Community health centers governance: experience in Belgium

1. Community health centers governance: experience in Belgium IAHP, December 12 2013 Isabelle Heymans, FMM

2. Community Health centers in Belgium • Inter-professional Teams: • family physician, nurse, physiotherapist, receptionist, • Social worker, dietician, psychotherapist • Health promoter • Missions: • Primary Health care, Accessibility, • Medico-Psycho-Social approach • Heath promotion and community development • Data collection, quality development • Participation of patients • Capitation • Public accreditation

3. Community Health centers in Belgium • Since 1972 - increasing number since 1990 • Today: 120 centers • 3-8 new centers a year • 5% of GP’s, 30% of GP’s <40 • 2% of population  15% in some places • Private, not-for-profit

4. Public or Private ? *Giusti and al, 1997

5. Public Purpose : 5 criteria’s * • Social perspective • concern for people’s well-being, autonomy, human promotion, dialogue, taking the context into account • Non-discrimination • with regard to race, gender, religion, political affiliation, social status, income level, … (sometimes positive discrimination for a kind of population or a specific disease with vertical program) • Population-based • to take responsibility for, and be accountable to a defined population  • Government policy guided • a concern to comply with government health policies and to fit in broader master plan (with discussion, agreements with authorities) • Non lucrative goals:   • Concern not to reduce the purpose of the service to profit making. • Good working and living conditions are a right for the staff. After that, profits should be reinvested in the service or other activities of social interest • * Giusti and al, 1997

6. Our experience Governance, oriented to supporting the public purpose? Some lessons from our experience • Co-Management : involving all the parties • Participation: strategy or objective ? • Mode of financing of the services and agents • Support organizations for quality development

7. Co-Management Involve all the parties • Workers • Users • Inter-sectoral • Public authorities « Gather collective intelligence to serve the objectives »

8. Co-Management • Workers • In the team, on the field: NO hierarchy • To support active participation of each one • Better for the quality • In the places to decide • Not only « representation », or « consultation » • Co-decision for the aims, missions, priorities, strategies, finances Know what they need to make a good job, See the evolutions on the field Hear the needs of the population …

9. Co-Management • Users • From their place in the services … to their place in the decision-making organs • Patients committee with representation in the GA, “professionnal patient”, one “patient in the board, … • Many intermediaries: Suggestion box, complaints office, mediation service, regular focus groups, Mediation process…. • Representativeness? Espress their needs and demands Evaluate quality : relation, organization, … …

10. Co-Management • Partners in the field • Other associations / services … • In the GA / Board / special consultative committees… Know what they need from us Also see the evolutions on the field Collaborate on different actions Give feedback on quality Control the pursuit of the aims…

11. Co-Management • Public authorities : National, regional, local (! Consistency) • Accreditation : recognition, missions given by the authorities, financing • Some agreements for additional activities / research/… • Dialogue : co-elaboration of the rules and criteria : objectives of authorities – knowledge of the « real work » on the field Democratic legitimacy Financing the service Control the use of the public funding Definition of quality criteria Can support this kind of service

12. Co-management • Dialogue public – private : Example : « ASI » • Missions = Accessibility, opening hours, inter professional coordination, data collection, quality development, health promotion and community development • 2014 : new law to support the launching of centers – thanks to our advocacy • Presence of the local administration in the GA ? Yes, but…

13. Balancing co-management • Place and Proportions… • Right place for each group • ! too few minorities • Concrete example: not-for-profit cooperative model (Scic–fr) / • One possible more category: the « guarantor »

14. Managing Co-management • Real conditions for democracy: • Managing the meetings, help everybody (or every group) to have info and understand, to have a voice, … • Need somebody to work for, and everybody to pay attention to • Co-decision of workers for the HR management: • collective = ok. Individual= hard… • Representativeness of the users in the organs • The role of a director? Leadership! • To facilitate collective decision-making, and to implement the decisions • Need education

15. Participation: strategy or objective ? • Strategy means… • only because it serves the quality of care • Objective! • Citizenship education can begin everywhere –> and there. • Awareness of the aims and challenges • Coherence • everyone is looking out for the aims ! It takes time, energy, means …= investment!

16. Funding • Mixed Financing of the CENTERS • Needs-based capitation • Function (Health promotion, coordination, …) • Fee for service • Target (a little) • Mixed financing of the AGENTS • Salary + fee for service • Some Freedom in allocation of the finances • for the allocation of means at a local level • not only to apply the top-down programs • Ex: community health action

17. Support organizations • Example: Our Federation: • A charter : Values and objectives : Solidarity, universal social security, equity, accessibility for all, support of autonomy of individuals and communities • Missions: • Support quality development (from quality of care to health promotion) • Support stewardship for public purpose and citizenship education • Advocacy for Primary health care and community orientation • MM/WGC KCE report 2005* *https://kce.fgov.be/fr/publication/report/comparaison-du-co%C3%BBt-et-de-la-qualit%C3%A9-de-deux-syst%C3%A8mes-de-financement-des-soins-de

18. Support organizations • KCE report 76 «Quality development in general practice in Belgium: status quo or quo vadis?»* : • An independent trustworthy body to : • Collect and analyze the data ; Provide feedback reports to the practices; Offer coaching and support for the practices; support the formative processes and reinforce learning activities; Issue accreditation certificates; • They communicate aggregated and anonymous data to the Health Authorities, and for research purposes • Separate support and control ! *https://kce.fgov.be/sites/default/files/page_documents/d20081027319.pdf

19. Thank You