeed, the use of a “security agent/trustee” is treated very differently in Belgium than it is across the Atlantic. It is not my wish to give a comprehensive comparative guide. Rather it is my ambition to touch upon the legal differences from a more theoretical point of view. The perspective of this dissertation will however mainly be of a Belgian one as opposed to an American one.

Executive–Legislative Relations Without a Government

Traditionally, it is assumed that the executive strongly controls Parliament within the Belgian political system. The absence of a federal government following the 2010 elections had three consequences on the activity of the Belgian Parliament. Some actions were put on hold, and essential reforms were delayed. On other issues, however, Members of Parliament took the lead, developing ad hoc majorities that cut across earlier cleavages between majority and opposition. Third, however, parties continued to vote along the majority of the caretaker government. While it could be expected that this situation, in the long run, might lead to a stronger position of Parliament vis-a-vis government, it is to be expected that traditional power relations will be restored once a full government has been formed.

How Do Countries Survive Without a National Government? Theoretical Reflections on the Belgian Case

In this debate section, four Belgian political scientists reflect on the theoretical relevance of the lengthy political crisis that Belgium has known following the elections of June 2010. It is argued that the absence of a federal government did not lead to a policy vacuum, as regional governments, the European Union, public service managers and Members of Parliament tried to expand the scope of their authority. Given trends towards multi-level governance, it is expected that the Belgian political system will manage to survive, even if one of the levels of government (temporarily) falls out.

Convergence and Divergence: the Federalization of Belgian Equality Policies

The development of an asymmetrical federal structure profoundly changed the institutional setting for Belgian gender equality policies. This contribution assesses the influence of this process on the development of the Belgian women's policy agencies and its gender equality policies. It argues that while the characteristics of the Belgian federal system—its asymmetrical structure and dual, centrifugal nature—stimulate the development of diverging structures, the nature of the issue—the cross-cutting character of gender inequality, the hegemonic approach to gender inequality—and the absence of national civil society actors push towards a convergence of policy approaches across different policy-making institutions.

Allocating liability in the event of fraudulent use of electronic payment instruments and the Belgian mobile payment instrument PingPing

With unauthorised (fraudulent) payment transactions, the question arises as to whether the payment service user or the payment service provider must bear the financial consequences. This article focuses on the Payment Services Directive, which determines who is liable in the event of an unauthorised payment transaction. First, there is a discussion of the allocation of liability with the use of a 'traditional' electronic payment instrument, such as a debit card or a credit card. In this part of the paper, specific attention is paid to the concept of gross negligence and the problems of the burden of proof. In the second part of the article, there is a discussion of the applicability of these rules on the allocation of liability to the new Belgian PingPing payment system.

The SGI Case: ECJ Approves Belgian System of Selective Profit Corrections in Relation to Foreign Group Companies

On 21 January 2010, the European Court of Justice gave its judgment in the Belgian SGI case, which concerns the compatibility with the freedom of establishment of selective profit corrections in regard to related companies resident in other Member States. A key element of the decision is the division of the burden of proof in assessing the presumed profit corrections by the tax administration.

Federalism and Compliance with International Agreements: Belgium and Canada Compared

This article aims to assess the effectiveness of two systems of governance with respect to the making of international treaties: the Canadian system, where the decision-making process is more centralized and where intergovernmental mechanisms are poorly institutionalized; and the Belgian system, where sub-state actors have the role of co-decision and where intergovernmental mechanisms are highly institutionalized. The central question to be discussed is: is the fact that one gives an important role to sub-state actors in the making of a country’s treaty by means of institutionalized intergovernmental mechanisms something that negatively or positively affects the foreign policy of a state? And is this a positive- or a negative-sum game at the level of the conclusion and implementation of treaties? The article concludes that the Belgian system is more effective, largely because its sub-state actors have an important role at every step of the conclusion of a treaty.

