Health care reform in Belgium: contracting for co-creating integrated care as change management strategy

Abstract

Introduction: The Belgian Health Care Reform: "Integrated Care for a better health" was approved by all competent ministers in 20151. This Plan is based on the principles of Triple Aim2, together with equity and job satisfaction for the care providers. The core strategy of the plan is to drive change in a 'mixed or guided bottom-up approach', with large-scale locoregional change piloting projects implemented on and by the field, and government as facilitator. Over the past year, field actors of pilot regions worked together to elaborate an actionplan with local collaborations and initiatives in order to achieve integrated care. Different stakeholders from health care as well as social care are involved including patients and citizens. In the course of the co-creation process between the wide variety of field actors and government several difficulties surfaced, both from the projects and policy perspective. Description of policy context and objective: Belgium has an accessible health care with a national, compulsory health insurance (covering 99% of the population). Fee for Service, fragmented services and lack of coordination and communication make the system inefficient and unsustainable for dealing with multimorbidity. A legislative basis is created to allow pilot regions to test new organizational structures (integration management), work across silo's and operate in a system of shared savings. Predicted expenditure, for the determined target population is guaranteed as revenue: by increasing efficiency, gains can be reassigned by the project. Target Population: The Plan targets the whole Belgian population with a focus on people with a chronic disease. 14 projects (2.584.824 inhabitants) are selected for implementation as from 1.1.2018. Highlights: Facilitators/barriers for implementation: - Anchoring visionary leadership in governance supported by stakeholder leadership on a national level - A national strategy for ICT system and data management is a priority and prerequisite for projects to be operational (national eHealth plan), and needs specific investment. Needs are identified in co-creation. - Close interaction between authorities and pilots - Dealing with institutional and legal hurdles between regional and federal authorities and the wide range of fractionated competencies in health and social care. - The projects are multi-stakeholder consortia with a mix (of conflicting) interests of partners. The uncertainty of achieving the triple aim makes projects hesitant to take risk for pre-financing innovative actions. Uncertainty on the impact on revenue challenges the confidence so hardly needed in the shift towards integrated care. - Need of social entrepreneurship with a population management scope conflicts with traditional social profit service delivery. Comments on transferability and conclusion: From a healthcare policy perspective, each country system is faced with the same complex process of changing the existing structures and cultures. The Belgian approach combines stimulation of bottom up ideas and entrepreneurship with guidance from the policymakers by setting out the framework for innovation, creating a safe environment for setting down sustainable system change. This takes time: uniting different stakeholders around the same vision, the will to embrace the complexity and to take the plunge.