“Promote an integrated health policy and not disease management policies”

Lhe Covid-19 crisis uncovered long-known and denounced health system failures. These are all opportunities for improvement to which public opinion is sensitive today and which we must seize.

Let’s go back in mid-March. The beginnings were marked by a focus on the hospital, the experts paraded on our screens, and the media highlighted the needs and innovations in progress in terms of technical equipment. Then came the questions of testing capacity and strategic stock in preparation for epidemics. Then only the tragic situation in the retirement homes, the first forgotten in the healing world, to which have been added since the precarious and homeless populations, mental health problems and other chronic diseases.

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A historical drift of our systems

If the urgency obviously imposed a first strong operational response, the following weeks revealed the effects of a historical drift in our systems, focused on reaction and not prevention, with a focus on curative, specialty and technicality. This phenomenon is all the more marked in Belgium, with a health system affected by the fragmentation between levels of power (federal, regions and communities), sectors (private and public), and networks of philosophical or political affiliation. This has moved us away from an integrated vision of health centered on the person, investing in the maintenance, promotion and prevention of health, and putting back in the spotlight the role of treating physicians and community and local socio-health services. . However, we now know that the virus has mainly affected already fragile populations, and that 99% of those who died suffered from other diseases (diabetes, heart disease, overweight, cancer, asthma, etc.), themselves influenced by socio-economic and environmental factors. These deaths are therefore also the result of an unpredictable and insufficiently integrated system.

Look at the patient differently

The crisis we are emerging from calls for a fundamental questioning of the way we conceive of health, and to look at the person not a posteriori, as a patient victim of diseases, but a priori, as an actor of his health. This supposes to conceive it in connection with its socio-economic environment, its mental health, its food, its environment of life and work, and its fundamental rights, including its freedom of therapeutic choice. Alongside the patient, the crisis has also brought back to the fore the role of health care and personal care personnel, and highlighted the importance of professions that are too little recognized. This is reminiscent of the expression of unease of the “white coats” in recent years, which has been insufficiently considered. The daily rounds of applause have shown a growing consensus in public opinion on a need for recognition and upgrading of these professions to which the Belgian State will have to respond.

Invest better

This echoes strategies for financing health policies which have been dominated by the search for economies of scale and cost reduction, while remaining excessively focused on curative and technology. This is how the regrouping into hospital networks of recent years, expected in order to improve quality, equity and safety, was essentially carried out on the basis of a logic of economic rationalization. Given the nature of the response to the Covid-19 epidemic, the way out of the crisis risks favoring the hospital’s reinforcement track. However, just as firefighters are not paid for the number of fires they put out, there is also a need to invest more and better in public and community health, health promotion and prevention activities. In institutional terms, this implies strengthened links with other sectors as well as with support and reception structures for the elderly, disabled and young people in difficulty in order to avoid the serious dysfunctions experienced in recent months.

Favor academic institutions

The system is also marked by lobbyists’ influence on health policies. Pharmaceutical and biomedical technology firms are overweight in funding and choosing research priorities, and de facto on policy and therapeutic directions. This tends to condition the choice of themes and budgetary investments on the existence of a market, as demonstrated today by the tensions between States and pharmaceutical companies for the discovery and provision of vaccines. This can also lead to an under-utilization of existing academic institutions, as manifested in the contracting of private firms for laboratory tests in the Covid-19 crisis. Universities, hospitals and academic laboratories have nevertheless demonstrated their willingness and their capacity to overcome institutional barriers and to collaborate concretely on common themes. This highlights the need for inclusive governance that is less subject to market logic.

A Green Deal too marginalized

Finally, our country is not yet up to the environmental challenges that are at the heart of the Covid-19 crisis: Belgium is one of the only European countries to stay on the sidelines of the Green Deal; the FPS Health does not invest enough in the link between environmental issues and public health, yet at the heart of the holistic One World One Health approach; the National Environment-Health Action Plan exists and is updated, but it remains under-used and under-funded.