A care time benefit as a timely alternative for the non-working spouse compensation in the Belgian tax system

Over the past decades, the growing labour force participation of mothers has rendered the Belgian personal income tax system increasingly outdated. Especially the marital quotient system - that allows spouses with monetary income to transfer part of their tax base to a spouse without monetary income - is no longer a tax allowance that compensates childcare efforts. It rather has become a subsidy to older cohorts for their past childcare efforts. As an alternative, we model in this article a system that is geared towards the effective care trajectories of nowadays parents. We thereby follow earlier ideas of Hilde Bojer, Patricia Apps and Ray Rees to reflect care efforts in the tax base of individuals. Following Bojer, we propose a system that incorporates a socially grounded amount of childcare time in household income, and simulate this with the Belgian microsimulation model MISIM. The amount relates to the number and age of children and can either be procured through childcare services or self-provision. In the proposed system both market- and self-provided care result in a similar ubsidy. We elaborate a monetary estimate of self-provided childcare on the basis of the detailed information of time use in the Flemish Family and Care Survey (2004-2005). For discussion we provide an overview of potential drawbacks and advantages and evaluate the redistributive impact of the simulated alternative.

Transfer of Juvenile Offenders to Adult Court in Belgium: Critical Reflections on the Reform of a Moderate Practice

Several Western European juvenile justice systems have become more punitive in the last few decades. This article explores whether the Belgian juvenile justice system, traditionally one of the most welfare oriented in Europe, has taken a punitive turn as well. An analysis of the recent amendment of the most punitive element in the Belgian juvenile justice system, transfer to Adult Court, does not provide a definite answer. The regulations on transfer were not made harsher by the new Youth Act. However, we will argue that the amendment, although `mild' at first sight, may, in practice, result in a punitive shift.

Life cycle cost analysis of alternative vehicles and fuels in Belgium

This paper investigates whether the vehicle taxation system in Belgium is stimulating the demand of clean vehicle technologies. A life cycle cost analysis will be performed to evaluate the cost-efficiency of several vehicle technologies within the current fiscal system. This life cycle cost will be weighted against the environmental performance of each vehicle to discover the market potential of environmental friendly vehicles and to define necessary fiscal regulations. Additionally, the yearly taxes and external costs (environmental, congestion, accident costs) of each vehicle will be compared, identifying the strenghts and distortions of the Belgian fiscal system with respect to the promotion of clean vehicles. Moreover, it will be examined whether a new vehicle taxation system, based on the environmental performance of vehicles, would be effective in tackling the current distortions while keeping the good incentives for stimulating the demand of clean vehicle technologies. This new vehicle taxation system will be based on a environmental rating tool, the so-called Ecoscore. The Ecoscore enables a comparison of the environmental burden caused by vehicles with different drive trains and using different fuels and is in this respect a very appropriate instrument to introduce a technology neutral reform of the fiscal system. By calculating the tax burden of several vehicles within the current and new fiscal system, it will be assessed whether this new fiscal system is able to evoke a shift in the composition of the vehicle fleet towards a more environmental friendly one.

Lord Leverhulme's ghosts: colonial exploitation in the Congo

In the early twentieth century, the worldwide rubber boom led British enterpreneur Leverhulme to the Belgian Congo. Warmly welcomed by the murderous regime of King Leopold II, Leverhulme set up a private kingdom reliant on the horrific Belgian system of forced labor, a program that reduced the population of Congo by half and accounted for more deaths than the Nazi holocaust. In this definitive, meticulously researched history, Jules Marchal exposes the nature of forced labor under Leverhulme's rule and the appalling conditions imposed upon the inhabitants of Congo. With an extensive introduction by Adam Hochschild, Lord Leverhulme's Ghosts is an important and urgently needed account of a laboratory of colonial exploitation.

