5. Provision of services 26
5.1 Public health
ublic health is “a social and political concept aimed at improving health, prolonging life and improving the quality of life among whole populations through health promotion, disease prevention and other forms of health intervention” (WHO 1998). These interventions can include promoting healthy behaviour, screening people appropriately for relevant disease, and reducing the number of individuals susceptible to infectious and chronic diseases. In all cases, public health policies and programmes are focused on the population as a whole in contrast to health care policies and programmes that tend to be focused on the individual.
5.1.1 Health promotion and preventive health care
In Belgium, the communities are responsible for health promotion and prevention of disease. However, a number of decisions directly related to public health are taken by the federal government. For instance, the level of taxes on cigarettes and alcohol, which are intended to reduce consumption, are determined by the federal authorities. On regular occasions, the federal government and the communities collaborate to coordinate and finance health policies (e.g. breast cancer screening, vaccinations against poliomyelitis and hepatitis B).
The Flemish community
The policy framework for the organization of preventive health care in the Flemish community was first described in the decree of 21 November 2003 (Vlaams Agentschap Zorg en Gezondheid 2004). This decree called for the establishment of initiatives concerning exogenous factors, endogenous factors and diseases in the initial phase. Initiatives concerning endogenous factors include: the detection of genetic factors and the prevention of specific diseases, such as cardiovascular diseases, cancer, mental illness, congenital diseases, developmental disorders and so on. Initiatives concerning diseases and exogenous factors are further described in the section on disease outbreaks and vaccinations (Section 5.1.5 Mechanisms for notification and surveillance of disease outbreaks).
Specific measurable health objectives were formulated in a health conference and approved by the Flemish Parliament, including:
- prevention of depression and suicide
- breast cancer screening
- promotion of healthy food and physical activity
- discouragement of smoking, drinking and using illegal drugs
- prevention of deadly accidents (private and traffic accidents)
- prevention of infectious diseases (in particular, by further increasing the vaccination rates for polio, pertussis, tetanus, diphtheria, measles, mumps and rubella).
Health conferences aim to define specific health objectives and consist of representatives of the Flemish government, experts, target groups and local health networks (LOGOs). For specific aspects, other representatives can be involved in a health conference, such as representatives of partner organizations, organizations in the field and so on.
Additionally, strategies for collaboration with other organizations are formulated so that they can work together to meet the health objectives. These organizations include: supportive working groups, the so-called partner organizations defined as centres of expertise in preventive health care, field organizations, individual health care workers, other governments and LOGOs.
LOGOs are intended to lead health promotion work at the district level, covering a territory with 97 000–475 000 inhabitants. They are composed of local initiatives and structures already in existence, and are meant to include all health and welfare workers. Each LOGO is supported and coordinated by a multidisciplinary central team and has to facilitate the implementation of evidence-based actions, which aim to reach certain health targets, set by the government. In 2010, the number of LOGOs was reduced from 26 to 15, with each LOGO now concentrated around a regional city (zorgregiodecreet) (Vlaams Agentschap Zorg en Gezondheid 2010d). In a resolution of the Flemish government (29 May 2009), the objectives of the LOGOs were extended to the prevention of health problems due to environmental factors.
For support with health promotional activities, the Flemish government appeals to the Flemish Institute of Health Promotion and Sickness Prevention (VIGeZ). VIGeZ is a centre of expertise that delivers a strategic vision, quality recommendations and training for professionals in health promotion. VIGeZ focuses on topics such as tobacco, healthy eating, promotion of physical activity and accident prevention. VIGeZ aims at intermediate target groups such as schools, working environments, local communities and the underprivileged. The Flemish government formed an agreement with VIGeZ in which subsidies and objectives were fixed. The objectives are: disseminating information to the whole population and making recommendations to the government and scientists; developing a methodology for different organizations which are responsible for working within the preventive health policy (such as the LOGOs); helping to introduce this methodology into the functioning of these organizations; evaluating the interventions; and organizing the training of professionals. The tasks are defined in an annual plan, which must be approved by the Flemish Care and Health Agency (VIGeZ 2010).
