This chapter covers the case study of the Belgian Mental Health reform. The case study includes an assessment of the Belgian Mental Health reform against the five best practice criteria, policy options to enhance performance and an assessment of its transferability to other OECD and EU27 countries.
Mental Health Promotion and Prevention
Best Practices in Public Health
Abstract
Description: The Belgian Mental Health Reform has led to a nationwide transformation in the provision of mental health care. Launched in 2009, it is divided into five action pillars that promote better and equitable access to mental health care and enhance organisation of mental health care services prioritising outpatient care. The reform has created over 30 multidisciplinary professional networks across the country for both children and adults. The reform provides both front-line and specialised psychological care tailored to the intensity of care required, ensuring the co‑ordination of services across multiple sectors and improving outreach to the population groups. The Belgian reform is a best practice transferred to countries within the EU-funded Joint Action ImpleMENTAL to improve mental health in Europe.
Best practice assessment:
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Criteria |
Assessment |
|---|---|
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Effectiveness |
The reform is associated with a 10% decrease in overall mental health disorders. Patients’ resilience has improved. Patients have nearly 40% less days of incapacity and over 30% less days of reduced functioning. Absenteeism is reduced, with days lost reduced by 60% after six months. |
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Efficiency |
The budget for Belgium’s front-line mental health care scheme is estimated at EUR 165 million per year (or EUR 1 122 per treated patient per year). The associated reduction in absenteeism is equivalent to economic savings of EUR 85.3 million per year. |
|
Equity |
The reimbursement of up to eight psychological sessions per year and outreach efforts improve access to mental health care for people of all socio-economic backgrounds. Despite improved access to mental health care, patients’ resilience and days of reduced functioning have improved little among individuals with vulnerabilities |
|
Evidence‑base |
An observational study was conducted on 2 750 patients to evaluate the effectiveness and efficiency of the front-line healthcare scheme. The overall study quality assessment was considered moderate, with a strong data collection method and moderate quality regarding patient retention, confounders and study design. |
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Extent of coverage |
The front-line mental health care scheme covers 147 000 patients per year, covering about 6% of people with mental health issues in the country. |
Enhancement options: To enhance effectiveness, particular attention should be drawn to improving care referral and further developing collaboration between networks. To enhance equity, it is crucial to ensure an equitable distribution of the financial resources of the networks in line with the disparities and needs of the population. Furthermore, it is essential to understand the reasons for the lower impact on the most vulnerable groups and to prioritise these groups for additional assistance to improve their outcomes. To enhance the evidence‑base, the evaluation of the reform can be improved by extending data collection and by including indicators on patient outcomes and experiences and educational and occupational outcomes where relevant. To enhance coverage, policies should be developed to further address geographical disparities to accessing mental health care, as well as to improve public communication on mental health care coverage. Finally, strategies that improve patient adherence to mental health care in the short and medium term would enhance the coverage and effectiveness of the front-line mental health care scheme.
Transferability: The reform is broadly transferable to other settings within OECD and European countries. For example, it is likely that such a mental health scheme will receive political support due to existing policies and programmes that integrate mental health in primary healthcare settings. However, some countries may face challenges regarding political priorities and the affordability of implementing the reform.
Conclusion: The Belgian Mental Health Reform has the potential to significantly reduce the incidence of mental health disorders and to improve outcomes related to work productivity.
The Belgian mental health reform encompasses a range of national policy changes resulting in structural transformations in the healthcare organisation to improve access to mental health care for the population. The reform was initiated in 2009 with the introduction of a new legislative framework governing hospitals and care institutions. This enabled a partial reallocation of the budget for hospital funding, ensuring the allocation of resources for the provision of mental health care.
The reform has introduced a global change in the healthcare provision model involving hospitals and community services. It enhances co‑operation and intersectionality in healthcare to improve mental health care provision and quality. The new Belgian model aligns with an international vision of enabling more patient-centred and personalised care in mental health, through improved access and adaptability. It also enhances patient outreach with the objective of ensuring that patients remain within their personal and social surroundings, by establishing individualised and timely therapeutic pathways. The reform has facilitated the development of professional networks, based on multidisciplinarity, intersectionality and on flexible intervention methods (Box 7.1). The reform is driven by the following principles:
Deinstitutionalisation, in which outpatient care is prioritised over inpatient care;
Intensification of healthcare programmes to reduce the length of hospital stays;
Inclusion through an improvement of rehabilitative care and the reintegration of patients within society;
Intersectionality based on co‑operation involving different institutions and professionals beyond the medical sector; and
Decategorisation of the previous system in creating circuits and networks between sectors.
