Belgium

As many of the policies addressing the challenges of long-term care and age dependency are set at a sub-national level, it is important to understand the demographic differences amongst the Belgian Regions. In the period 2019-2050, the share of 65+ people in the Belgian population is expected to grow from 18.9% to 25.2% (EU-28: 20%-28.5%), with most of the growth happening before 2030. At the same time, the share of 85+ will double from 2.8% to 5.6% (EU-28: 2.7%-6.1%). As a result, in 2050, 25,2% of the Belgian population will be 65 years or older (EU-28: 28.2%). Yet, in Brussels higher fertility rates and increased migration will result in merely about 18.5% of 65+ and only 3.8% of 85+.

Over the same period, the old-age dependency ratio measured as the proportion of 65+ compared with the 15-64-year-old population will rise from 29.5% to 46% (EU-27: from 31.4% to 53.4%[1]).The overall dependency rate would be highest in Flanders (48.2%) and much lower in Brussels (29.5%).

[1] Eurostat data: proj_19ndbi.

Life expectancy for men and women at age 65 is projected to progressively rise from 18.5/21.9 years (EU-28: 18.1/21.4) in 2017 to 18.8/23.1 years (EU-27: 21.8/25.1) respectively by 2060.

These evolutions will undoubtedly lead to an increase in LTC dependency. Generally, it is expected that the number of persons in need of LTC will double by the year 2060. Under an assumption of no policy change, the Ageing Report scenario suggests that public expenditure as share of GDP would rise from 2.3% to 4.2% (EU-27: 1.6%-3.1%) by 2070.  The impact of a progressive shift from the informal to the formal sector of care in Belgium would entail an estimated increase by 100% in the share of GDP devoted to public expenditure on long-term care (128% on average for the EU27).

From an organisational point of view, long-term care in Belgium is part of an integrated system of health care, complemented by social service provision. The focus on health care is accentuated by the fact that there is no specific long-term care legislation at the level of social security legislation.

For decades, Belgium has had a well-developed system of social protection covering the needs of dependent persons, such as the elderly and persons with disabilities or chronic diseases. This social protection scheme includes both cash and in-kind benefits, as well as some care allowances. The provisions for the elderly are for the most part distinct from those for disabled persons younger than 65, although there are initiatives to make the two systems more integrated. The system is, however, multi-layered and sometimes hidden within health insurance; other provisions come under regional competencies for social services. Its complexity makes it difficult to assess the total level of public spending on long-term care (LTC).

On the Federal level (social security), reimbursement for the medical aspects of long-term care is provided through the federal public compulsory health insurance system. The federal level is also responsible for the overall long-term care budget (for residential care and home nursing care, which are part of the public health insurance system), overall capacity planning (the number of beds in nursing homes), fees and level of public intervention. Medical services are organised and paid for by the federal health insurance system, while personal care is organised on a regional level. How these services are provided depends on the specific care settings.

From 2013, there was a substantial devolution of responsibilities for LTC from the federal level to the regions – including, from 2015, of residential care and the care allowance for the elderly (CAE). At the federal level the most important LTC service is now district nursing. Financing and regulation of in-kind and cash benefits are devolved to the regions, or so-called Communities. The most important residential care setting is the old-age home, with growing − but nevertheless insufficient − public financing.

Communities are further responsible for organising the provision of long-term care, the recognition of service providers, the integration of services and quality monitoring. Both the Flemish and French Communities regulate and organise home care, aimed at enabling patients to continue to live in their own home while they receive care. Home care is the most important form of community care, financed by the regions and to a lesser extent (some 15 to 20% of the total cost) by the user.

Costs for the patient that are not covered by social security benefits or the cost-compensation mechanisms of the health care system have to be borne personally. But cash benefits seek to balance expenses related to non-medical long-term care, which are otherwise borne by the individual. At federal level, a monthly allowance for disabled persons and the elderly (Tegemoetkoming voor hulp aan bejaarden; Allocation pour l’aide aux personnes âgées) is allocated to people above 65 years old for whom severe care needs are certified. This allowance is means-tested. Several other types of allowances exist, aimed at specific costs (e.g. incontinence material) or circumstances (e.g. palliative care at home). The LTC cash benefit (care allowance for the elderly), which amounts to a maximum of €571 per month on average for the whole of Belgium[1], helps to sustain affordability.

[1] This allowance amounts to €130 per month in Flanders

At municipal level, services and even residential care are provided as part of the social assistance package, through the involvement of Public Centres for Social Welfare (OCMW). Patients in residential care who do not have the means to pay for board and lodging are helped through social assistance services, which are provided by the municipalities.

The following in-kind long-term care benefits are also available in Belgium.