The French community
The government of the French community defines its objectives for health promotion in a five-year programme. In the latest five-year programme (2004–2008), the priorities in the areas of health promotion and prevention were (Ministère de la Communauté française, Direction Générale de la Santé 2008):
- prevention of addiction
- prevention of cancer
- prevention of infectious diseases (by promoting vaccination programmes, prevention of AIDS and sexually transmitted diseases (STDs) and the fight against tuberculosis)
- prevention of injuries and promotion of security
- promotion of physical activity
- promotion of oral/dental health
- promotion of cardiovascular health
- promotion of well-being and mental health
- health promotion for early childhood
- promotion of a healthy environment.
The 2008–2009 programme emphasizes the following priorities, based on the objectives of the five-year programme (Ministère de la Communauté française – Direction Générale de la Santé 2009):
- prevention of AIDS and STDs
- fight against tuberculosis
- screening of neonatal deafness
- screening of congenital anomalies.
In the French community, health promotion is organized by the Local Centres for Health Promotion (CLPS), which have to coordinate, on the local level, the implementation of the five-year programme and the community plans for health promotion. These local centres operate at the request of all the actors within the competence of their territory. The responsibilities of the CLPSs are: to work out an action plan respecting the objectives of the five-year programme; to coordinate the execution of the action plan on the level of the organizations or people who mediate with the population or the public targeted by the objective; to bring methodological help to the organizations and people who develop actions in the field of the health promotion and preventive health care; and to encourage the development of partnerships in the territory, in particular by the realization of local conferences in health promotion. There are nine CLPSs in Wallonia and one in Brussels (Communauté française, Centre de documentation administrative 1997; Communauté française, Centre de documentation administrative 2009).
Health promotion and preventive health care policies in the French community are assisted by the Community Services for Health Promotion (SCPS). These community services give logistic and methodological assistance (i.e. formation, documentation, communication, research and evaluation) to the government, the CLPSs, the Superior Council of Health Promotion and the organizations or people who develop actions in the field of health promotion. There are four accredited community services, each with their own specificity: “Question Santé”, a non-profit-making organization responsible for communication in health promotion; RESOdoc-UCL (Unité d’Education pour la Santé) of the Catholic University of Louvain (UCL) responsible for documentation, research and formation; SIPES-ULB (Service d’Information Promotion Education Santé) of the Free University Brussels responsible for methodological help for the collection and diffusion of data; and APES-ULG (Appui en Promotion et Education pour la Santé) of the University of Liège for intervention and evaluation methodology (Ministère de la Communauté française, Direction Générale de la Santé 2010).
The German community
In the German community, the Council for Health Promotion (Beirat für Gesundheitsförderung) defines the global concept of health promotion, consisting of a structural level (improving infrastructure, health promotion networks, and coordination between health care organizations) and an individual level (age-specific information and self-responsibility). In the global concept, specific health objectives are determined every two years (German Community 2006). For 2008–2009, the three main objectives for health promotion are:
- promotion of healthy nutrition
- promotion of physical activity
- promotion of well-being and mental health.
These objectives are elaborated in information and sensitization campaigns, focused on the prevention of health hazards and determined for age-specific groups (e.g. the elderly, youngsters, young parents). The Council for Health Promotion, composed of representatives of the German-speaking government, sickness funds, social health services and Service for Child and Family (Dienst für Kind und Familie), supports health promotion on the local level by co-financing non-profit-making organizations and specific projects (German Community 2004).
From 1 November 2019, the prohibition of selling tobacco products to minors has been extended such that the age limit was raised from 16 to 18 years old.
