Sustainable Solidarity Under Scarcity: A Philosophical and Political Analysis of Veranderen om te behouden (2026–2036)

 Abstract

Voor de hervorming van het Belgische ziekenhuislandschap: Veranderen om te behouden (2026–2036) proposes a fundamental reorganisation of Belgian hospital care. It differentiates hospital sites by function, concentrates acute and complex care, expands day care and intermediate care, centralises emergency triage, and seeks closer coordination between hospitals, primary care and community services. The report presents this programme through the Quintuple Aim, integrated people-centred care, positive health, solidarity, equity, patient empowerment and professional wellbeing. Its normative centre, however, is more specific than this plural vocabulary suggests. The governing principle is sustainable solidarity under conditions of scarcity: universal access to good care should be preserved, but preserving it requires the concentration of scarce personnel, expertise and infrastructure. The report therefore gives priority to system-level quality and workforce sustainability over the continued availability of every existing hospital function at every current site.

This is a defensible philosophical position. It reflects public-health consequentialism, egalitarian solidarity, relational autonomy and institutional stewardship. Yet the report does not adequately explain how these values are weighted when they conflict. Its most consequential recommendations rely heavily on hospital-bed and activity thresholds that are not logically entailed by its ethical framework and are only partially supported by the evidence presented. The report is therefore suitable as an agenda-setting expert blueprint and a basis for political negotiation, but not yet as a sufficient normative and evidentiary foundation for binding decisions on hospital conversion, merger or closure. The June 2026 interministerial compromise confirms both conclusions: the central model survived, but several rigid criteria were weakened, deferred or removed.

Introduction

The title Veranderen om te behouden, or “change in order to preserve,” contains the report’s basic political philosophy. The authors do not describe reform as an opportunity to replace the solidaristic Belgian healthcare model with a market-oriented alternative. They argue that the existing model can be preserved only if its institutional form changes. Hospital sites, departments and historical entitlements are treated as instruments rather than ends. The ends are accessible, high-quality and affordable care, delivered by a workforce that can sustain it.

The report was prepared by an expert group at the request of the Interministerial Conference on Public Health. Its mandate was to recommend how Belgium should organise its hospital landscape so that high-quality care remains possible while financial and personnel resources are used efficiently. Its central formula is that care should be provided nearby where possible and concentrated where necessary. The group based its work on existing scientific and policy reports, ministerial documents, stakeholder submissions and nine expert meetings. It deliberately excluded psychiatric hospitals, residential elder care, some rehabilitation institutions and several parallel reforms concerning hospital financing and medical remuneration from its immediate scope (Expertgroep Hervorming Belgisch Ziekenhuislandschap, 2025, pp. 7–9).

The philosophical significance of the report lies in the relationship between its expansive statement of values and its comparatively narrow operational machinery. Its ethical vocabulary includes quality, affordability, equity, patient wellbeing, professional wellbeing, solidarity, continuity, proximity, participation and empowerment. Its binding policy mechanisms, by contrast, are hospital categories, minimum bed numbers, activity thresholds, centralised emergency functions, mergers, site conversions and control over recognition and funding. This gap does not make the report incoherent. All public policy must translate general values into administrable rules. The relevant question is whether the selected rules are justified by the principles they are said to implement.

The argument developed here is that the report has a defensible normative centre but an incomplete theory of implementation. Its strongest idea is role differentiation: not every hospital site must perform every function, and equality of access does not require institutional uniformity. Its weakest move is to translate a multidimensional conception of justice into rules dominated by bed numbers and service volumes. The direction of reform is better supported than its numerical thresholds.

Clarifying the central concepts

Quality

“Quality” is the report’s most important concept, but it is not given a single definition. At different points, it refers to clinical outcomes, patient safety, continuity, professional competence, permanent availability, patient experience and compliance with structural or volume standards. These dimensions should not be treated as interchangeable.

A hospital may meet a minimum volume requirement without producing superior outcomes. Conversely, a lower-volume service may perform well because of effective clinical protocols, experienced teams, referral arrangements or case selection. The international literature supports a volume-outcome relationship for a number of surgical and highly specialised interventions, but the strength and form of that relationship vary substantially by procedure, outcome measure, case mix and research method. Volume can be a useful proxy, especially where direct outcome information is unreliable, but it is not a universal measure of quality (Levaillant et al., 2021).

