History

A HISTORY OF MEDICAL CENTRES IN FRANCOPHONE BELGIUM

How did they come about? How did they develop?

In the 1970s, a major social, political and cultural movement swept through Belgian society as a whole, as well as other countries around the world. This movement, which was protest-oriented from the outset, criticised the functioning of all the institutions that form the basis of society’s organisation: a justice system that favours the rich, a two-tier healthcare system, and companies run by bosses with little regard for the well-being of their workers… It denounced the unequal distribution of the wealth produced, the alliance between political and economic powers, and a democracy that was more formal than real. All this resulted in an unequal and unjust society in the areas of health, education, culture, housing and justice… A society in which the rich were getting richer and the poor poorer.

In Belgium and across Europe, this movement has led to the establishment of medical centres, family planning centres, mental health centres, legal advice centres, management advice centres, alternative schools, consumer organisations…

This was also the period of the Alma-Ata Declaration (1) and the Ottawa Charter (2). In Third World countries, revolutionary movements emerged. All these initiatives sought to change the existing situation in their respective fields and to demonstrate that an alternative way of organising was possible.

Based on the principles of equality, fairness, solidarity, democracy, participation, autonomy, justice and respect for differences, these projects have sought to apply these values to their internal workings and in their dealings with service users.

In 1980, the Federation of Francophone Medical Centres and Health Collectives (FMMCSF) was founded.

From the outset, in its founding principles, the FMMCSF had championed a model of healthcare organisation based on primary care that was comprehensive, continuous, integrated and characterised by maximum accessibility. The economic crisis of the 1970s led the political authorities to give these practices a degree of visibility and to make tentative efforts towards recognition and funding, without, however, adhering to the principles championed by these groups, let alone seeking to promote their wider application. This support has led to improvements in certain aspects of practice within Medical Centres (prevention, infrastructure, etc.).

Furthermore, discussions on an alternative funding model to fee-for-service have progressed, and what we refer to as the flat-rate (capitation) scheme has been negotiated with political stakeholders. The basic idea was to enable more coherent funding in line with a model of comprehensive, continuous and integrated care. This also helped to improve affordability and strengthen solidarity between the healthy and the sick. It was in 1984 that the first ‘Maison Médicale’ put this flat-rate funding system into practice.

In the 1990s, the economic crisis deepened. The Berlin Wall fell and, with it, an entire system of values and social organisation disappeared, giving way to the total hegemony of the liberal system. At the same time, reactions to the consequences of widespread neoliberalism (3) emerged in the form of a global movement: the anti-globalisation movement.

Now in Belgium

The structural crisis that our society has been experiencing for the past thirty years or so has led to a reduction in government intervention across all areas of social security: cuts to pensions, unemployment benefits and child benefit, a reduction in healthcare provision (lower reimbursement rates for medicines, higher patient co-payments, and increased patient contributions in the event of hospitalisation). At the same time, we are witnessing a profound crisis in the world of work, with a rise in the number of people without employment (the unemployed, those on early retirement, and those on minimum income support) and an increase in the number of people without social security cover (illegal immigrants, the homeless).

This crisis is not inevitable, nor does it follow the natural course of history. It is, in fact, the consequence of an economic system that promotes liberalism as an ideology and free enterprise as a model to be followed. This model is underpinned by the fundamental idea of preserving the freedom of entrepreneurs, whilst curtailing any capacity on the part of citizens – and indeed of states – that might challenge their power. It also involves the idea of extending its reach to all sectors of human activity capable of generating profit (the commodification of services), including areas hitherto recognised as falling within the remit of states: education, transport, healthcare, communications and energy management.

This neoliberal model is currently in place almost everywhere across the globe. The global consequences are evident everywhere:

• growing inequality in the distribution of wealth, with wealth being transferred from the poor to the rich;
• reduced access to education, healthcare and housing, as well as to water, food and work, to varying degrees depending on where in the world one is.