• Non-medical home care services are regulated and organised by the Communities. These services include help with personal care tasks (e.g. help with eating or moving around, hygienic help) along with instrumental help (e.g. light housework, preparing meals).
• Medical home nursing care, which consists of services such as wound dressing and drug administration.
• Day care and “short-stay” care centres provide nursing and personal care to elderly persons for whom home care is temporarily unavailable. This is meant for people who do not need intensive medical care but who require care or supervision and aid in the activities of daily living. A fixed daily compensation is paid by the compulsory health insurance.
• Elder persons who do not require much care can also be serviced in a semi-residential setting, where individual living arrangements are combined with collective facilities such as meal services or home help services. These arrangements are commonly known as “service flats”.
• Patients with moderate to severe limitations who do not need permanent hospital treatment are admitted to nursing homes (Rust- en verzorgingstehuis (RVT); maison de repos et de soins (MRS)). Each nursing home must have a coordinating and advisory physician who is responsible for the coordination of pharmaceutical care, wound care and physiotherapy. While patients must finance the residency costs themselves, nursing care is reimbursed by the compulsory health insurance.
• At Flemish level the VAPH (the Flemish Agency for Disabled Persons) subsidises services and institutions which provide care for disabled persons through day care or guidance. The current financial system has been revised and is replaced by a personal budget ‘Persoonsvolgende Financiering’ (PVF) provided to the person with a disability (since April 2016).

The service voucher is a means of payment, subsidised by the regional authorities, which allows a private user to pay an employee of a recognised company advantageously for household work. This system was originally designed as an employment policy, but became a substantial element in home help for the elderly. An important objective of the Service Voucher Scheme is to contribute to people’s work-life balance. Activities can take place both inside (cleaning, ironing, preparing food and doing occasional sewing work) and outside (ironing, shopping, supervised transport of persons with reduced mobility). Each adult living in Belgium can buy up to 500 service vouchers per year (i.e. 1,000 service vouchers per year per couple). The limitation per year can even amount 2,000 service vouchers for a limited number of categories (e.g. disabled users and parents with a disabled child). The first 400 vouchers cost EUR 9 each, the remaining 100 vouchers EUR 10 each. However, the user is eligible to a tax credit of 30 per cent on his personal income tax, reducing the real user cost per voucher to EUR 6.3 for the first 400 vouchers, and to EUR 7 for the remaining ones.

[1] This allowance amounts to €130 per month in Flanders

Number of carers

Recent and reliable statistics on the number of informal carers in Belgium is scarce. According to the Belgian Health Interview Survey (2013), 9.4% of the population aged 15 and over (i.e. about 870.000 persons) indicated they were informal carers. The percentage of informal carers nevertheless tends to increases with age, to reach a proportion of up to 15% of the population in the 55-64-year-old age bracket. In addition, women provide the lion’s share of informal care in the country (women: 10.9% vs men: 7.8%). According to a study by the Belgian Institute of Public Health, the contribution of informal carers to care systems is equivalent to 150.000 full-time jobs. Informal carers are therefore vital to the sustainability of care in the context of an ageing population.

Several surveys and studies provide insight into the characteristics of informal carers. The probability of providing care depends to a large extent on the gender and occupational status of the potential carer. Based on the data available for Belgium, a typical carer is a woman aged 45 to 75. Figures also suggest that people with a low income are more likely to be involved in informal help or care. Questions on the time spent on informal care reveal that 2 out of 3 informal carers of working age spent less than 10 hours per week on the provision of informal care, 16% spent 10 to 19 hours per week and 17% spent more than 20 hours per week. The time spent on informal care does not increase significantly with age[1].

[1] See figures on the time-use of Belgian people http://www.time-use.be/en/statistics

Recognition and definition of carers

In March 2013, the government proposed a new Act towards a legal recognition of informal carers. The text, which was adopted in 2014, seeks to define what constitutes an “informal carer” (mantelzorgers, aidants proches). Some elements in the definition are that informal carers provide help in a non-professional way and in cooperation with at least one care professional, and that the time spent providing informal care must amount to at least 20 hours per week.

While warmly welcomed by the organisations representing informal carers in Belgium (see Eurocarers membership), the Act suffered from a lack of clarity and specific categories as well as the (financial and other) rights and obligations attached to the legal recognition as informal carer were not properly defined. On the 15^th October 2019, the Belgian government approved two royal decrees which sought to address these issues by introducing the following provisions:

• A person providing care to someone with impaired independence will be able to request an official recognition as “informal carer” through the submission of a declaration on honour to the compulsory health insurance (mutuelle) and will, as a result, have access to a series of social rights, including a paid care leave as well as flexible working conditions. Health insurance services will check that the beneficiaries comply with a set of specific criteria regarding the relationship between the carer and care recipient.
• For recognised informal carers, the full-time leave scheme for medical assistance will be extended from 12 to 18 months.
• Measures will be put in place to alleviate the administrative burden faced by informal carers.
• Finally, civil servants and employees of public authorities will have access to a carer’s leave.