The mental health networks have been established through collaboration with partners from various sectors, both within and outside the healthcare profession, in order to enhance access to mental health care and facilitate communication among professionals. The networks and partnerships are designed to implement community-oriented care and provide better guidance for patients seeking psychological care, while ensuring continuity of care. Front-line mental health practitioners (e.g. psychologists and educational therapists) often liaise with other psychologists, psychiatrists or general practitioners. Communication can also extend to professionals from other fields, including psychomotor therapists, physiotherapists, family planning centres, and more. Overall partnerships are continuously evolving, involving general healthcare services, vocational reintegration environments, youth support services, social services and the education sector, among others (Jansen et al., 2023[1]). The allocation of resources in each network is determined by the healthcare needs of the population in the respective territories.
Since the start of the reform, 32 regional mental health networks have been established across Belgium. The networks are structured as follows: 20 are allocated for individuals aged 15 and over, 11 networks for children and adults under 24 years, and a subsequent network operates for both children and adults. The networks are working in collaboration to implement the reform.
The reform is structured around five strategic pillars, although this chapter focusses on the evaluation of the first pillar particularly. The first pillar aims to increase the prevention and promotion of mental health, including early detection, screening and diagnosis of mental health disorders, through better co‑operation between medical centres, general practitioners, and other existing front-line care services (Jacob and Lucassen, 2011[2]). This pillar involves the creation of a community-based front-line mental health care scheme that is affordable, accessible and in proximity to all. Key initiatives include policies such as the reimbursement of both low-threshold and specialised psychological care, covering up to eight and 20 psychological sessions per patient per year, respectively. Additionally, the previous requirement for a medical prescription (referral) to access mental health care has been removed, enabling direct and timely access to psychological care. However, patients can still be referred to a psychologist by their general practitioner. The reform has enhanced the effectiveness of referral, by streamlining clinical assessments to evaluate the patients’ mental health condition, facilitating appropriate referral to either front-line or specialised mental health care based on the required intensity of care. The first pillar plays an important role in alleviating the burden on mental health care and psychiatric services. It mainly addresses mild to moderate clinical issues that reflect temporary situations, which are the most common among patients seeking mental health care (Jansen et al., 2023[1]). These issues include, for instance, anxiety, depression, burnout, behavioural problems, grief, addictions, and relationship difficulties.
The four remaining pillars seek to improve (2) access to intensive outpatient care using mobile units, (3) rehabilitative care, (4) social inclusion and reintegration, and (5) residential treatment units for intensive and chronic care provision. These initiatives adopt a targeted approach to mental health care, addressing specific needs within the community. To support individuals with acute and chronic mental health conditions, mobile teams have been established to improve access to intensive outpatient care, as an alternative to hospitalisation, when feasible. For patients needing supervised intensive residential care, residential treatment units provide necessary support during emergencies or when patients require assistance and intensive supported housing. Additionally, programmes have been developed to support patients in their rehabilitation and reintegration into society, focussing on autonomy, social skills, and professional development. Lastly, the reform includes the development of residential care facilities, offering housing for dependent patients suffering from chronic psychiatric disorders who have limited autonomy and face challenges in social integration.
This section analyses the Belgian Mental Health Reform against the five criteria within OECD’s Best Practice Identification Framework – Effectiveness, Efficiency, Equity, Evidence‑base and Extent of coverage (see Box 7.2 for a high-level assessment). Further details on the OECD Framework can be found in Annex A.
Effectiveness
The reform is associated with a 10% decrease in overall mental health disorders after six months.
Patients’ resilience scores have increased by 10% after six months. Days with incapacity have reduced by 40%, and days with reduced functioning by over 30%.
