Better health and without expenses: it is in Germany, why not in Belgium?


Our health system is cracking everywhere: shortages of nursing staff, shortages of general practitioners, long waiting lists when shrinking, salty bills after hospital visits… To ensure the right to health, changes are necessary. Therefore, “Medicine for the People” is looking for good experiences abroad. This is what brought us to Hausach in Germany, in the Black Forest region. There is a healthcare system like no other: Gesundes Kinzigtal.

Aurélie Decoene works in the Department of People’s Medicine. Serima Tebbache is a paediatrician and in 2021 she launched the assistant doctors’ strike in order to improve working conditions.

What is Gesundes Kinzigtal?
“Gesundes” means “in good health.” Kinzigtal is the name of the region. A rural area with a population of 80,000 where doctors work differently. their ambition? Make people healthier. This includes, among other things, preventing people from (really) getting sick. This is called investing in prevention. Because they are convinced: 90% of health problems can be solved outside the hospital.

More prevention, fewer ministers
Wanting to prevent people from getting sick, it seems obvious to say so. But the health system in Belgium does not work for this purpose. Example: Doctors and hospitals get paid according to the number of consultations and examinations they perform, not according to their results. This leads to waste and does not stimulate disease prevention. And investments to prevent people from getting sick are ridiculously low. For former N-VA MP Lorraine Barris, who has become PFL president, the reason is as follows: “It’s clear that every euro invested (by Flanders) in prevention benefits the federal government.” silly. With nine health ministers, this is where we come in. It must change.

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Sarah Maessen (medical student), Aurelie Decoin and Sirima Tabache in front of the Gesunds Kinzigtal health centre. (Photo by Aurelie Dequin)

1. The project

Step 1: Get to know each other and work together

The project began in 1992, when a few doctors from the Kinzigtal region decided to join forces to make the healthcare system more efficient. Like many general practitioners in rural areas, the workload is overwhelming. Everyone works their corner, 7 days a week, from emergency to emergency. Little or no vacation. The result: the job doesn’t make you want to and young doctors often prefer to move to the city.

By cooperating with each other, they learn each other’s strengths, distribute guards, etc. One of the founding doctors tells us: “At some point, we realized that nursing home residents who were sent to the hospital were often sent between 7pm and 9pm. Why? Because GPs are not very available at this time and carers often see In nursing homes, the only solution is to call an ambulance.Then they devised two solutions: They set up a call number that can be called in the evening until 9 pm, and they established protocols in cooperation with caregivers in nursing homes to determine the necessary care depending on the problems they face.

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Gesundes Kinzigtal has set up a collaborative and supportive process for various assignments, which is very attractive to young clinicians. (Photo by Aurelie Dequin)

They are gradually creating guidelines for all common problems (such as smoking, physical inactivity, diabetes, osteoporosis, obesity, depression, etc.). Before, everyone worked alone. Today, these guidelines govern 80% of their work. This saves a lot of time and better working conditions help convince young doctors to settle there.

Step 2: Health as a goal

The project took on a new dimension in 2005 when the Doctors Network decided to join the OptiMedis organization. Leitmotif: to produce health, thus investing as much as possible in the prevention of disease. This approach assumes a certain type of financing that gives Gesundes Kinzigtal a certain freedom to invest according to his goal. Each patient gets a certain amount each year, whether or not the person uses the healthcare system. This type of funding pays to prevent people from getting sick. This is called pooled financing. This is the opposite of the funding we have in Belgium. Here, the majority of doctors are paid according to the number of patients they see in consultation or pass under the scanner.

Half of the area’s GPs have since joined the project. They work with specialist doctors (cardiologists, pediatricians, gynecologists, etc.) and a few physiotherapists. This makes about fifty doctors in total. Every six weeks, they see each other in interdisciplinary teams, that is, between doctors who do not do the same job (in Belgium, this is not done). They actively cooperate with hospitals, nursing homes and pharmacies. They have a large health center where they meet and where registered patients can exercise. And all this in the middle of the mountains for a population of 35,000 patients spread over ten villages. Can you imagine it in the middle of the Ardennes?

deficiency under control

The shortage of young doctors is now under control because there are many advantages for them to work at the Gesundes Kinzigtal. In addition to interdisciplinary exchanges with other types of doctors, they also receive great administrative and IT support. They estimate that 30% of young doctors would leave the region tomorrow if Gesundes Kinzigtal stopped.