Access to information and advice

Health insurance companies also increasingly tend to provide information to informal carers about their rights and ways of preventing the negative impact of caregiving on their daily life, including through ICT-based platforms and hotlines.

The SAM online platform, for instance, provides access to a health and social directory as well as to a series of tools aiming to address the need for information, exchange and support often expressed by informal carers. The platform, which is only available in French, was developed by carers and organisations representing them, is accessible for free and is now promoted by one of the health insurance companies (Partena) as a key service to informal carers.

Informal carers are also supported through a growing number of social and psychological services and the existence of day centres and short-stay care centres which allow to alleviate temporarily the burden of informal caregiving.

Access to respite care

Respite care is available in residential care facilities and by other initiatives from different actors, such as sitting home-respite care provided by the sickness funds. Different regional and local organisations and institutions (social services of the sickness funds, informal carer associations, social services of the hospitals, public municipal welfare centres, etc) provide information to informal carers.

Patients who still live in their own homes, but who have limited or temporarily restricted access to informal care are helped under semi-residential care arrangements provided in day care and “short-stay” care centres.

Social inclusion of carers, access to education and employment:

In Belgium, support for informal carers is scattered over federal and regional authorities, provinces and municipalities. The wide scope of professional services for the elderly and dependent persons provides fairly good support to informal carers and enables them to combine care responsibilities with working life. Financial affordability is ensured by means of cash allowances.

 

Carer’s Allowance

A carer allowance (mantelzorgpremie) is available at the level of several Flemish local authorities (provinces and municipalities). Each local authority sets the eligibility requirements and the amount attributed to the informal carer.

Allowance for assistance to the elderly (AAE) (Tegemoetkoming voor hulp aan bejaarden / Allocation pour l’aide aux personnes âgées – see above) and the integration allowance (IA) (integratietegemoetkoming / allocation d’intégration): in 2014, some 153,000 persons benefited from an IA and a similar number of persons received an AAE. The number of claimants of an AAE increased in 2014 by 11% compared to 2009.

Supplementary allowance for children with disabilities under the age of 21: A supplementary allowance was paid to 58,937 children with disabilities (situation at 31 December 2014) (Federal Agency for Child Benefits, 2015).

 

Carer’s leave

A well-developed system of care leave also exists. People who are in paid employment (i.e. employees and civil servants) have access to a well-established system of paid leave schemes to care for a seriously ill family member up to the second degree. In addition, other existing leave arrangements, not specific to caring for an ill person, can be used to temporarily exit the labour market, but their main objective is not defined in terms of a care need. During the paid leave periods, payment of social contributions is provided by the social security. People receiving an unemployment allowance may be exempted from the duty to look for employment and can refuse a job offer when being in a difficult family situation. The National employment office (Office nationale de l’emploi – Rijksdienst voor Arbeidsvoorziening) approves or refuses the access to this benefit (dispense liée à difficulties sociales et familiales – vrijstelelling voor sociale of familiale moeilijkheden).

At the end of 2016, the federal government approved a new law on workable and flexible work (wet werkbaar en wendbaar werk), which includes regulations to encourage the provision of care leave. From February 2017, palliative care leave was extended from 2 to 3 months (1 month + 2 possible extensions). The maximum duration of time credit was also extended from 36 or 48 months to 51 months.

As of September 2020, a new carer’s leave was introduced allowing carers to take a carer’s leave of 6 times 1 month (for a full-time employee) over the duration of a career with a financial compensation of €1400 gross per month. Employers cannot reject the request for leave (as long as it is sent at least 7 days in advance), there is no seniority requirement and employees benefiting from the leave are immune to dismissal.

Time credit (Tijdskrediet/ Crédits temps) with a specific reason and career break in the context of leave for medical assistance or for palliative care: the career break in the context of a leave for medical assistance (15,461 claimants in 2014) has become a particularly highly appreciated carers’ leave. The number of claimants increased in 2014 by roughly 15% compared to 2013 and by 178% compared to 2007 (Table 1). Also based on figures for June 2007, approximately 3 in 4 claimants of a carers’ leave for medical assistance or for palliative care were female.

