Surgical training in a statutory health insurance system: Belgian experience

Health care delivery in Belgium is based on a compulsory insurance system, installed and controlled by the government since 1945 for employees; in 1963 the system was expanded to include self-employed citizens. Mutual benefit organizations act as insurance carriers for all patients, whether cared for in the office or hospital. The cost of state-financed medical care has grown to such an extent during the last few decades that cost-sharing in ambulatory practice is being extended to in-clinic services. The free choice of practitioners as well as free access to medical and specialist education have always been keystones of the Belgian medical care system. A well regulated scheme of surgical training combined with strict rules imposed on instructors, hospitals, and trainees guarantee high quality and state-controlled surgical education. Developments in the Belgian political landscape may considerably affect health care delivery and surgical education. A constant rise in the number of medical practitioners and the sociopolitical discrepancies between the Flemish and French speaking parts of the federalized kingdom have paralleled burgeoning medical health care costs and have induced rationalization and possibly federalization of health care delivery as well as ongoing debates concerning the limitation of medical and surgical practitioners.