For more details (in French), see: https://www.health.belgium.be/fr/news/adaptation-de-la-limite-dage-pour-la-vente-de-tabac
A national plan (2014-2019) to fight against HIV has been presented by the Minister of Social Affairs and Public Health in October 2013. This plan proposes 58 action points structured around four pillars: prevention, screening and access to care, care for people with HIV, and quality of life of people with HIV. For more details:http://www.health.belgium.be/internet2Prd/groups/public/@public/@dg2/@myhealth/documents/ie2divers/19089658_en.pdf (in English)
Since October 2012 and for a period of one year, a global approach on the policy for the elderly has been elaborated in the German-speaking community, as part of a global concept of regional development. The objective was to assess the needs for organizational measures that should be taken in all the following areas of action: habitat, lifestyle, advices and information, participation in the society, civic engagement, health and care, support for informal caregivers, proposals for specific target groups, as well as cooperation structures and network implementation. More information can be found on the following link: http://www.dg.be/fr/desktopdefault.aspx/tabid-2805/5347_read-34677/
In July 2011, the French Community has amended its decree on prevention measures for communicable diseases in schools of 17 July 2002, updating the list of diseases implying the implementation of prevention and screening measures as well as their processes and procedures. Even if the diseases are roughly the same, some recommendations were updated to reflect the reality of the field in practice and the evolution of prophylaxis. They have also foreseen to provide a series of 16 fact sheets with more specific information for the medical staff. More information can be found on the following link:
Since September 2010 in the Flemish community and since September 2011 in the French and German communities, free vaccination programs include vaccination against human papillomavirus (HPV). More details can be found in the Health Policy Reform Update on vaccination programs.
5.1.2 National screening programmes
In Belgium, two national screening programmes for early detection of diseases exist: breast cancer screening and neonatal screening for congenital metabolic diseases.
Breast cancer screening
In 2000, the communities and the federal government signed a protocol to organize and finance, on a national scale, a campaign for breast cancer screening for women between 50 and 69 years old, based on the directives developed by the Europe Against Cancer programme (Christiaens et al. 2007). The federal government pays for the radiological costs (via the NIHDI), while the organization’s costs are paid for by the communities.
The responsibility for the coordination of the campaign is attributed to recognized screening centres. Seven screening centres were identified: one in the Walloon region, five in Flanders (in four Flemish universities and one in Bruges) and one screening centre for Brussels. The screening centres are responsible for the identification of the target group, sending the invitations, the second assessment of the mammography,27 data recording and reporting to the referring physician. In Flanders, the campaign started in June 2001, while in the Walloon and Brussels-Capital regions, the campaign started in June 2002. Breast cancer screening in the German community is part of the programme of the French community. The coverage of breast cancer screening in Belgium is detailed in Section 7.5 Quality of care.
The goal of neonatal screening is the early detection of 11 congenital metabolic diseases in neonates. To guarantee the quality of test performance, centres for detection of metabolic diseases (specialized laboratories) are certified by the communities (three in the French community and three in the Flemish community) (Communauté française 2009). These laboratories collaborate with partners who take the blood samples (from maternity wards, GPs, independent midwives) and partners who take care of the follow-up for babies with a positive test result (paediatricians, centres for metabolic diseases).
A Flemish study group developed a strategy for the standardization and optimization of neonatal screening. This strategy is a working instrument for all health care workers and is updated on a regular basis (Vlaams Agentschap Zorg en Gezondheid 2010e).
Since January 2013, cervical screening tests are fully reimbursed every 3 years. Patients pay no co-payment. For more details: http://www.presscenter.org/fr/pressrelease/20121221/conseil-des-ministres-du-21-decembre-2012
5.1.3 Non-national screening initiatives
Other screenings initiatives are not yet organized at federal level but exist at the level of communities.
Since March 2009, the detection of colorectal cancer for those aged 50–74 is organized in the French and the German communities. The test consists of an examination of blood in the stools, followed by a colonoscopy in persons at risk and is performed every five years after normal results, or every 1–3 years depending on the number of adenomas found during colonoscopy. In the Flemish community the screening is organized in local pilot projects and with a different diagnostic technique (examination of the blood with immunochemical tests) (Jonckheer 2009).
The detection of cervical cancer in women aged 25–64 is organized in pilot projects or as opportunistic tests in Belgium. The target group is invited to have a Pap smear taken once every three years (Stichting Tegen Kanker 2010). The coverage of cervical cancer screening in Belgium is detailed in Section 7.5 Quality of care.
The prevention campaign for cervical cancer is extended with the availability of a vaccination against the human papilloma virus (HPV) for girls aged 12–18. This vaccination is reimbursed by the NIHDI. (Hoge Gezondheidsraad 2007; BS–MB 2008)
5.1.4 Family and child health care
Three different institutions (K&G for the Flemish community, ONE for the French community and Kind und Familie for the German community) are in charge of the organization of preventive medical, psychosocial and parenting/pedagogical services for parents-to-be and families with young children. In addition to this, they provide consultations for children up to six years old as well as childhood immunizations.