Absenteeism from work was reduced by 60%. Days of absence were reduced from five to two days per month, after six months.
Access to mental health care was facilitated with the reimbursement of up to eight psychological sessions per year and direct access to psychological care without prescription.
Efficiency
The budget for Belgium’s front-line mental health care scheme is estimated at EUR 165 million per year, equivalent to an average cost of EUR 1 122 per treated patient or EUR 14 per capita per year.
Reduced absenteeism is associated with economic savings equivalent to EUR 85.3 million per year. Savings related to presenteeism are potentially higher than that of absenteeism.
Equity
One in four adults benefiting from the front-line mental health care scheme belongs to a potentially socially vulnerable group.
The introduction of the reimbursement of psychological consultations helps overcome the financial barrier to access to mental health care.
Despite improved access to mental health care, patients’ resilience and days of reduced functioning have improved little among socially vulnerable groups.
Evidence‑base
An observational study was conducted on 2 750 patients to evaluate the effectiveness and efficiency of the front-line healthcare scheme. The study had a “strong” data collection method and performed moderately in areas such as patient retention, confounders and study design. However, the overall quality of assessment was considered moderate.
Extent of coverage
The front-line mental health care scheme covers around 147 000 patients per year, representing 1.3% of the entire population and 6% of individuals with mental health issues in the country.
Adherence to psychological sessions decreases by a third after six months. Patients tend to dropout of psychological treatment: after completing the eight reimbursed sessions per year, only 10% to 40% of patients continue seeking mental health care.
Effectiveness
A study published in 2023 (EPCAP 2) presents an evaluation of the outcomes of 2 750 patients benefiting from the front-line or specialised mental health care scheme, which provides psychological support tailored to the required intensity of care (Jansen et al., 2023[1]). Data collected include the patient’s clinical profile and previous access to care, using a range of assessment tools (Box 7.3). Patient data were collected at three, six and 12 months following inclusion, although data at 12 months are not available at the time of writing this report (Jansen et al., 2023[1]). The measured outcomes were related to clinical diagnosis of mental disorder, quality of life, work absenteeism and psychological resilience (which is defined as the capacity to respond to stress, personal competence, perseverance and adaptability).
Study participants were given a set of different standardised and valid questionnaires assessing mental health status, healthcare utilisation, well-being, and demographics.
Psychiatric disorders and mental health problems were measured with the Composite International Diagnostic Interview (CIDI‑3.0), the WHO’s World Mental Health survey and the Diagnostic and Statistical Manual of Mental Disorders (DSM‑5). Psychological crisis and suicidality were measured through the Crisis Triage Rating Scale (CTRS) and the Columbia Suicidal Severity Rating Scale respectively. The CIDI‑3.0 questionnaire also assesses healthcare utilisation, measured by at least one contact with a healthcare professional for mental health in the previous year.
Quality of life and functional limitations associated with mental health were evaluated with the Sheehan Disability Scale and a shortened version of the WHO Disablement Assessment Scale. Well-being was self-assessed with the help of the OECD’s Well-Being Core Set and the WHO‑5 items. Patients’ resilience was measured with the Connor-Davidson scale, which is based on factors such as capacity to adapt to difficult situations, reaction towards stress, personal efficacy and stability, and social support (Connor and Davidson, 2003[3]). Patients’ motivation for change was measured with the 12‑item Readiness to Change Questionnaire (RCQ), comprising items on stages of change, such as precontemplation, contemplation and action.
Sociodemographic variables such as age, gender, work and living conditions, marital status, and educational level were collected as well, in a standardised manner.
Participants were divided into three age groups: youth (11‑17 years), adults (18‑64 years) and older people (65 years and over). Questionnaires were standardised for each age group. Patients aged 65 and over were presented with the same questionnaires as adults, along with two additional surveys addressing psychosocial well-being: the Severity of Dependence Scale (SDS) and the Loneliness scale.
Source: Jansen et al. (2023[1]), “Eerstelijnspsychologische zorg in België - EPCAP-studie ”.
