Interview with Laurette Onkelinx, Minister of Public Health, Federal Public Service (FPS) Health, Food Chain Safety and Environment

With an expenditure of more than 10% of GDP on health, Belgium maintains one of the world’s leading healthcare systems. That said, could you please comment on the current state of the healthcare system and the governments’ key priorities with respect to health?

Indeed, Belgium does boast a highly commendable healthcare system which provides a high standard of services to patients. Nonetheless, our primary objective and key challenge today is ensuring the sustainability of the system by preparing ourselves for the future and bolstering the ballooning expense levels. Viewed in the broader context of the government’s budget, it was not uncommon to have budgetary cuts imposed on our expenditure. However, since the economic crisis we have experienced dramatic increases in the size of these mark-downs, culminating with an unprecedented massive decrease in the government budget in excess of €12 billion in 2012. Without a doubt, this introduced a new era in the governments tightening budget. Fortunately, I managed to maintain a sufficient, though smaller, growth in the healthcare budget.

More specifically, although our challenges are not widely dissimilar to those experienced throughout Europe, Belgium is faced with a rapidly aging population as well as a declining availability of healthcare professionals. That is, owing to innovations in healthcare and medical treatments, we are fortunately able to improve the wellbeing and life expectancy of the population. At the same time however, this is leading to a situation where we have an increasingly larger aging population that out numbers the younger population. Obviously, this gives way to two key issues. First being the increased burden on the healthcare budget and therefore its sustainability since the elderly require medical care. Second is the system’s increasing difficulty in coping with these demands due to the declining availability of healthcare professionals (namely nurses and general practitioners) as a result of the professions dwindling attractiveness.

On a more personal level, I am also particularly concerned with the inequality of people’s access to healthcare. Several local as well as European studies have indicated that there is to some degree a level of inequality in terms of access to healthcare for those from lower educational backgrounds, lower incomes or even different gender groups. Hence, in line with my socialist views, I would like to ensure that all patients are guaranteed equal access opportunities regardless of their backgrounds.

Broadly speaking, these represent the key issues which we have prioritised and have been working towards addressing. Nonetheless, there remains much room for improvement and we are dedicated to addressing these throughout the future.

What specific strategies have you devised in order to address these afore mentioned challenges you are facing in the healthcare system?

Naturally, addressing the topic of sustainability is an annually recurring issue where we try to determine how we will go about financing the healthcare system. This is of courses a complex task since setting this year’s budget and cost containment measures has a direct effect on the following year’s budgets and so on. Hence, although it is difficult with annual decision making to develop long term policies for cost containment, our measures are recurrent and structural and do generally have a positive budget impact on the future.

On the other hand, with regards to increasing the availability of skilled healthcare practitioners, we have implemented a range of measures designed to increase the appeal and attractiveness of those professions. For instance, we have executed a number of financial plans that assist general practitioners in establishing their practices or making them more affordable through resource sharing schemes. Similarly, we are currently evaluating the educational system’s capacity to fulfil the adequate supply of practitioners. Based on these findings, we will subsequently take the necessary actions to create an adequately progressive environment that will stimulate the pursuit of such qualifications.

You mentioned earlier that 2012 saw a slower growth in the healthcare budget. Having said that, do you foresee a point in the future where we can expect to see the levelling off of these measures?

The budgetary cuts of 2012 were arguably the peak of such significant measures and we expect these to be less dramatic in the following year. After all, these proceedings are structural as I mentioned earlier and hence they need not be recurrent. That said we will soon see how this pans out since the budgetary allocations for 2013 are fast approaching, however we do not expect them to be as intense as this year’s containment measures.

Do you think that maintaining or improving the healthcare system relies on increasing the financial means or implementing more effective policies?

I would say that sustainability of the healthcare system relies on a combination of both financial means as well as more effective policies. All in all, cost containment involves improving the quality of services while employing fewer resources.

As the ministry of health, we are responsible for balancing public health requirements with budgetary constraints. To put it into perspective, Belgium makes extensive, if not excessive, use of radiological devices illustrating one of the pitfalls of providing high levels of accessibility to healthcare. Not only is this an expensive practice, but it also poses significant public health risks due to inordinate exposure to irradiation. Hence, not only will we be able to reduce radiation health issues by decreasing this activity to cases where it is essential, but this will also have a positive effect on healthcare expenses, thereby combining public health objectives with cost objectives.

On a similar note, how does the Ministry of Health balance its cost containment objectives with its ambition to improve healthcare by ensuring access to the latest innovative medication?

Simply put, our predominant objective is not cost reduction; rather it is ensuring access to the best available medicines. More specifically, we first allocate a budgetary target applicable to drugs and then within these parameters, our goal is to provide full access to innovative drugs. Hence, we have placed access to novel medicines as an absolute priority for the public healthcare system while the means employed in realizing this remain provisional and dependant on the expenditure levels at the time. In other words, the cost containment measures will never be directed at denying access to new and innovative drugs.

Would you say that the industry, or other stakeholders, can contribute in one way or another towards guaranteeing the healthcare systems sustainability?