Vaccination coverage is described in Table5.1. Levels of child immunization against diphtheria, tetanus, pertussis and poliomyelitis have been stable and reached 99% in 2007. Immunizations against Haemophilus influenzae type b and hepatitis B have increased significantly since 2000, up to 97.5% and 94.4% respectively in 2007 (see Table5.1). Since 2004, the financing of all vaccines (listed in the vaccination calendar) is regulated with the same distribution code for all communities: two-thirds is financed by the federal government and one-third is financed by the communities (NIHDI 2007b).
These institutions also organize hearing screening for neonates. This comprises screening, the possibility of controlled referral to a highly qualified centre, diagnosis, treatment and home-based guidance, as well as registration in a central database. The screening test is free.
A pioneering community-based eye screening for amblyogenic factors has been organized by K&G, in collaboration with five Flemish university ophthalmologic departments. The programme aims to reduce the number of children with lazy eye from 6% to 2%, using a powerful and convenient infrared video-refractometer. The programme covers screening, referral to an ophthalmologist, follow-up, registration and feedback. Nurses perform the test in children at the age of 1 and 2 years old.
In both the Flemish and French communities, school health care services are provided for nearly every nursery, primary and secondary school (up to the age of 18 years old). On a regular basis (once in primary school and twice in secondary school), pupils go to a school medical centre for a preventive medical examination, which includes screening for physical and mental disorders, sight and hearing tests, vaccinations (such as hepatitis B) and verification of vaccination dates. In addition, teams composed of a physician and a graduate nurse visit schools for prevention of communicable health problems (e.g. tuberculosis, head lice) and health education.
To allow a continuous follow-up of children and their families at the psycho-medico-social level until end of their secondary school years, the services for child and family (Dienst für Kind und Familie, DKF), the Psycho-medico-social services and the centres for health and dental health promotion in schools have been merged in one structure. This new service will begin its activities from September 2014 and will be centre on needs of the child. A more holistic approach will be followed, with cooperation and networking including the family, social networks and municipalities. For more details: http://www.etaamb.be/fr/2014200948.html
In the academic year 2010-2011, the animation program on dental hygiene has been redesign. Animations are now organized in the 3rd Kindergarten and in the 1st and 2de years of primary school to provide information and awareness on oral and dental hygiene, on a healthy diet and water consumption, on brushing techniques appropriate to their age and on the importance of bi-annual dental visits.
Source: DG Live (2012) [web site]. Zahnpflege in Kindergärten und Primarschulen. Eupen, Deutschsprachige Gemeinschaft Belgien (http://www.dglive.be/desktopdefault.aspx/tabid-423/447_read-2803/, accessed 24 July 2012).
5.1.5 Mechanisms for notification and surveillance of disease outbreaks
Notification of an infectious disease
The specific proceedings to encounter an infectious disease outbreak are regulated by the communities.
In the Flemish community, the proceedings for infectious diseases contain five domains: primary prevention (vaccination of the population); curative approach (diagnostic and treatment); surveillance of infectious diseases; case management (individual contagion); and outbreak management (collective contagion) (Burgmeyer, Hoppenbrouwers and Bolscher 2007).
The Flemish community determines the list of infectious diseases, the proceedings for notification and the assignment of the local state epidemiologists (one per province) (Vlaams Agentschap Zorg en Gezondheid 2004; Flemish Government 2009b). These health inspectors are responsible for taking measures to confront the disease outbreak (such as communicating with the health authorities, organizing the medical examination of patients and the provision of specific medical treatment) and supervising the performance of these measures. The measures for dealing with an outbreak of disease also depend on the target group (patient, unknown patient, susceptible contacts and individuals) and the different components of contagion.