The Belgian mental health reform improves population mental health status, increases resilience, and reduces the number of days with incapacity and absence from work
Front-line mental health scheme is associated with a reduction of the prevalence of mental health disorders. The 2023 EPCAP study shows a nearly 10% reduction in the prevalence of mental health disorders among patients receiving front-line care after six months following the intervention, although a control group was not included (Jansen et al., 2023[1]). The improvement rate varied by mental disorder type, with major depressive episodes showing the greatest reduction. At three months, the rate was 68% lower, and at six months, it was 75% lower. Patients with mental health disorders that severely impact daily functioning, also saw significant improvement, with a 33% reduction of disorders at three months, and a 60% reduction at six months.
Results show that patient’s resilience scores increased by 5% and 10%, at three and six months respectively. The average resilience score went from 4.2 (out of 8) points at the start of treatment, to 4.4 at three months and 4.6 at six months.
Belgium’s front-line mental health care scheme is also associated with a decrease in the number of days with incapacity and with reduced functioning, and a reduction in absenteeism at work. The number of days with incapacity were reduced from eight days to five days per month, corresponding to a nearly 40% decrease at three months, and remained stable at six months. Similarly, the number of days with reduced functioning decreased from 12 days to 9 days per month after three months, and to 8 days after six months. Absenteeism from work significantly decreased from five days per month at the starting point, to two days per month after six months.
Belgium’s mental health care scheme improves patients’ access to mental health care. The EPCAP report notes that the reform has removed the financial barrier to access by reimbursing psychological sessions and allowing direct access without the requirement of a medical prescription (Jansen et al., 2023[1]). Specifically, nearly 40% of patients benefiting from the new scheme indicated that they had previously refrained from seeking mental health care due to financial reasons when the consultations were not reimbursed. Besides, one in two patients benefiting from the new scheme, reported that the scheme served as their first point of contact with mental health care services. Patients also waited less time to seek psychological care, as the admission process has become faster and more fluid since the beginning of the reform.
The EPCAP report also underlines that overall, the reform has led to better co‑operation between healthcare professionals and has improved social acceptance towards mental health care.
Efficiency
The total cost of the reform is estimated at EUR 342 million per year, with nearly half of this annual budget allocated to the front-line scheme (EUR 165 million, equivalent to EUR 1 122 per treated patient and EUR 14 per capita1). Within the front-line scheme, over 50% of the budget is allocated to care for adults and around 30% to children and adolescents. The remaining 20% of the budget is allocated to the implementation of the front-line care, including training of professionals, communication strategies and scientific studies. The remaining budget is distributed to the other four pillars, as follows: EUR 45 million is allocated to mobile teams, over EUR 76 million to institutions and over EUR 65 million to cross-sector projects.
The reform is estimated to have a positive impact on costs in the labour market, with less absenteeism and higher productivity. The EPCAP report pointed out that among patients benefiting from the front-line mental health care scheme, 60% were professionally active, representing 90 000 individuals per year. The reform was associated with an average reduction of three days of absenteeism at six months, equivalent to economic savings of EUR 948 per treated patient. In total, absenteeism-related costs are estimated around EUR 85.3 million per year (Jansen et al., 2023[1]). Savings related to presenteeism – that is reduced productivity while at work – are potentially higher than those due to absenteeism. A study found that the productivity losses due to NCD-related presenteeism tend to be two to three times higher than that due to absenteeism, in 12 OECD and G20 countries (Rasmussen, Sweeny and Sheehan, 2016[4]).
Equity
Belgium’s front-line mental health care scheme effectively reaches vulnerable populations, facilitating access to healthcare. The EPCAP study shows that more than one in four adults benefiting from the scheme belong to a potentially socially vulnerable group. This includes single parents (10.5%), individuals with low socio-economic status (9.8%), patients with severe physical health problems (5.5%), non-nationals (5.0%), unemployed people (3.5%), young parents (0.6%) and patients aged 75 and over (0.4%). The main barriers to mental health care include cost and distance. Before the reform, financial barriers accounted for up to 40% of reasons reported by patients for delaying seeking mental health care (Jansen et al., 2023[1]). The introduction of the reimbursement for psychological consultations helped overcome the financial barrier to access mental health care. Another barrier that the reform addresses, is about the distance to mental health facilities. The reform successfully improves physical or remote access to mental health care by developing teleconsultation services and outreach venues (locations close to patients) that improve proximity with patients. Home‑based and remote sessions represent 25% of all sessions. The EPCAP study shows that around one in six sessions takes place in outreach venues, and this proportion increases to one in four sessions for patients facing vulnerabilities.