Figures reporting the average monthly amount paid by the National Employment Office (on average between EUR 350 and EUR 400 for 2014) (Table 1) suggest that most of the persons are taking a part-time career break rather than a full-time career break (see also Frans et al., 2011). It results in a temporary reduction of working hours rather than a full-time leave with a return to the job after the period of care leave. Moreover, the risk of poverty is (partly) reduced by combining part-time employment with part-time care leave given that the level of payment for persons with a dependent relative is mostly less than the poverty threshold.

Palliative care for self-employed persons (since October 2015 called ‘uitkering mantelzorg’/ allocation d’aidant proche): Only a limited number of self-employed persons (22 in 2011)12 made use of the old arrangement (before October 2015). No figures are available yet on usage of the new arrangement (since October 2015).

These schemes allow taking time off to care for a dependent person whilst receiving a replacement income provided by the unemployment insurance scheme. Periods of leave taken under these schemes count as contributions to other social security benefits such as pensions. As a result of the measures aimed at increasing the effective retirement age and extending career durations, the use of these schemes is, however, becoming more restricted. This highlights the need for a specific recognition and social protection of informal carers.

Carer’s leave

A well-developed system of care leave also exists. People who are in paid employment (i.e. employees and civil servants) have access to a well-established system of paid leave schemes to care for a seriously ill family member up to the second degree. In addition, other existing leave arrangements, not specific to caring for an ill person, can be used to temporarily exit the labour market, but their main objective is not defined in terms of a care need. During the paid leave periods, payment of social contributions is provided by the social security. People receiving an unemployment allowance may be exempted from the duty to look for employment and can refuse a job offer when being in a difficult family situation. The National employment office (Office nationale de l’emploi – Rijksdienst voor Arbeidsvoorziening) approves or refuses the access to this benefit (dispense liée à difficulties sociales et familiales – vrijstelelling voor sociale of familiale moeilijkheden).

At the end of 2016, the federal government approved a new law on workable and flexible work (wet werkbaar en wendbaar werk), which includes regulations to encourage the provision of care leave. From February 2017, palliative care leave was extended from 2 to 3 months (1 month + 2 possible extensions). The maximum duration of time credit was also extended from 36 or 48 months to 51 months.

As of September 2020, a new carer’s leave was introduced allowing carers to take a carer’s leave of 6 times 1 month (for a full-time employee) over the duration of a career with a financial compensation of €1400 gross per month. Employers cannot reject the request for leave (as long as it is sent at least 7 days in advance), there is no seniority requirement and employees benefiting from the leave are immune to dismissal.

Time credit (Tijdskrediet/ Crédits temps) with a specific reason and career break in the context of leave for medical assistance or for palliative care: the career break in the context of a leave for medical assistance (15,461 claimants in 2014) has become a particularly highly appreciated carers’ leave. The number of claimants increased in 2014 by roughly 15% compared to 2013 and by 178% compared to 2007 (Table 1). Also based on figures for June 2007, approximately 3 in 4 claimants of a carers’ leave for medical assistance or for palliative care were female.

Figures reporting the average monthly amount paid by the National Employment Office (on average between EUR 350 and EUR 400 for 2014) (Table 1) suggest that most of the persons are taking a part-time career break rather than a full-time career break (see also Frans et al., 2011). It results in a temporary reduction of working hours rather than a full-time leave with a return to the job after the period of care leave. Moreover, the risk of poverty is (partly) reduced by combining part-time employment with part-time care leave given that the level of payment for persons with a dependent relative is mostly less than the poverty threshold.

Palliative care for self-employed persons (since October 2015 called ‘uitkering mantelzorg’/ allocation d’aidant proche): Only a limited number of self-employed persons (22 in 2011)12 made use of the old arrangement (before October 2015). No figures are available yet on usage of the new arrangement (since October 2015).

These schemes allow taking time off to care for a dependent person whilst receiving a replacement income provided by the unemployment insurance scheme. Periods of leave taken under these schemes count as contributions to other social security benefits such as pensions. As a result of the measures aimed at increasing the effective retirement age and extending career durations, the use of these schemes is, however, becoming more restricted. This highlights the need for a specific recognition and social protection of informal carers.

• The 2021 Long-Term Care Report, Trends, challenges and opportunities in an ageing society, EC 2021
• The 2018 Ageing Report, Economic and Budgetary Projections for the EU Member States (2016-2070), EC, 2018
• ESPN Thematic Report on Challenges in Long-Term Care, Belgium, EC, 2018
• ESPN Thematic Report on work–life balance measures for persons of working age with dependent relatives, Belgium, 2016
• Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability, EC, 2016
• Adequate social protection for long-term care needs in an ageing society, European Commission, 2014
• Support for informal caregivers – an exploratory analysis – KCE, 2014