Every physician, head of a laboratory of clinical biology and supervising physicians working in a school, work environment and in residencies for children, youth and elderly are compelled to report a case of an infectious disease to a health inspector within 24 hours. The mentioned diseases are listed in a pre-determined and regularly updated list (which is the responsibility of the communities) (Flemish Government 2009a). More detailed information about infectious diseases can be found on the web site of the Flemish community (Vlaams Agentschap Zorg en Gezondheid 2010c). The reporting of a case contains information about the disease (syndrome, diagnostic technique, course and beginning of the disease) and demographic components.
In the French community, the notification of infectious disease outbreaks occurs in a similar way as in the Flemish community. The list of diseases includes: food poisoning, active tuberculosis, STDs, diseases which can be prevented by vaccination, bacterial infections, legionnaires’ disease, widespread diseases, zoonosis and rare diseases. More detailed information about the list of diseases can be found on the web site of the French community (French Community 2010b).
The German community applies the same proceedings as the French community.
On the federal level, the FPS Health, Food Chain Safety and Environment is supported by the Superior Health Council (scientific advisory department).
In the case of a major disease outbreak (e.g. the risk of national contagion or a disease outbreak in neighbouring countries), the communities will collaborate with the federal government to coordinate a national action plan.
Surveillance of an infectious disease
The goal of surveillance is the organization of the systematic collection, analysis, interpretation and dissemination of data in order to optimize the preventive programmes of each community. The surveillance of infectious diseases occurs in three ways: compulsory notification of infectious diseases by physicians and laboratories; registration by an extensive network of sentinel laboratories; and the organization of projects and programmes (for example the programme for STDs).
The IPH gathers the necessary epidemiological information (by using and/or reinforcing the existing surveillance system or by creating new ones), coordinates the risk assessment and gives epidemiological support (e.g. intervention, survey) to the health authorities.
5.1.6 Measures on lifestyle behaviours
A national campaign against drink-driving (BOB-campaign) was set up in 1995 by the Belgian Institute for Traffic Safety (BIVV-IBSR). Because of its huge success, the BOB-campaign has been renewed at the end of each year and has been copied by other countries. Local projects on the prevention and treatment of addictions can be financed by the Fund for the Fight Against Addictions. In 2008, a National Action Plan for Alcohol was also defined (see Chapter 6).
The main restrictions in place to protect minors from the negative effects of alcohol abuse include age limits (strong drinks, e.g. hard liquor, can only be sold to adults over 18 years old, other alcoholic beverages, e.g. beer and wine, only to persons over 16 years old). Advertisements for alcoholic products are also restricted. They may not be aimed at minors or involve minors (Act of 17 November 2006) (FPS Health, Food Chain Safety and Environment 2010a).
Prohibition of tobacco use includes the ban on smoking in public places, schools and work environments. Also, since January 2010, it is prohibited to smoke in the catering industry. The only exception is allowed for drinking houses where only drinks are served (Royal Decree of 22 December 2009 and Royal Decree of 13 December 2005). In addition, there are numerous prevention campaigns organized by schools and local health networks.
Schools are supported in providing a “smoke-free” school environment and a “smoke stop” course is organized to help adolescents give up smoking.
In line with European legislation, the sale of tobacco products is restricted to adolescents over 16 years old (Act of 1 December 2004). In places that sell tobacco products, leaflets and posters must warn the buyer of the health risks of smoking. Advertising tobacco products (and sponsorship by these companies) is prohibited. Furthermore, a warning about health risks on the cigarette packs is compulsory (Ministerial Decree of 27 October 2005).
Several initiatives are in place to promote healthy eating and exercise in schools. These include promoting the consumption of healthy food and drinks (eating fruit, healthy drinks and healthy snacks) and the integration of a nutrition and physical activity policy (see also Subsection Prevention measures in Section 6.1.1 Increasing accessibility). The promotion of healthy nutritional eating habits is coordinated by the local health networks.
Definition of vaccination programmes
A Belgian official calendar of recommended vaccines in Belgium is defined by the Federal Superior Health Council. Only the polio vaccination is compulsory and is under the responsibility of the federal state. For other recommended vaccines, each community develops its own policy: target groups, free (childhood) vaccination programme, public information, choice of providers, etc). Vaccination programmes slightly differ between the Flemish community and the French and German communities in terms of brand of selected vaccines or vaccination age (see HYPERLINK "http://www.zorg-en-gezondheid.be/basisvaccinatieschema/"http://www.zorg-en-gezondheid.be/basisvaccinatieschema/ for the programme of the Flemish community and http://www.sante.cfwb.be/index.php?id=vaccination0 for the programme of the French and German communities). In the region of Brussels Capital, both programmes are applied. The Superior Health Council is responsible for the coordination of these programmes.