Despite improved access to mental health care, patients’ resilience and days of reduced functioning have improved little among individuals with vulnerabilities. Patients’ resilience scores (measuring the ability to respond to stress, personal competence, perseverance and adaptability) have remained relatively unchanged six months after enrolment in the scheme, for patients aged 75 and over, as well as those who are unemployed and those with low socio-economic status. Similarly, the number of days of reduced functioning remained high for patients with low socio-economic status and those with a long-term condition (Jansen et al., 2023[1]).
Evidence‑base
The evidence on the Belgian Mental Health reform is mainly collected from the observational EPCAP study, evaluating the effectiveness and efficiency of the reform through qualitative and quantitative methods (Jansen et al., 2023[1]). The data were collected between 2020 and 2023, in 31 mental health care networks for both adults and children, including in total 2 750 patients receiving front-line care, and 483 healthcare professionals. This study relies on a before‑after comparison, limiting the evaluation about the causal impact of the reform.
The Quality Assessment Tool for Quantitative Studies assesses the quality of evidence as strong in the domain of “Data collection methods”, moderate in “Study Design” and “Confounders”, and weak in “Selection Bias” and “Withdrawals and Dropouts” (see the table below) (Effective Public Health Practice Project, 1998[5]).
Source: Effective Public Health Practice Project (1998), “Quality assessment tool for quantitative studies”, https://www.nccmt.ca/knowledge-repositories/search/14; Jansen et al. (2023[1]), “Eerstelijnspsychologische zorg in België - EPCAP-studie”.
Extent of coverage
The reform’s front-line mental health care scheme covers adults, as well as children and adolescents, experiencing mental health issues and in need of mental health care. It covers around 147 000 patients per year, representing 1.3% of the entire Belgian population in 2023. Providing that in 2019, 25% of the Belgian population experienced mild or moderate mental health issue (OECD analysis based on the European Health Interview Survey 2019, see Chapter 2), the reform covers around 6% of people in needs of mental health support. In 2023, nearly 850 000 psychological sessions were delivered to patients, corresponding to around six sessions per patient.
Adherence to treatment slightly decreases with time, with 8 in 10 patients adhering at three months and two in three patients adhering at six months following the start of treatment (Jansen et al., 2023[1]). Once exceeding the limit of reimbursed sessions, only 10% to 40% of patients persist in attending mental health care sessions, demonstrating the importance of the reimbursement of sessions in fostering the continuity of mental health care.
This section outlines policy options to enhance the performance of the Belgian Mental Health reform against the five best practice criteria.
Enhancing effectiveness
The Belgian Mental Health Reform aims to improve access to mental health care for the entire population by offering patients a healthcare scheme that provides affordable and easily accessible mental health services. Individual needs are assessed through streamlined diagnosis, followed by direct referral to front-line and specialised care for further treatment with a healthcare professional. Improvements can however be made to further enhance the effectiveness of the reform.
Improving diagnosis and patient pathway allocation by using tailored clinical tools and assessments. Challenges have been identified by healthcare professionals in areas of diagnosis and care attribution. Patients are not always referred to the most appropriate professional to meet their needs, depending on the intensity of their disorders. The effectiveness of the referral can be enhanced by using clinical instruments and questionnaires adapted to a variety of mental health disorders, to enable more accurate diagnosis. This would lead to improved allocation towards the suitable care pathway (either front-line or specialised mental health care, type of therapy, etc) (Jansen et al., 2023[1]). These clinical instruments should effectively assess patient needs and objectives, while also facilitating the comprehension on the clinical diagnosis.
Improving network collaboration for better quality of care. Findings from the EPCAP study indicate that enhancing organisation and coherence within networks can enhance the successful execution of the reform (Jansen et al., 2023[1]). Ensuring clear criteria to evaluate practices (for diagnosis and therapy) within networks and ensuring their uniformity across regions is crucial. The performance of networks can be improved by carrying out regular assessments and establishing clear guidelines for network co‑ordination. Moreover, strengthening existing network collaboration and fostering the exchange of best practices among co‑ordinators and healthcare professionals can lead to better care quality and delivery.
