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With a population of about 11 million, Belgium has reported more than 9,000 coronavirus-related deaths, i.e. 804 deaths per million inhabitants (France has 435, Germany 100, and Italy 542). This sad European record is less a sign of a failure of the Belgian health system than a reflection of a specific accounting method. All residents of care homes suspected of having died from Covid-19 were counted as victims of the epidemic, even though they were not tested.
Belgium was in the midst of a government crisis when the virus broke out. In order to respond to the health crisis, the country’s political parties rather surprisingly agreed to form a minority government for a six-month period. On March 17, 2020 the Wilmès II government became a fully-fledged government with special powers. Despite a tense political situation, the government quickly proved itself. However, the differences in positions between the Walloon and Flemish parties have not disappeared, as the debates on the exit strategy proved.
The Belgian health system showed resilience during this crisis: In spite of a tense situation and thanks to a large number of ventilators and intensive care beds, hospitals were never overwhelmed. By managing the crisis at federal level, patients could be reallocated depending on hospital capacity. However, this good management highlighted the lack of staff and of protective equipment.
The coronavirus broke out in Belgium at the beginning of February, when the country was in the midst of a government crisis. After polarizing elections in May 2019, negotiations between the two winners at the federal level, the Flemish Nationalists (NV-A) and the Walloon Socialists (PS) had little chance of succeeding. However, on March 17 the political parties agreed to form a crisis government. French-speaking Sophie Wilmès, who had been acting prime minister since October 2019, was thus able to form a six-month crisis government with special powers. For the very first time in Belgian political history, a large majority vote led to a minority government.
The coronavirus broke out in Belgium at the beginning of February, in the midst of a government crisis.
The Wilmès II government therefore became a fully-fledged government with special powers to respond to the crisis. However, the political situation remains fragile, with a lack of trust between the political parties. These conflicts became particularly apparent during the debates surrounding the "exit strategy".
The new government's first concern was to ensure adequate levels of healthcare and to respond to the rapid increase in cases. The main objective was to have a sufficient number of beds to cope with the increasing influx of infected patients. Hence the drastic measures imposed by the government on citizens as of March 18, 2020, two days after French President Emmanuel Macron’s televised address. The evolution of the epidemic and the situation in hospitals were the two determining factors behind the duration and severity of the measures imposed on Belgian citizens. While the Walloon political parties declared themselves in favor of a swift and restrictive lockdown similar to the French one, the Flemish were more skeptical, wary of the economic losses linked to an overly strict lockdown.
The government response was more composed in Belgium than it was in France. No "state of war" was announced, and despite the fragile political situation, the new government proved it was capable of managing a crisis. According to the Brussels correspondents of the Financial Times: "Contrary to what some might have expected, the Belgian government is showing that a divided country can still provide a clear and determined response to a national crisis."
Belgian public opinion clearly supported the lockdown measures enforced by the Wilmès II government. However, this acceptance did not translate into support for the federal government, despite transparent communication efforts. The Prime Minister intervened regularly to explain the situation to the country’s citizens and the Interfederal Crisis Center for Coronavirus Control (Centre de crise interfédéral de lutte contre le coronavirus) held daily press conferences to publish statistics and share prevention advice.
While some criticised the government’s lack of response at an earlier stage, public authorities nevertheless seem to have reacted fairly quickly as soon as the number of intensive care cases and patients increased. The lockdown measures implemented from March 12 and 17 were relatively strict. They included social distancing, self-isolation of citizens, the closing of schools, bars and restaurants along with "non-essential" shops. These measures were extended twice, in early and mid-April. They were more restrictive than the German lockdown measures, but less so than the French ones. During this period, Belgians were allowed to go outside in order to shop or exercise, without having to print out a specific authorization.
From mid-March onwards, checks were organized at the Belgian borders to prevent any movement deemed non-essential. While the Benelux countries are in one of the most integrated regions in Europe, they also turned inwards with strict border closures. This led to the Belgian police sending back about 700 Dutch people who tried to cross the border to do their shopping or to fill up their gas tank, as the lockdown rules in the Netherlands were much laxer than in Belgium.
Furthermore, Belgium also refused to take coronavirus patients from other European countries. Requests from Dutch or Italian hospitals were turned down, although Belgium had vacant intensive care beds. According to the Prime Minister, as long as the country hadn’t reached the infection peak, medical care should be reserved for residents of Belgium.
On the other hand, Belgium strongly criticized the medical equipment export bans introduced by some European countries, such as Germany and the Czech Republic. Belgian Health Minister Maggie de Block called for solidarity in the distribution of protective masks, stating that such blocks were not in "the spirit of the European Union".