Ambitious and realistic solutions exist

The observation that we draw here is shared with many countries. However, there are ambitious but realistic solutions, for which we are ready to invest alongside governments and all stakeholders in the Belgian health system. To start the process, the health component of the Sophia Plan offers four central avenues, which we explain here.

1. Promote an integrated health policy, not disease management policies.

The analogy of the firefighter can be repeated here: it is better for everyone to prevent the fire than to put it out once it has started. In terms of health, focusing only on the curative aspects and the hospital in particular would be a similar mistake. In practice, this involves redefining the contours of a social contract in health and co-constructing organizational models which put the person at the center of his own journey and his choices, and take into account the determinants of health in his context. (poverty, employment, housing, environment, education, eating habits, etc.). It also means seeing the hospital as a component on a continuum, with regard to preventive measures and the different levels of care and help (including outside health). Lastly, this implies setting up research as a public good on priority themes to promote health, by pooling public and private funds and by stimulating open source mechanisms for sharing scientific data and the results of this research.

2. Progress towards collaborative governance in health.

If health is everyone’s business, it’s about everyone being involved. It is possible, in each sector of activity, to identify actions that strengthen the impact of the sector on the prevention, protection and promotion of the health of populations (e.g. school food, soft mobility). This can ultimately translate into participatory and transparent governance mechanisms, which can anchor health in other sectoral policies. A parallel issue is to give a voice to the actors of the system and to its users, by considering each citizen as a responsible actor, able to pose the best choices for his health in his environment. This would make it possible to work on a better balance of powers between public, private and industrial sectors, in an approach of health democracy.

3. Revalue and rebalance the status of caregivers and support staff.

The reform of the law on health professions announced by the federal government in 2017 had already highlighted the need for multi- and multidisciplinary teams with a shared approach between professionals in health management, without this having happened. materialized. This is the type of approach that we think is necessary. The Prime Minister now seems to have heard the rage of hospitals and their staff. However, it will also be a question of maintaining a focus on upgrading professionals in general medicine, public and community health and other local multidisciplinary services.

4. Increase the volumes of health financing and improve their allocation.

Funding for health is insufficiently allocated to the most value-creating activities (health promotion and prevention, societal benefits). At the same time, they also do not allow health facilities, especially hospitals, to balance their accounts. Strategies need to be reviewed to gain relevance, with increased use of flat-rate pricing approaches. In addition, the health budget and the budgets of other sectors must make it possible to act upstream on the determinants of health, by promoting a healthy lifestyle and strengthening the immune system of people.

Short-term priorities

Rome did not happen overnight, nor would the ideal healthcare system be after the crisis. The first step is to identify realistic, affordable actions that can facilitate the emergence of the following actions. From the tracks identified above and the good practices recommended by international organizations, three first actions seem to us to be a priority:

1. Build and institute the social contract for health through a broad consultative process with the different levels of power, actors on the ground and citizens. This aims to outline the contours of an integrated health policy (targeted under our first recommendation) and stimulate action. In particular, this involves transcending the barriers of administrative powers separating the hospital (under federal authority) from first-line and local socio-health services (under the authority of the regions) and certain prevention services (under the authority of the communities).

2. Coordinate a series of sectoral debates (education, employment, industry, telecommunications, environment, social, regional planning, etc.) leading each sector of activity to strengthen its health agenda (see our second recommendation). This aims to create a common and sustainable transversal vision of health, respectful of the environment and the living and working conditions of the populations. These debates will notably result in a series of indicators used in the following action.

3. Implement tools and platforms for collective measurement of the impact of any political decision on the state of health of the population. There is a watermark here to strengthen the dialogue and interactions between the strategic and operational levels, by holding decision-makers accountable for the realities on the ground, and in return by strengthening the involvement of the field in the definition and monitoring of strategies.

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