Enhancing population mental health literacy for improving ability to seek care and adhere to prescribed therapies. Health literacy refers to “an individual’s knowledge, motivation and skills to access, understand, evaluate and apply health information” (Moreira, 2018[6]). Individuals that are health literate will more likely seek mental health care and adhere to the medical recommendations they receive, thus improving the effectiveness of the reform.
Enhancing efficiency
Policies that boost effectiveness and coverage without significant increases in costs will have a positive impact on efficiency. For instance, enhancement options development under effectiveness and extend of coverage would help to increase efficiency.
Enhancing equity
Although the reform targets the whole community, vulnerable groups may experience greater barriers to access to mental health care. To maximise levels of healthcare utilisation, policymakers should consider the options listed below.
Ensure an equitable distribution of the financial resources of the networks in line with the disparities and needs of the population. The EPCAP study report emphasises the importance of integrating considerations for vulnerability and precariousness at regional and local levels (Jansen et al., 2023[1]). The allocation of financial resources within the network should therefore consider the specific characteristics of communities, regions, and networks, in terms of vulnerabilities and inequalities, guided by the principle of solidarity.
Implementing strategies to increase affordability of psychological sessions in the long run. The Belgian reimbursement plan covers up to eight individual psychological sessions, or up to five group sessions, per year. The study shows that affordability represents a financial barrier in patients seeking mental health care and that half of patients do not continue treatment with their assigned healthcare professional beyond the reimbursed sessions. To enhance continuity of care and equitable access, it is essential to develop strategies to promote long-term affordability, particularly for patients with a lower socio-economic status.
Improving outreach efforts. Further development of field interventions and outreach efforts, notably by involving mobile ambulatory teams, is crucial for effectively reaching and assisting vulnerable populations. The study indicates that outreach efforts are more successful in delivering care to vulnerable patients compared to other populations (Jansen et al., 2023[1]). It is recommended to conduct situational analyses and local needs assessments for optimising outreach activities. Furthermore, regional co‑ordinators can better address challenges faced by specific priority groups (such as older people and non-native speakers) by collecting data on their healthcare utilisation and identifying barriers to mental health care access. Regional co‑ordinators can tailor the healthcare scheme to align with local and cultural needs of communities, and foster collaboration with community stakeholders to enhance outreach efforts towards priority groups.
Enhancing the evidence‑base
To strengthen the evidence‑base, it is important to collect data on mental health outcomes (by symptom severity) and to extend indicators to measure educational and occupational outcomes where relevant. Data on patient outcomes and experiences would help monitor trends in mental health care utilisation and the quality of care. It is also essential to analyse data over longer periods to provide insights into the long-term impact of the reform.
Enhancing extent of coverage
Coverage of the intervention can be enhanced by addressing the known barriers to seeking professional help for mental health issues.
Addressing geographical disparities in access to mental health care. Mental health care services should be provided remotely by using teleconsultation services and further developing mobile outreach efforts. This allows for individuals to access support and counselling when facing geographical or scheduling barriers. Moreover, it is crucial to promote e‑interventions and psychological self-help programmes, as research shows that these serve as stepping stones to further treatment (Eilert et al., 2021[7]). Finally, access can be improved through the continued development of partnerships with sectors such as healthcare institutions, social services, education and socio-professional reintegration sectors.
Increasing communication. Improving communication on access to mental health care can improve coverage at local levels. Effective communication campaigns can ensure that the information reaches individuals in need of mental health care and can therefore optimise coverage. Mental health awareness and information campaigns also play a role in destigmatizing mental health disorders, which remains a barrier to pursuing mental health care (Latha et al., 2020[8]).