As a public institution, we must first ascertain that our financial resources are employed effectively and efficiently. Therefore, although the incidences of non-value added, so called ‘me-too’, drugs is generally on the decline, we must ensure that our resources are expended on more urgent and necessary activities; namely, unaddressed medical needs. Fortunately, pharmaceutical companies today are increasingly directing their research efforts towards addressing the myriad of therapeutic areas with unmet needs including oncology, orphan diseases and even basic pathologies that still have research gaps, among many others. Having said that, such efforts by the pharmaceutical industry will certainly contribute towards minimizing inefficient healthcare spending and we are delighted that this is the general trend we are observing in the industry today.

Similarly, despite the fact that we as a public institution have widely dissimilar objectives from the market driven profit-orientated pharmaceutical companies, we do share a level of understanding of our respective situations and constraints. As a result, we have been able to find a common ground and are increasingly engaging in partnerships where we attempt to share the costs in some occasions. For example, in instances when we are presented with certain highly innovative but prohibitively expensive drugs, we manage to strike a deal which gives us access to these drugs at affordable price levels. These are negotiated contracts between INAMI – the local reimbursement authority – and the respective companies where either the costs or risks associated with the drug are shared.

Broadly speaking, such sharing schemes are a relatively new practice in the industry but I believe this is a reflection of the changing environment which necessitates a more unified approach. It comes as no surprise therefore that we have been able to form close and constructive collaborative initiatives with the industry which certainly has positive outcomes. After all, it is much easier to be constructive now that we have common goals which primarily include ensuring full access to critical drugs.

In your opinion, what makes Belgium such and attractive market for innovators and how can the environment be further improved upon to ensure its continued leadership?

Belgium most certainly has secured a favourable framework which appeals to the innovative pharmaceutical industry that has grown to employ more than 31,000 employees in Belgium. This is an impressive figure by any measure, demonstrating the importance of the industry to the local economy, and that continues to grow.

In recognition of the importance of the sector, I believe Belgium has always maintained a conducive and dynamic fiscal policy, both from the federal as well as the regional governments, that aims to attract R&D activities through incentives including patent deductions, tax breaks and advantageous measures for employing R&D staff. Moreover, Belgium boasts a high standard of education of qualified professionals with a dense network of top academic institutions, further contributing to the country’s appeal.

In addition to this, Belgium prides itself on its leading clinical trials sector which offers some of the most rapid approval times, high quality of services and expertise; all key drivers of the clinical trials industry. Likewise, Belgium’s widespread access to healthcare also ensures relatively swift patient recruitments as well.

Some have pointed out that although the reference pricing system could make sense in some countries, this could be potentially damaging for countries like Belgium with a strong presence in the industry particularly in pharmaceutical R&D and exports as well as causing a spiralling effect on drug prices. What is your position on this?

This clearly represents one of our cost containment measures which we spoke of earlier. To be frank, we felt that such drastic cost containment measures were necessary because of the overall pressure on the government’s global budget. In other words, we were left with no option but to exercise some taboos, if you will, which we generally wished to avoid. The reference pricing system (RPS) is certainly one of them.

Nonetheless, I think we have been quite reasonable and have kept an open and direct line of communication with both companies and industry representatives on the topic. Through dialogue, we were able to evaluate the impact of this measure and make it as reasonable as possible, taking into consideration the industry’s constrains. Ultimately, we will able to reach our objective and reduce our costs by means of the RPS while minimizing its impact on patented innovative drugs.

Hence, our overall aim in this respect is not to decrease the prices of recently introduced novel drugs, thereby safeguarding the companies’ investments. Instead, we allow the companies to reduce the costs of their other products which are more mature and established.

What are the possible scenarios that you foresee in which the government and the pharmaceutical industry could cooperate together to broaden access to innovative medication in Belgium?

We do have a number of projects designed to further stimulate the availability of innovative medicines to patients. For instance, we are currently developing a new regulation that will allow for accelerated market access of truly innovative drugs that address unmet medical needs. Due to its complex and multidisciplinary nature, this project has been several years in the making but we are pleased to announce that we expect to finally introduce it early next year. Without a doubt, this a pioneering project which will contribute significantly towards ensuring the treatment of unaddressed pathologies by introducing these novel drugs to the market 12 to 18 months earlier.

In terms of healthcare, what is on your agenda for the foreseeable future? What challenges do you wish to overcome, and what reforms would you like to precipitate in the market?

Generally speaking, my primary focus is on ensuring that all Belgians are offered comprehensive access to healthcare. In addition to this, since the recent breast implant scandal which sparked a revamp of EU medical device rules, I am also emphasizing on guaranteeing the security of our patients. Along with this, I would also like to ensure that patient’s wellbeing is preserved by reducing the exposure to irradiation from radiological devices, for instance, by reducing their overzealous and unnecessary uses as mentioned earlier. This has become a public health concern and we intend to control this health risk, both for the wellbeing of the patient and the healthcare budget.

Finally, it goes without saying that I intend to ensure that the overall sustainability of the healthcare system is maintained, as is the case with most, if not all, of my European counterparts.

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