With a population of approximately 11 million inhabitants, Belgium has reported more than 9,000 coronavirus-related deaths, i.e. the highest ratio of deaths per inhabitant in Europe. However, this sad record is not a sign of a failure of the health system. It is mainly due to the chosen measurement method. All the people who have died in care homes since the beginning of the crisis have been counted as coronavirus victims, even though they have not all been tested. On May 22, of the 9,186 people who had died until then, 48% died in hospitals and 51% in care homes. The deaths recorded in hospitals are almost all confirmed cases, while the deaths in care homes cover both confirmed (24%) and suspected cases (76%). Despite the high degree of transparency it implies, this accounting method has been staunchly criticized for the potential damage it could do to Belgium's international reputation during this crisis.
In order to ensure the figures are accurate, the government decided to massively and quickly increase the number of tests carried out, especially in care homes. The Belgian government focused first and foremost on hospitals, fearing a situation similar to that in the east of France, where there was a serious shortage of intensive care beds. However, the fact that deaths in care homes were only included in the statistics at a late stage might suggest that the "Belgian coronavirus tragedy" occurred mostly in the country’s care homes.
This sad ratio of deaths to inhabitants is not a sign of a failure of the health system. It is mainly due to the chosen measurement method.
Moreover, despite this different accounting system compared to most European countries, Belgium still has a fairly high number of contaminations: 56,000 confirmed cases for a population of 11 million, while France reported more than 144,000 cases for a population of 65 million. This amounts to 0.49% of the population tested positive in Belgium compared to 0.22% in France (Sciensano, 2020). This higher rate is due to three factors. First, Belgium is a small country. Therefore, once the virus is established in an area, it spreads at a similar speed as in large countries, but affects the population more rapidly. Secondly, the density of the Belgian population is high (374 inhabitants per square kilometer), which increases the risk of contact and consequently of transmission. Thirdly, and in contrast to France, testing capacities were drastically increased in Belgium, which enabled more infections to be detected.
When it comes to health care spending, Belgium is one of the best performers in Europe. In 2020, the Belgian budget for health care amounts to a total of €27.5 billion, or about 10% of its GDP. However, while health spending has increased among its European neighbors, Belgium has not recently increased the share of its budget dedicated to health. As such, according to the Federal Planning Bureau, the healthcare budget should increase by 2.5% each year in order to keep pace with the evolution of costs. But the health care budget’s standard for annual growth has been set at 1.5% since 2015. As noted by the European Commission: "Despite the Belgian health system’s efficiency in terms of intensive care, there are still some shortcomings affecting its resilience when faced with a health crisis".
In particular, Belgium faces a structural shortage of health professionals. This shortage has been felt in hospitals but also in care homes, which are managed separately from hospitals (Le Soir, 2020). Indeed, hospital infrastructures fall under federal jurisdiction, while care homes fall mainly under regional jurisdiction. The lack of coordination of public authorities therefore directly affected the number of coronavirus deaths in care homes (51%).
Health care workers expressed their discontent through the symbolic gesture of medical staff who turned their backs on their Prime Minister, Sophie Wilmès, during a visit to a hospital in Brussels on May 16. This "guard of dishonor" was also a reaction to the healthcare budget cuts decided by Sophie Wilmès when she was Federal Budget Minister between September 2015 and October 2019. Indeed, she demanded greater efficiency from hospitals given that many beds were empty before the crisis. In addition, many unions filed strike notices in May, deploring poor working conditions and the government's lack of action.
Hospital staff called for the €400 million so-called "white gown" fund to be released in order to improve working conditions in the nursing sector. This law was passed by Parliament at the end of 2019, but the funds remain inaccessible for the moment, as there was no federal government that could propose a finance law before the end of 2019. Moreover, the publication of two royal decrees on May 6 was badly received by health workers. One of these decrees aimed to allow the requisitioning of health personnel as part of the fight against Covid-19, the other concerned the delegation of medical acts to other health professionals. These decisions would have put health care personnel under even greater pressure. Since then, the Belgian government has backtracked and both decrees have been suspended. Social consultations will follow in order to find common solutions.
Belgium avoided facing a shortage of intensive care beds and was able to quickly increase its capacity.
The "surplus" of beds, deemed ineffective by the Prime Minister when she was Budget Minister a few years prior, has proven to be useful during this health crisis. Indeed, Belgium avoided facing a shortage of intensive care beds and was able to quickly increase its capacity. Geographical redistribution measures were undertaken to avoid saturation of hospitals in certain regions.
Hospital admissions reached their peak in early April. On April 7, 5,759 beds were occupied by coronavirus patients; on April 8, 1,008 patients were on ventilators; and on April 9, 1,285 people were in intensive care, the highest number so far. On March 22, Belgium had 621 free intensive care beds, out of the 943 dedicated to Covid-19 patients (L'Echo, 2020). By mid-March, Belgium had 2,169 ventilators, which enabled the country’s hospitals to meet the growing demand. Intensive care capacity was expanded to 1,800 beds to manage the situation in mid-April.
