Case study: Flanders’ Primary Care Reform towards people-centred, integrated care

Bart Van Gansen

Since February 2017, Flanders, Belgium, has been implementing primary-care reform based on the “WHO framework on integrated people-centred health services”, introducing major changes to improve the equity, efficiency, effectiveness and responsiveness of its health system.

Primary health care: from Alma-Ata to the Declaration of Astana

Primary health care is the cornerstone of a strong, supportive health system.  This was recognized in the 1978 “Declaration of Alma-Ata” and recently confirmed in the 2018 “Declaration of Astana”. In the 21st century, when the world community has committed itself to achieving the United Nations Sustainable Development Goals and WHO has embraced a mission to “promote health, keep the world safe, serve the vulnerable”, primary health care is as important as ever.  What is needed now is that it meets current needs.

Flanders’ Primary Care Reform

The Flanders region in Belgium has about 6.5 million inhabitants. The Belgian health system is characterized by a compulsory health-care insurance system and health policy is the responsibility of both the federal and regional levels.  In 2014, the Sixth State Reform shifted competencies related to the organization of primary care to the regional level.

The major reallocation of functions between the federal and the regional levels gave Flanders the once-in-a-generation chance to create the primary-care services it wanted. In working towards the Reform, Flanders has had to take a range of factors into account. The aim was to tackle the following identified challenges:

  • demographic changes and population ageing, which are generating an epidemiological shift towards chronic diseases, putting pressure on health-care organization;
  • fragmentation and bureaucracy in the existing system;
  • changing expectations, scientific innovations and new communication possibilities (which can unsettle existing convictions while offering opportunities for improvement at the same time).
    Addressing both the challenges and opportunities of contextual change requires a holistic vision of health combined with urgent action.

In February 2017, Flanders endorsed its Primary Care Reform. Since then, thanks to strong political commitment and the involvement of all segments of society through a large consultation process, the Flanders primary-care system has been substantially reoriented and restructured. Along with this, adjustments have been made in many other areas of government and administration.

The Reform aims to transition primary care towards people-centred, comprehensive, integrated care by:

  • integrating health and social care through the development of primary-care zones at the local level to improve coordination and planning. These will be grouped within regional care zones to facilitate the organization of services for larger parts of the population;
  • ensuring adequate primary-care capacity and continuity of care through the coordination of care for people with complex and/or long-term care needs, involving the health and non-health sectors and engaging informal caregivers as care partners;
  • promoting the Health-in-All-Policies approach to achieving health and well-being with a focus on the social gradient in health and vulnerable groups;
  • promoting a shift in mindset towards integrated, people-centred and multidisciplinary action, and providing the health workforce with the necessary knowledge and skills, through training, to position primary care at the centre;
  • establishing a knowledge centre for integrated care in the new Flemish Institute of Primary Care to provide a permanent source of expertise and stimulus;
  • developing information and communications technology to strengthen digitalization as an important catalyst for change and a resource for better collaboration in primary care;
  • focusing on the citizens, through social mapping, to better target interventions, and structuring the policy and services development process to involve them (including patients).

The Flanders Primary Care Reform, still in progress, is a radical, visionary and far-reaching process. It is about setting a cultural change in motion.

The whole reform process, which is expected to be completed by 2025, is being handled carefully and systematically. This includes considering the interests of all relevant parties in a bottom-up approach, which is crucial to creating ownership.  Sustained political support has been vital and an established professional consensus has strengthened the ability of the Minister of Health to advocate and facilitate change.

A forthcoming Regions for Health publication

A forthcoming Regions for Health (RHN) publication entitled “Creating twenty-first century primary care in Flanders and beyond”, will provide an in-depth analysis of Flanders’ experience in reforming its primary-care system. It will also include brief case studies of recent developments in some of the other regions participating in RHN. These present some of the differences in approach to primary care across the European Union and draw attention to the importance rightfully placed on it.  The publication will be launched at the 25th annual meeting of RHN in June 2019.