Integration or Fragmentation of Health Care? Examining Policies and Politics in a Belgian Case Study

Document Type : Original Article


1 Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium

2 Department of Family Medicine and Population Health (FAMPOP), Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium

3 Centre for Population, Family & Health, Department of Social Sciences, University of Antwerp, Antwerp, Belgium

4 Centre for Health Systems Research & Development, University of the Free State, Bloemfontein, South Africa


Globally, health systems have been struggling to cope with the increasing burden of chronic diseases and respond to associated patient needs. Integrated care (IC) for chronic diseases offers solutions, but implementing these new models requires multi- stakeholder action and integrated policies to address social, organisational, and financial barriers. Policy implementation for IC has been little studied, especially through a political lens. This paper examines how IC policies in Belgium were developed over the last decade and how stakeholders have played a role in these policies.
We used a case study design. After an exploratory document review, we selected three IC policies. We then interviewed 25 key stakeholders in the field of IC. The stakeholder analysis entailed a detailed mapping of the stakeholders’ power, position, and interest related to the three selected policies. Interview participants included policy-makers, civil servants (from ministry of health and health insurance), representatives of health professionals’ associations, academics, and patient organisations. Additionally, a processual analysis of IC policy processes (2007–2020) through literature review was used to frame the interviews by means of a chronic care policy timeline.
In Belgium, a variety of policy initiatives have been developed in recent years both at central and decentralised levels. The power analysis and policy position maps exposed tensions between federal and federated governments in terms of overlapping competence, as well as the implications of the power shift from federal to federated levels as a consequence of the 2014 state reform.
The 2014 partial decentralisation of healthcare has created fragmentation of decisive power which undermines efforts towards IC. This political trend towards fragmentation is at odds with the need for IC. Further research is needed on how public health policy competences and reform durability of IC policies will evolve.



Commentaries Published on this Paper 

  • Overcoming Political Fragmentation: The Potential of Meso-Level Mechanisms; Comment on “Integration or Fragmentation of Health Care? Examining Policies and Politics in a Belgian Case Study”

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  •  Belgium’s Healthcare System: The Way Forward to Address the Challenges of the 21st Century; Comment on “Integration or Fragmentation of Health Care? Examining Policies and Politics in a Belgian Case Study”

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  • Policy by Pilot? Learning From Demonstration Projects for Integrated Care; Comment on “Integration or Fragmentation of Health Care? Examining Policies and Politics in a Belgian Case Study”

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  • Integration of Healthcare in Belgium: Insufficient, but There Is Hope; Comment on “Integration or Fragmentation of Health Care? Examining Policies and Politics in a Belgian Case Study”

         Abstract | PDF


  • Integration of Chronic Care in a Fragmented Healthcare System; Comment on “Integration or Fragmentation of Health Care? Examining Policies and Politics in a Belgian Case Study”

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Authors' Response to the Commentaries

  • The Tale of Nine Belgian Health Ministers and a Multi-level Fragmented Governance System: Six Guiding Principles to Improve Integrated Care, Responsiveness, Resilience and Equity; A Response to the Recent Commentaries

         Abstract | PDF



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