However, Belgium has faced a shortage of protective equipment, in particular masks, gloves and gowns. Three million FFP2 masks were ordered from a Chinese producer at the end of March. These were found to be non-compliant and therefore unfit for use. A delivery of five million masks was cancelled because the supplier was "dishonest". To cope with the shortage of masks, Belgian authorities decided to put the country’s prison population to work; 32,500 masks have been produced so far.
The Belgian end of lockdown strategy consists of several phases, the implementation of which depends on the infection figures and the situation in hospitals. The country has thereby chosen to follow two strategies: on the one hand, a significant increase in testing and on the other hand, the tracing of infected persons.
Belgium carried out very few tests at the beginning of the health crisis, with only 3,930 tests performed in the first week. This was also due to the fact that there was no government in place before March 17 to manage the crisis. However, the country made significant efforts to increase its testing capacity. At the end of March, Belgium was carrying out 3,000 tests a day, reaching over 10,000 daily tests by mid-April and over 25,000 on 9 May, bringing the country closer to Germany's testing capacity. As a result, Belgium is now among the top 3 European countries in terms of testing. The switch to 25,000 daily PCR tests, the distribution of masks and a tracing method are the conditions imposed by the government to implement the lockdown exit measures, according to a report by the expert group for the exit strategy (GEES).
However, tracing is particularly complex because of Belgium's federal system, with eight ministers of health and competences spread between the federal and regional levels. For the time being, tracing is mainly done through call centers, which the regions are responsible for implementing. The method used, also known as "social bubbles", should help re-establish a limited social life while curbing the risks of spreading the virus. It requires each household to indicate 4 external persons with whom its members can come into contact. This measure should enable the tracing of the contamination chain, even if its correct application is virtually impossible to verify.
As is the case in many other European countries, Belgium has also discussed the potential introduction of a digital tracking application. Two draft royal decrees were submitted by Philippe de Backer, the Minister in charge of the Digital Agenda. These aim to regulate the use of tracing applications at the federal level as well as the creation of a citizens' health database within Sciensano, the national public health institute. However, the Data Protection Authority (APD) shared its concern regarding the legal framework of this proposal as well as data protection issues it raises.
Tensions and conflicts between the Flemish and Walloons were particularly strong during the discussions surrounding the lockdown exit plan. Flanders, Belgium’s richest region, was in favor of a quick opening of schools and businesses in order to reduce the crisis’ economic and educational impact. The differences between the Walloons and the Flemish are such that even the most local decisions can become a source of conflict. For example, the city of Brussels’ decision to create new cycle paths to relieve public transport congestion was interpreted as "anti-Flemish" by Theo Francken, the leader of the NV-A.
Indeed, the Flemish people who live in the surrounding area and work in Brussels have to use their car to commute. This decision could therefore be understood as a form of discrimination against them... Despite these tensions, the first phase of the lockdown exit plan was implemented starting on May 4 and extended on May 10. Belgium moved to phase 2 on May 18, with a very gradual reopening of schools. The third and final phase of this plan should begin from June 8. It entails the reopening of bars, restaurants and other gathering places, and s non-essential travels abroad might be potentially allowed again.
Differences in positions between the Walloon and Flemish parties were amplified in particular during the debates regarding the lockdown exit strategy
Even before the crisis, Belgium was in the midst of a particularly delicate economic situation. The state budget had already reached an €11 billion deficit, which would have to be covered by 2021. In 2020, the budget deficit could reach €24 billion, i.e. twice as much as in 2019 and seven times as much as in 2018. In 2020, the public deficit could therefore amount to 5% of the country’s GDP, well above the 3% authorized by the European Union. However, European rules have been revised due to the pandemic, giving countries such as Belgium more leeway to deal with the economic consequences of the crisis
Since the beginning of the crisis, the measures taken by the country's various governments have already amounted to €10.5 billion in additional spending. According to National Bank estimates, each further lockdown week results in a loss of around €4 billion. Belgium currently counts more than one million furloughed employees and more than 300,000 self-employed persons who can’t work.
In addition to the emergency measures already taken to support businesses and the self-employed during the lockdown, Belgium is slowly moving towards a longer-term economic strategy. The federal recovery strategy should amount to 10% of GDP and is based on a similar model than in France, Germany or the Netherlands In particular, these measures intend to support sectors heavily affected by the lockdown, such as the hospitality, tourism, and the cultural, and event industries. However, the political situation – and a crisis government in office for six months only – could complicate longer-term recovery plans. Political parties are thus preparing for new negotiations, ideally starting in June, in order to decide on an economic plan with a new government from September 2020. Otherwise, Belgium will have to organize further federal elections in October 2020.
Belgium was caught in the midst of a government crisis when the virus was first detected in the country. In response to the health crisis, the main political forces agreed to form a minority government for a period of six months. Despite a tense political situation – differences in positions between the Walloon and Flemish parties were amplified in particular during the debates regarding the lockdown exit strategy – the provisional government managed to achieve popular backing around its crisis management.
Copyright: Kenzo TRIBOUILLARD / AFP
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