Integration or Fragmentation of Health Care? Examining Policies and Politics in a Belgian Case Study

Background: Globally, health systems have been struggling to cope with the increasing burden of chronic diseases and respond to associated patient needs. Integrated care (IC) for chronic diseases offers solutions, but implementing these new models requires multi-stakeholder action and integrated policies to address social, organisational, and financial barriers. Policy implementation for IC has been little studied, especially through a political lens. This paper examines how IC policies in Belgium were developed over the last decade and how stakeholders have played a role in these policies. Methods: We used a case study design. After an exploratory document review, we selected three IC policies. We then interviewed 25 key stakeholders in the field of IC. The stakeholder analysis entailed a detailed mapping of the stakeholders’ power, position, and interest related to the three selected policies. Interview participants included policy-makers, civil servants (from ministry of health and health insurance), representatives of health professionals’ associations, academics, and patient organisations. Additionally, a processual analysis of IC policy processes (2007–2020) through literature review was used to frame the interviews by means of a chronic care policy timeline. Results: In Belgium, a variety of policy initiatives have been developed in recent years both at central and decentralised levels. The power analysis and policy position maps exposed tensions between federal and federated governments in terms of overlapping competence, as well as the implications of the power shift from federal to federated levels as a consequence of the 2014 state reform. Conclusion: The 2014 partial decentralisation of healthcare has created fragmentation of decisive power which undermines efforts towards IC. This political trend towards fragmentation is at odds with the need for IC. Further research is needed on how public health policy competences and reform durability of IC policies will evolve.