What does the Organisation of Community Health Centers do?
The Organisation of Community Health Centers (OCHC) is an umbrella-organisation for all the Flemish
CHCs and has formulated in its policy 2010-2015 the following strategic objectives:
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Professionalization and quality improvement of CHC in the domains of concepts of care, offer
of care and organizational management.
Increasing the accessibility of health care for patients in Flanders and Brussels and
development through the stimulation of new CHCs.
Development and follow-up of the implementation of the concept CHC and advocating it in
the health landscape, increasing its visibility.
Representation of the members and advocating for the sector (including patients) in the
domains of financing, politics and employment.
Influencing policies in order to achieve the goals.
Development of an organizational model for the CHCs adapted to context and goals.
Short history of the Community Health Centers in Flanders.
The first community health centers in Flanders started in the mid-seventies on the initiative of family
physicians who were active in their student time in all kinds of socio-medical working parties in the
Flemish medical faculties. This initiative was a follow-up of the critical student movement of May ’68.
The initiatives were inspired by societal movements like “world schools”, looking for answers on the
questions that a lot of students in medicine were facing: “How can we make the medical profession
more responsive to the needs of the society, especially the needs of those who are socially
deprived?”. At the international level, inspiration was found in Quebec (Canada), where the model of
“Centres Locaux de Santé Communautaires (CLSCs) was developing, as a result of a cooperation
between students and citizens.
Working groups formulated a concept of “Community Health Centers” (1974) as an alternative, to
make the medical profession more relevant to the needs of society. The concept defined the
community health center at the level of primary care, operating in neighbourhoods, whith a
multidisciplinary team (family physician, nurses, social work, physiotherapy, dieticians,…) addressing
the physical, psychological and social problems of the local population with a lot of attention for
prevention and health promotion and participation of the target population.
Accessibility and a low financial threshold were important principles. This was the main reason for
the search of another payment than the prevailing fee-for-service payment in the Belgium health
system. In the late seventies, the Flemish Association for Capitation Payment was established. Apart
from the financing system, there were other barriers for the realization of horizontal
multidisciplinary cooperation. The deontological code as defined by the “Order of Physicians”
hindered interdisciplinary cooperation on an equal bases.
Most of the Community Health Centers started in the seventies as initiatives of motivated family
physicians and other health care providers. More recently, also the social sector took initiatives for
the start of new health centers.
The first Flemish Community Health Center started in Alken, an initiative from “World Schools Alken”
in 1976. This was followed by the Community Health Center “De Sleep” in Gent in the same year. In
1978, the Community Health Center Botermarkt (Ledeberg – Gent) started and the next year CHC
“De Brug” (Brussels). In the eighties CHC “Brugse Poort” (Gent, 1981) and CHC “ZwartbergWaterSchei” (1983). In 1995, the first center in Louvain (De Ridderbuurt) started.
In 2000 the Public Welfare of the city of Ghent, together with Ghent University, took the initiative to
start the “Universitary Center for Primary Health Care” (Nieuw Gent) and in 2003, CHC “Daenshuis”
(Aalst) started, followed by CHC “De Central” (Kessel-lo). In 2005 CHC “De Kaai” (Gent) and “De Vlier”
(St-Niklaas) were established. In 2007 followed CHC “Wel en Wee” (Mechelen). In 2008 three new
health centers started: CHC “MediKuregem” (Anderlecht) en CHC “De Regent” (Antwerpen) and “De
Vaart” (Vilvoorde). In the recent years the following CHC started: “Vierkappes” (Tienen, 2009), CHC
“Kappelenberg” (Gent, 2010), CHC “Watersportbaan” (Gent, 2010), CHC “De Punt” (Gentbrugge,
2013), CHC “Lokeren” (2013).
All the Flemish community health centers use the capitation system. Actually 60.000 Flemish patients
are on the list of CHCs, with an annual increase of 5%.
Capitation payment system.
Article 52§1 of the law of 14 July 1994 indicates that a capitation system is possible, for the payment
of primary health care delivered by family physicians, nurses and physiotherapists.
