Reform of the Belgian Hospital System: Where Do We Stand?

by Violette Wathelet, CPAS councillor in Etterbeek

1. What is the starting point?

The Belgian hospital system is facing a triple pressure:

• Financial: Nearly one quarter of general hospitals are experiencing negative cash flow, suffering from inflation and from a complex historical funding model.
• Human: A severe staff shortage and increasing absenteeism are exhausting healthcare teams on the ground.
• Structural: The current funding model (partly based on the volume of medical acts performed) can encourage medical overconsumption rather than prevention or appropriate care.

2. The main pillars of the reform (Draft bill & Expert recommendations)

The reform project aims to move from a system focused purely on activity volume toward an integrated care model. The reform is notably based on a report by an independent group of experts mandated by the Interministerial Public Health Conference. The main pillars include:

• Reforming hospital financing: Separating the actual operating costs of hospitals from physicians’ remuneration. The goal is to create a more transparent global budget based on pathologies and the complexity of care (prospective model), in order to reduce financial incentives for excessive medical procedures.
• Restructuring the hospital landscape: The expert report recommends a clear hierarchy of healthcare institutions by 2031. Local care services would be maintained wherever possible, while highly specialized care and major emergency services would be concentrated in larger infrastructures (Reference General Hospitals or University Hospitals).
• Regulating extra fees and physician agreements: To counter the increase in non-contracted specialists, the reform seeks to better regulate additional medical fees so that access to healthcare does not depend on patients’ financial capacity.
• Digitalization: Integrating health records through a single secure digital platform to improve data sharing between healthcare providers.

3. Timeline and outlook

Please note: nothing has been voted on yet. The proposed timeline is as follows:

• Current consultation phase: The draft bill has been submitted to various healthcare stakeholders for feedback.
• Progressive implementation (2026–2031): Experts foresee the reform beginning concretely in 2026 with a ten-year transition period divided into two five-year phases, including an intermediate evaluation. Strict minimum standards regarding hospital site size (number of acute care beds) should fully apply by 2031.

4. Key concerns and tensions in the debate

A reform of this scale is generating intense debate between unions, doctors, and public authorities, touching directly upon our ecological and social values:

• Social dialogue: Workers’ unions denounce the initial lack of consultation and demand formal guarantees: no layoffs resulting from mergers or site reconversions, and massive investment in improving working conditions (Non-Market Agreements).
• Territorial accessibility: Concentrating specialized services and emergency departments raises concerns about geographical distance for patients, but also commuting times for healthcare workers.
• Funding the transition: The sector is demanding the creation of a properly financed transition fund, refusing to let this restructuring happen solely under budget-cutting pressure.

Focus on Etterbeek: What impact for the IRIS Sud Network, our Emergency Services and Primary Care?

As residents of Etterbeek, we are directly concerned by the healthcare structures operating in our municipality, foremost among them the Etterbeek-Ixelles site of the Réseau des Hôpitaux IRIS Sud. This public network embodies the model of a human-scale local hospital. Yet the ongoing reform directly affects the core missions of this type of institution: emergency care management and its connection with primary healthcare.

1. Reforming emergency care: Preserving proximity in Etterbeek

The hospital reform plans a rationalization and strict hierarchy of emergency services. The aim is to reduce pressure on infrastructures by redirecting major emergencies (serious trauma, strokes, complex cardiac conditions) toward large highly specialized centers, known as “Reference General Hospitals”.

• For the Etterbeek-Ixelles site (IRIS Sud): Vigilance is essential for the local Ecolo branch. The objective is to defend the maintenance of an efficient and accessible local emergency department operating 24/7 at the heart of our municipality and police zone. Blind concentration toward larger Brussels hospitals would increase ambulance travel times in an already dense urban environment and overload other facilities.
• Triage and orientation: The reform project aims to integrate general practitioners’ on-call services directly alongside or connected to emergency departments. The goal is for non-urgent cases (which currently represent a large share of admissions) to be immediately redirected to GPs, freeing time for genuine hospital emergencies and reducing pressure on IRIS Sud care teams.

2. The missing link: Strengthening primary healthcare

For hospital reform to succeed without leaving patients behind, ecologists consider the parallel reinvestment in primary healthcare (general practitioners, community health centers, home nurses) to be an absolute necessity. In Etterbeek, this coordination is crucial:

• Reducing pressure on hospitals upstream: Hospitals within the IRIS Sud network suffer from a form of “default overcrowding”. Due to the difficulty of obtaining quick appointments with family doctors or the lack of local on-call services, many Etterbeek residents turn to hospital emergency departments for basic healthcare needs. Strengthening primary care in Etterbeek means ensuring every citizen has access to nearby medical follow-up.
• The outpatient shift: The reform strongly encourages shorter hospital stays and more “day treatments” (outpatient care). This means that post-hospital follow-up (dressings, treatment administration, post-operative care) will increasingly shift to patients’ homes. Without a strong, interconnected and properly funded local primary care network, this transfer of responsibility will weigh heavily on informal caregivers and create harmful gaps in care, particularly for elderly or vulnerable residents.

3. Ecolo’s priorities for Etterbeek

In light of these developments, our local branch’s action and advocacy revolve around clear priorities:

1. Defending a public and social hospital model: The Réseau des Hôpitaux IRIS Sud is a public-sector actor linked to municipalities and CPAS/OCMW public welfare centers. It guarantees accessible healthcare for all, without financial discrimination. Reforming funding mechanisms must not weaken this model in favor of private or purely commercial structures.
2. Creating local synergies: We support strong integration between the Etterbeek-Ixelles hospital site, local community health centers, and Etterbeek’s GP network. Secure medical data sharing should simplify patients’ journeys between their neighborhood doctor and the hospital, without ever becoming a source of digital exclusion.
3. Rejecting strict austerity policies: Reforming hospitals cannot simply mean closing beds to save money. If second-line acute care beds eventually close in Brussels due to restructuring, every euro saved must be contractually reinvested into local emergency primary care, prevention, and mental health services.