The main topic of discussion with young doctors? They want to become employees because it allows for a better work-life balance. Thus, the graduates, who all remained self-employed, are seriously considering moving to the payroll system within the next five years.

2. Sick

Results in

In a few years, the patients’ lifespan increased by 1.2 years. Elderly patients can live 1.4 years longer without needing home care. The icing on the cake: It costs less and saves about 40 million euros. Half of this amount is reinvested in prevention, and half is donated to the general insurance companies that finance the project.

What is changing for patients?

To prevent patients from getting (really) ill, the first visit to the doctor is crucial. Physicians are financially incentivized to invest the time in the first meeting to fully understand the patient’s situation.

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Gesundes Kinzigtal speaks: Patients registered at the health center have the opportunity to exercise there. (Photo by Aurelie Dequin)

After this assessment, patients who require it begin a journey with problem-specific follow-up (dietary follow-up, smoking cessation, psychotherapy, discussion groups, home visits to assess risk factors, etc.). The patient has a partner throughout the procedure. In total, 8,000 of the 35,000 patients choose to participate in one program or the other.

3. Money

How much does it cost?

For patients of Gesundes Kinzigtal, nothing changes in terms of costs. Two general insurance companies agreed to finance the project. So they fund the Gesundes Kinzigtal on a flat rate basis for their 35,000 patients. German patients pay less than Belgium to go to the doctor or hospital. On the other hand, they pay very dearly to their health insurance fund, i.e. between 7.5% and 15% of their salary depending on the level of income. Medicine for the People is calling for full funding through Social Security without additional costs for patients, like what happens in Scandinavia.

(It’s not) all about the money

A healthy population is the first priority of Jesonds Kinzigtal. But they are being pressured by the insurance companies that finance them. These require short-term financial results. But investing in prevention (eg in nutrition education in schools) can only lead to long-term effects. Insurance companies are also questioning the interest of the project because such efforts are not worth it for such a small population. Gesundes Kinzigtal says: “We stand for a culture of quality, mutual trust and innovation, not a culture of money. This type of project can only work on a local scale, for a population of between 50,000 and 150,000 people as a maximum. The more homogeneous the needs of the population, the better the organization of care.” What will help them? “Having to deal with just one general insurance company…and making the whole health care system work like ours.”

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Patients are offered a specific program based on their health problem. (photo by Aurelie Dequin)

The ambition of the Gesundes Kinzigtal is a great inspiration for all those who fight for the right to health. Their difficulties also show the importance of linking this struggle to a community of people first, not to profit.

4. Think big

Comprehensive Care: Traveling around the world

Gesundes Kinzigtal is a good experience of so-called “integrated” healthcare. This type of model makes it possible in principle to achieve a triple objective: improving the patient experience, improving the health status of the population, and reducing spending at the same time. Good experiences of this kind abroad bring a lot of perspectives to organize our healthcare system in Belgium in a different way. Between mounting bills, growing waiting lists, and worsening nursing staff shortages, it’s clear we’re going to need it.

Gesundes Kinzigtal invested heavily in sports infrastructure (“because there was a huge void to be filled in the region”). Other experiences of this kind abroad show the large number of areas in which prevention can be invested. In New Zealand, Manukau Health is actively collaborating with the public social housing company Housing New Zealand to improve housing quality and relocate families who do not live in health-friendly housing. In a very different vein, in Alaska, the Nuka Cooperative Health Care System prioritizes combating violence against women. In the United States, Kaizer Permanente prioritizes nutrition education.

We are one

Can you imagine such an initiative in Belgium? An organization that works to improve people’s health and makes it happen. An organization that makes health professionals collaborate intelligently and provides a tangible response to shortage problems.

50 years of medicine for the people: “To change the world, we must have people with us”

The challenge is even more complex in Belgium, with nine healthcare ministers. Their plans and directions are contradictory. Their separate budgets separate healthcare providers. Getting all health sectors on the ground to work together means creating unity of leadership at the top. And for that we need a Minister of Health.

Health is right

The preventive approach to health care is one of the three unique ideas in Medicine for the People for the Right to Health for All. For more information:

Interview published in Solidaire magazine.
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