In 2010, these programmes included vaccination against poliomyelitis, pertussis, tetanus, diphtheria, haemophilus influenzae type b, hepatitis B, measles, mumps, rubella, meningococcus type c, and pneumococcus.
Since September 2010 in the Flemish community and since September 2011 in the French and German communities, these programmes also include vaccination against human papillomavirus (HPV):
- In the Flemish community, this vaccination (using Gardasil ®) is available freely for girls in the first year of secondary school.
- In the French and German communities, this vaccination (using Cervarix ®) is available freely for girls in the second year of secondary school (girls aged between 13-14 years old in specialised schools are also concerned: “1ière S”; “1ière D”). Vaccinated girls will also have to undergo, at the age of 25 years, a cervical smear (currently recommended every 3 years).
Purchase and financing
Communities are responsible for the bulk purchase and distribution of vaccines, through contract directly with companies that produce them. Since 2004, the purchases of all vaccines listed in the vaccination calendar established by the superior council of health (with the exception of the rotavirus) are co-financed by the federal government (2/3) and the communities (1/3). The payment by the federal authority can be done under a system of advance and balance since 2007. For the region of Brussels capital, both communities and the Joint Community Commission (GGC/COCOM) are implied in the financing: the Flemish and French communities are responsible for mono-community institutions and the GGC-COCOM is responsible for institutions with both communities and private practitioners. The GGC-COCOM delegates the purchase and distribution of vaccines to the two communities but in return, they send invoices of vaccines supplied by institutions with the two communities and by private doctors to the GGC-COCOM.
Vaccines not provided freely by the communities (such as Rotavirus vaccine) are provided by the pharmacies and are partly reimbursed by the National Institute for Health and Disability Insurance.
For the distribution of free vaccines, practice modalities slightly differ between the communities. In the French and German communities, the free access to vaccines is only possible through the ordering of vaccines by the vaccinating physician to the French Community. Pharmacies do not provide access to the free vaccine programme of the French Community. Stickers necessary to obtain the free recommended vaccines for children up to 6 years are provided to the parents. At the time determined by the vaccination calendar, parents ask to the doctor of their choice (ONE consultation, school or nursery doctor, general practitioner or pediatrician) to carry out vaccinations. In return, they must give to the doctor the appropriate stickers. The physician is then able to replenish his stock. In order to preserve the quality of vaccines, sensitive to poor storage conditions, they are only available for vaccinators’ physicians.
In the Flemish community, vaccinators’ physicians can order the vaccine to the Flemish community by mail, fax or e-mail but also via Vaccinnet. Vaccinet is an electronic platform for the registration of vaccinated persons and the ordering of vaccines. The development of a similar system in the French community is in progress. With this application, vaccinators can order vaccines at any time, adjust the delivery times, where appropriate, and consult or register the vaccination status of the child. At the time determined by the vaccination calendar, parents can ask to the doctor of their choice (Kind & Gezin consultation, school or nursery doctor, general practitioner or pediatrician) to carry out vaccinations.
The fact that there is a system of stickers in the French community that does not exist in the Flemish community could cause problems if a Flemish child wants to be vaccinated by a French doctor. It should also be noted that when a child pass from the ONE to Kind & Gezin or vice versa, information on vaccinations are currently transmitted as a paper file.
- Vlaams Agentschap Zorg en Gezondheid (2011). Vaccination. Brussels, Vlaams Agentschap Zorg en Gezondheid.
- Question santé (2011) [web site]. Vacc.info. Les recommandations officielle en communauté française de Belgique. Bruxelles, Question santé.
- NIHDI (2008). Article 56. Campagne de prévention vaccination. Rapport 2004-2007. Brussels: National Institute for Health and Disability Insurance.
- Personal Communication (Murielle Deguerry from Irisnet)