Every month, the CHCs receive a fixed amount per patient on the list. Since the 1st of May, the
capitation is calculated based on an annual “photograph” of the patient population, using 80
variables describing the “needs” of the population (age, sex, morbidity, social status, urbanization,
disability,…). An average is calculated per CHC, reflecting the “average need” of the population
served. This approach prohibits “risk selection”, as the capitation increases when the population is
more ill. The capitation is used to pay for consultations and home visits. Technical interventions (ECG,
cryotherapy,…) are paid in fee-for-service, using a third-party payment mechanism. There is no copayment at all for the patients on the list for services of family physicians, nurses, physiotherapists.
The patient commits him/herself to always consult a care provider from “his/her” community health
center. If he/she sees a provider outside de CHC, he/she has to pay, without reimbursement. The
exception is when this happens in the framework of continuity of care (night, weekend,…).
The capitation system stimulates prevention and health promotion. Moreover, there is a special
allowance for preventive activities for 45+. Most of the CHC develop specific programs like “diabetes
clinic”, focusing on empowerment of patients, often using a “group approach” where experiences
can be exchanged and shared.
A lot of CHCs offer other services like nutritional consultations, Tabacology (supporting to quit
smoking), podology and almost all the CHCs have social workers in their team. Health promoters in
the CHCs do not limit their activities to a patient on the list, but look at the population of the whole
community, in cooperation with local health promotion agencies.
In 2008, a study by the Federal Knowledge Center on Health Care
(http://www.vwgc.be/media/Documenten/GESLOTEN%20GEDEELTE/Forfait/KCE%20reports%2085A.
pdf) studied the performance of the community health centers in the capitation system, compared to
usual care in the fee-for-service system. The study revealed that at the level of access the CHCs were
much more accessible than the providers in the fee-for-service system: it was impossible to match
the 27.000 study samples in the CHCs with 27.000 patients in the “usual care” that had the same
level of depravation. The CHCs were more cost-effective as their patients spent less resources in
secondary care. At the level of quality, CHCs used less resources in medical imaging, lab testing and
prescribed less antibiotics. Moreover, they performed better at the level of immunization and
screening. For none of the quality-indicators the performance of the CHCs was worse than in the
usual care fee-for-service system.
Criteria for Community Health Centers.
1. Multi-disciplinary cooperation “under one roof”.
A Community Health Center should offer at least 3 disciplines: family physician, nursing and a third
discipline at the primary care level. There should be regular interdisciplinary meetings.
2. Community Oriented Approach.
A CHC focuses on the individual and the community and participates actively in local health policy. In
cooperation with other actors, the CHC takes initiatives to detect and address local health needs.
3. Territorial approach.
A CHC focuses on a clearly defined geographical area. This can be a neighbourhood or a village.
Patients, living in the defined area have access to the CHC.
4. Structural cooperation.
A CHC cooperates actively with local and regional partners in the domains of health and welfare. A
CHC strives for a structural cooperation with the actors in order to provide an appropriate answer to
the needs of patients and inhabitants of the neighbourhood.
5. Disease prevention and health promotion.
A CHC creates an offer of individual and group-oriented disease prevention, focusing on the patients
on the list, based on Evidence Based Medicine and using a systematic approach. Apart from that
health promotion activities focus not only at the patients on the list, but at the whole local
community, in order to strengthen empowerment and self-reliance of patients and citizens.
6. Integrated care.
A CHC integrates pro-actively physical, psychological and social components of health.
7. Accessibility.
A CHC uses the capitation system or a systematic third party payment system, enhancing financial
accessibility of the services. A CHC organizes physical accessibility and is open to every person in the
area irrespective his/her culture, social or political background. A CHC actively addresses the barriers
that hinder the accessibility of the services. A CHC uses participatory approaches in order to enable
patients and citizens to actively contribute to the development and the activities of the CHC.
8. Continuity.
A CHC offers a continuity, a least during 10 hours daily (Monday to Friday). There is an electronic
integrated interdisciplinary record for every patient, that is used by all the providers.
9. Quality.
A CHC invests in efforts to optimize the quality of patient care and practice organization and assesses
the quality regularly.
10. Organisational structure.
A CHC is a private not-for-profit organization. A delegation of the personnel is represented in the
General Assembly with voting rights. Delegates of the personnel are actively involved in the decision
making process in the Executive Committee.
11. Independence and Pluralism.
A CHC is independent, pluralistic and not related to a political party.