Introducing strategies to nudge patients towards adherence. Patient adherence to mental health consultations was reported as insufficient, with frequent absenteeism and high dropout rates (Jansen et al., 2023[1]). About 18% of patients terminated their psychological follow-up before the end of the reimbursed sessions. To optimise patient adherence to consultations, it is advisable to implement strategies that encourage patients to actively participate in their mental health care journey. This could result in better patient outcomes and improve the programme’s effectiveness. Strategies that previously showed to be effective, include appointment reminders and actively engaging patients in their treatment process by providing informative briefs explaining the programme, the fee system, and providing encouragement (Reda, Rowett and Makhoul, 2001[9]).
This section explores the transferability of the Belgian Mental Health Reform and is broken into three components: 1) an examination of previous transfers; 2) a transferability assessment using publicly available data; and 3) additional considerations for policymakers interested in transferring the Belgian Mental Health Reform.
Previous transfers
The Belgian Mental Health reform is one of the two best practices identified and transferred to 14 European countries, as part of the 2022-2024 EU-funded Joint Action ImpleMENTAL (JA-ImpleMENTAL, n.d.[10]). The Joint Action ImpleMENTAL supports countries in the implementation process, such as assessing the situation and needs in the target countries, establishing local networks for mental health, sharing knowledge, setting achievable goals, fostering stakeholder engagement and advocacy, and building capacity for mental health care services.
Transferability assessment
This section outlines the methodological framework to assess transferability followed by analysis results.
Methodological framework
A few indicators to assess the transferability of the Belgian mental health reform were identified (see Table 7.2). Indicators were drawn from international databases and surveys to maximise coverage across OECD and non-OECD European countries. Please note, the assessment is intentionally high level given the availability of public data covering OECD and non-OECD European countries.
Results
Results from the transferability assessment using publicly available data are summarised below (see Table 7.3 for results at the country level):
In terms of access to mental health care, 9.5% of the Belgian population reported consulting mental health care or rehabilitative care professionals, compared to around 6% on average across OECD countries. Belgium performs well in the Healthcare Access and Quality Index, with a rate higher than the OECD average. More than two‑thirds of OECD countries have a score over 80%.
The analysis shows that the number of psychologists is higher in most countries compared to Belgium. As in Belgium, patients can access mental health care without the need of a referral in most OECD countries.
Spending on prevention is typically higher in the studied countries than in Belgium (i.e. only 11 of the 43 countries analysed spent less on prevention than Belgium). Belgium’s expenditure on primary healthcare aligns with the OECD average, which typically lies around 1.4% of the gross domestic product (GDP).
A majority of countries have strategies or action plans to guide implementation of mental health policies and around 80% of them have policies or programmes to enable mental health promotion, prevention and treatment of mental health conditions in primary healthcare – including Belgium.
A darker shade indicates the Belgian Mental Health Reform is more suitable for transferral in that particular country.
Note: n/a = no available data. The shades of blue represent the distance each country is from the country in which the intervention currently operates, with a darker shade indicating greater transfer potential based on that particular indicator (see Annex A for further methodological details). The full names and details of the indicators can be found in Table 7.2.
Source: Eurostat (2022[11]), Self-reported consultation of mental healthcare or rehabilitative care professionals by sex, age and educational attainment level, https://doi.org/10.2908/HLTH_EHIS_AM6E; IHME (2017[12]), Global Burden of Disease Study 2015 (GBD 2015) Healthcare Access and Quality Index Based on Amenable Mortality 1990-2015, https://ghdx.healthdata.org/record/ihme-data/gbd-2015-healthcare-access-and-quality-index-1990-2015; OECD/WHO Regional Office for Europe (2023[14]), Mental Health Systems Capacity Questionnaire 2023 - Policies and programmes to enable mental health promotion, prevention and treatment of mental health conditions in primary health care; OECD/WHO Regional Office for Europe (2023[15]), Mental Health Systems Capacity Questionnaire 2023 - Strategy or action plan that guide implementation of the mental health policy; OECD (2024[16]), OECD Data Explorer - Prevention spending as a percentage of GDP, http://data-explorer.oecd.org/s/1nl (accessed on 7 April 2024); OECD (2024[17]), OECD Data Explorer - Primary health care expenditure as a percentage of GDP, http://data-explorer.oecd.org/s/1nl (accessed on 11 April 2025).