In Belgium, we are subject to policies that follow the same line and are leading to companies relocating and mass redundancies, for purely economic reasons. We are facing an increase in precarious work (temporary work, increased work rates, job insecurity, overqualification) and a decline in unskilled work. Furthermore, political authorities are increasingly subject to the dictates of unelected bodies such as the World Trade Organisation(4), whose standards dictate how governments must act, outside any democratic scrutiny.

This leads to a reduction in the protection that states provide for their citizens.

At the same time, responsibility for everything that causes problems is being shifted from political and corporate authorities onto individuals, who are forced to work in precarious conditions and to find a job… Yet industrial pollution, inhumane working rates, job insecurity, redundancies and large-scale fraud are rarely held to account. In Belgium, there are certain areas that remain the responsibility of the state. In the field of healthcare, the social security system, although now inadequate, remains a pillar of solidarity. We believe it is under threat, given that calls for a split along community lines are being heard, accompanied by clearly stated arguments for dismantling solidarity and an obvious risk of privatisation.

The move towards recognising the role of primary care and the importance of a multidisciplinary approach are positive developments at present. We should also mention the increase in funding for palliative care, the existence of decrees recognising integrated care associations (ASI), the revitalisation of general practice, the development of generic medicines, the recognition and provision of abortion services, and increased access to mental health services… At the same time, however, there is no health policy that takes a comprehensive approach to the population’s health problems, and we are witnessing ever-increasing investment in secondary and tertiary care, prioritising curative over preventive care, not to mention constantly rising pharmaceutical expenditure that is not subject to any evaluation.

In this context, which is by no means unique to Belgium, safeguarding the long-term viability of the social security system, whilst strengthening solidarity, seems to us to be a priority. The medical centres and all those who believed in the possibility of a more united society had hoped that the political authorities in power would take on board the merits of what we have been trying to achieve and proposing throughout these thirty years of our existence.

It has to be said that local action in each sector has not prevented the situation from developing as it has, even though we remain a privileged country, including by European standards. A second priority is the establishment of a genuine democracy that enables citizens to participate in major decisions affecting society and provides them with the means to do so. To achieve this, we will need to work not only at a local level, but also on a broader scale, in partnership with other sectors of society which, like us, have come to the same realisation and share the same values.

As of today (January 2025), the FEDE (Federation of Community Health Centres) comprises around 140 Community Health Centres.

(1) The Alma-Ata Declaration (1979): proposed by the WHO and adopted by many states, it emphasised the importance of a holistic approach to health and reaffirmed the right to health for all. It established this as a fundamental social objective and emphasised the importance of primary health care: «essential healthcare based on practical, scientifically sound and socially acceptable methods and techniques, made universally accessible to all individuals and communities within the community with their full participation, and at a cost that the community and the country can afford. It forms an integral part of the health system, of which it is the cornerstone, as well as of the community’s economic and social development.».

(2) Ottawa Charter (1986): the first international conference to promote Health for All by the year 2000 and beyond. This conference was, above all, a response to the expectation of a new global public health movement. Discussions focused on the needs of industrialised countries, whilst taking into account the problems facing all other regions.

(3) Neoliberalism: the revival of liberal ideas following a turning point that can be traced back to the 1970s (the fading prospect of a new international economic order). This process, pioneered by Milton Friedman and the «Chicago Boys», advocates the elimination of the state’s role as a regulator of trade relations, excessive privatisation and the primacy of market forces as the supreme arbiter between companies and nations.

(4) World Trade Organisation (WTO): an international organisation responsible for promoting free trade, understood in the broadest sense: tariffs, telecommunications, financial services, etc. Established in April 1994 from the ashes of the GATT (General Agreement on Tariffs and Trade), at the Marrakesh Conference, it was officially established in January 1995. The WTO’s aim is to remove customs barriers in areas where they still exist. These barriers can take various forms. With its liberal ethos, the WTO draws on classical theories regarding the primacy of the market (supply and demand) and the idea that if everyone (every country) pursues their own individual interests, the common good will be served. The members of the WTO are nation states.