Hospital case-mix funding and the necessity to adjust for socio-economic status

Although the efficacy of hospital case-mix funding in reducing resource use has been largely documented (at least in the short term), many debates persist as regards its consequences on equity. Several authors have pointed to the failure of risk-adjustment methods to accurately reflect the patient's condition and needs, raising the threat of patient and unfair penalization of hospitals. Most of this debate has centered around the failure to risk-adjust for the severity of disease, pointing to the drawbacks of diagnosis classification systems. In this paper, we emphasize the importance of the patient's socio-economic status (SES). The of Belgium is an interesting example of this risk-adjustment debate. Simply put, the Belgian system consists of paying in-patient services a per diem for a normative number of in-patient based on the patient's characteristics (AP-DRG, age and hospitalization, or not in a geriatric ward). The hospitals with excess days with respect to the norm are financially penalized, while the others are financially rewarded. On the one hand, the pro-SES argue that the AP-DRG/age classification system is limited in predicting the differences in length of stay between poorer and richer patients. Hence, hospitals with a large proportion of underprivileged patients are unfairly penalized, while other hospitals receive windfall gains. Meanwhile, the failure to adjust payments to patients' SES rewards hospitals practicing case selection while punishing hospitals doing well in treating the poor. On the other hand, the opponents contend that the socio-economic condition is accounted for by severity indicators, particularly since the shift from AP- to the refined APR-DRGs. In 2007, the Belgian government decided to adopt a series of socio-economic characteristics as risk-adjustors, starting from the 2008 financing. In this paper, we present the evidence that sustained this decision.

COSTS AND LENGTH OF STAY ASSOCIATED WITH ANTIMICROBIAL RESISTANCE IN ACUTE KIDNEY INJURY PATIENTS WITH BLOODSTREAM INFECTION

Introduction: Antimicrobial resistance negatively impacts on prognosis. Intensive care unit (ICU) patients, and particularly those with acute kidney injury (AKI), are at high risk for developing nosocomial bloodstream infections (BSI) due to multi-drug-resistant strains. Economic implications in terms of costs and length of stay (LOS) attributable to antimicrobial resistance are underevaluated. This study aimed to assess whether microbial susceptibility patterns affect costs and LOS in a well-defined cohort of ICU patients with AKI undergoing renal replacement therapy (RRT) who developed nosocomial BSI.Methods: Historical study (1995-2004) enrolling all adult RRT-dependent ICU patients with AKI and nosocomial BSI. Costs were considered as invoiced in the Belgian reimbursement system, and LOS was used as a surrogate marker for hospital resource allocation.Results: Of the 1330 patients with AKI undergoing RRT, 92 had microbiologic evidence of nosocomial BSI (57/92, 62% due to a multi-drug-resistant microorganism). Main patient characteristics were equal in both groups. As compared to patients with antimicrobial- susceptible BSI, patients with antimicrobialresistant BSI were more likely to acquire Grampositive infection (72.6% vs 25.5%, P<0.001). No differences were found neither in LOS (ICU before BSI, ICU, hospital before BSI, hospital, hospital after BSI, and time on RRT; all P>0.05) or hospital costs (all P>0.05) when comparing patients with antimicrobial-resistant vs antimicrobial-susceptible BSI. However, although not statistically significant, patients with BSI caused by resistant Gram-negative-, Candida-, or anaerobic bacteria incurred substantial higher costs than those without.Conclusion: In a cohort of ICU patients with AKI and nosocomial BSI undergoing RRT, patients with antimicrobial-resistant vs antimicrobial-susceptible Gram-positive BSI did not have longer hospital stays, or higher hospital costs. Patients with resistant “other” (i.e. Gram-negative, Candida, or anaerobic) BSI were found to have a distinct trend towards increased resources use as compared to patients with susceptible “other” BSI, respectively.

The Implementation of Directive 2001/20/EC into Belgian Law and the Specific Provisions on Pediatric Research

The European Clinical Trial Directive (2001/20/EC) was implemented into the Belgian legal system by the Law of 7 May 2004 concerning experiments on the human person (LEH). Apart from implementing the European Directive, this law also broadens the scope of the Directive from interventional clinical trials to all medical experiments involving human persons. This article offers an overview of the requirements for involving minors in medical experiments that are captured in the LEH, illustrates the process of protocol review by an ethics committee, and discusses the dissimilarities between the LEH and the European Directive.