To help consolidate findings from the transferability assessment above, countries have been clustered into one of three groups, based on indicators reported in Table 7.2. Countries in clusters with more positive values have the greatest transfer potential. While this analysis provides a high-level overview assuming some simplifications, it is important to note that countries in lower-scoring clusters may also have the capacity to adopt the intervention successfully. For further details on the methodological approach used, please refer to Annex A.
Key findings from each of the clusters are below with further details in Figure 7.1 and Table 7.4:
Countries in cluster one, including Belgium, have populational, sector specific, political, and economic arrangements in place to transfer the Mental Health Reform. Overall, these countries are less likely to experience issues associated with implementing the reform in their local context. This group includes 27 countries.
Countries in cluster two have populational and sector specific arrangements to support the reform. Prior to transferring the practice, however, these countries may wish to consider ensuring that the implementation is affordable and that it aligns with political priorities. This group includes six countries.
Countries in the remaining cluster may wish to undertake further analysis to ensure the programme is affordable, aligns with political priorities, and can be implemented within the existing healthcare infrastructures. This group includes six countries.
Note: Bar charts show percentage difference between cluster mean and dataset mean, for each indicator.
Source: OECD analysis.
Note: Due to high levels of missing data, the following countries were omitted from the analysis: Colombia, Chile, Cyprus, Malta.
Source: OECD analysis.
New indicators to assess transferability
Data from publicly available datasets alone is not ideal to assess the transferability of public health interventions. Box 7.4 outlines several new indicators policymakers could consider before transferring the Mental Health Reform.
In addition to the indicators within the transferability assessment, policymakers are encouraged to collect information for the following indicators:
Population context
What is the level of mental health literacy in the population?
What are the main barriers to accessing mental health care?
What percentage of the population is aware of the steps necessary to access mental health care services?
What percentage of the population is satisfied with the mental health services provided to them?
Sector specific context
What is the average delay to access mental health care?
What is the rate of educational therapists per 100 000 inhabitants?
How does access to mental health care differ regionally?
Political context
Are there intersectoral partnerships aimed at improving access to mental health care?
What type of mental health care is covered by the national medical insurance?
Economic context
What is the spending on mental health prevention as a percentage of health expenditure?
What fraction of total mental health expenditure constitutes out-of-pocket costs?
The Belgian Mental Health Reform is a mental health prevention programme targeting individuals with mild to severe mental health issues. The purpose of the reform is to improve access and quality of mental health care services in Belgium, in restructuring the care delivery system, developing outpatient care and establishing networks for intersectoral collaboration.
The reform has resulted in improvements in mental health outcomes and productivity. Among individuals who have received front-line and specialised care through the mental health reform, there has been notable progress in reducing the prevalence of mental health disorders and mitigating workforce impairment, linked to incapacity and absenteeism. Reduced absenteeism is then associated with economic savings.
The reform has improved access to mental health care. The front-line care scheme has effectively reached vulnerable groups and facilitated access to mental health care by addressing financial and geographical barriers. Improvements can however be made in long-term affordability strategies and initiatives that address regional needs to enhance outreach efforts.
The Belgian Mental Health reform is highly transferable in nearly 70% of OECD and EU countries with available data (27 out of 39 countries), and intermediately transferable to six countries. All countries have the opportunity to tailor mental health prevention strategies according to their specific needs, resources and contexts. This also applies to certain countries that may encounter challenges related to political priorities and the affordability of implementing the reform.
Box 7.5 outlines next steps for policymakers and funding agencies.
Next steps for policymakers and funding agencies to enhance the Belgian Mental Health Reform are listed below:
Consider policies that aim to improve affordability of mental health care in the long term.
Establish efficient communication strategies, to raise awareness among the population about mental health care access.
Improve the clinical guidelines for healthcare professionals, to facilitate diagnosis and patient care attribution.
Continue collecting patient data on health outcomes, experience and healthcare utilisation, as well as healthcare provider feedback regarding experiences, perspectives and challenges encountered within the healthcare framework.
References
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← 1. According to recent demographic data, Belgium’s population stands at 11 697 557 inhabitants on 1 January 2023. https://statbel.fgov.be/en/themes/population/structure‑population.