The report recognises that quality must eventually be measured through indicators and made publicly transparent. It proposes linking quality information to recognition, financing and policy decisions, with the possibility that services failing to meet standards could lose recognition. This is an important correction to a purely structural approach. Yet the numerical reorganisation of the hospital landscape precedes the creation of a sufficiently developed outcome-based quality system. Bed numbers and service volumes therefore carry more decision-making weight than the report’s own multidimensional conception of quality would warrant (Expertgroep Hervorming Belgisch Ziekenhuislandschap, 2025, pp. 56–58).

Accessibility and proximity

The report correctly distinguishes accessibility from the physical presence of a full hospital. Many consultations, diagnostic procedures, minor interventions, follow-up services and forms of day care can be provided locally without maintaining a complete acute hospital infrastructure. Accessibility is therefore functional rather than institutional. What matters is whether people can obtain the care they need within an acceptable time, not whether every municipality retains an institution called a hospital.

This distinction is philosophically important. Egalitarian healthcare does not necessarily require equal quantities of every service in every location. It requires substantively fair access to appropriate care. A complex intervention may be safer at a specialised centre, while routine treatment may be more accessible at a local medical or day-care site. Differentiated provision can consequently advance equality rather than undermine it.

The report’s empirical treatment of accessibility is much narrower. Its main geographical model uses private-car travel times, calculated under a particular traffic scenario, to estimate the proportion of the population living within thirty or forty minutes of an acute hospital. The model indicates that removing acute functions from smaller sites would have particularly visible effects in parts of Hainaut, Liège, Namur and Luxembourg. For Luxembourg, the proportion within thirty minutes would fall from approximately 94 per cent to 78 per cent, although approximately 98 per cent would remain within forty minutes (Expertgroep Hervorming Belgisch Ziekenhuislandschap, 2025, pp. 45–49).

Car travel time is a relevant measure, but it is not an adequate philosophical or social definition of access. It omits access to a vehicle, public transport, disability, ambulance mobilisation, language barriers, caregiver availability, border crossings, the affordability of travel and the cumulative burden of repeated treatment. Centralisation can improve clinical outcomes while transferring costs from institutions to patients and families. Research on the centralisation of cancer surgery, for example, shows that travel burdens can increase even when clinical rationalisation is justified (Versteeg et al., 2018). A serious equity analysis must identify who bears those additional burdens, not merely calculate average travel times.

Equity, equality and solidarity

The report invokes both equity and solidarity. These concepts are related but distinct. Equality concerns comparable treatment or access. Equity permits unequal arrangements when these are necessary to respond fairly to different needs or circumstances. Solidarity concerns the collective acceptance of responsibility for risks and costs that individuals cannot reasonably bear alone.

Belgian compulsory health insurance is grounded in institutionalised solidarity. Contributions and public resources are pooled so that access does not depend entirely on individual health risk or purchasing power. The report does not challenge this principle. Its reform project seeks to protect the institutional conditions under which solidarity can continue. In this respect, it is neither libertarian nor primarily market-oriented.

Its conception of solidarity is nevertheless demanding. It requires communities to accept the loss or transformation of familiar hospital functions when concentration is judged necessary for the quality and sustainability of the system as a whole. It also requires stronger hospitals to assume regional responsibilities and institutions to share personnel, strategy and resources. The proposed mergers and integrated legal structures are therefore not merely administrative devices. They represent an attempt to convert solidarity from a financing principle into an organisational principle.

The difficulty is that the report does not define an acceptable minimum of territorial or social equity. It states that vulnerable populations require attention, but it does not specify distributional indicators, permissible inequalities or compensatory duties. It does not say, for example, how much additional travel burden can legitimately be imposed on rural communities, low-income households or people requiring frequent treatment. Equity remains a stated objective rather than a fully operational constraint.

Sustainability and stewardship

“Sustainability” is the concept that connects the report’s clinical, financial and workforce arguments. It refers to the capacity of the health system to continue delivering appropriate care despite demographic ageing, technological development, rising complexity, personnel shortages and budgetary pressure. The report treats scarcity as structural rather than temporary. It therefore rejects the assumption that every existing function can be preserved by adding more money or staff.

This position reflects an ethic of stewardship. Public authorities and healthcare institutions have a duty to protect collectively financed resources and to prevent scarce professional capacity from being dispersed across arrangements that deliver insufficient benefit. Nancy Kass’s public-health ethics framework is relevant here: policy should identify its objectives, assess likely benefits and burdens, compare alternatives, minimise coercion and distribute burdens fairly (Kass, 2001). The Belgian report is strongest on the first two tasks. It identifies an intelligible public objective and explains why maintaining all existing configurations may be harmful. It is less developed on alternative institutional scenarios and the fair distribution of reform burdens.

The report’s claim that Belgium faces workforce pressure is empirically credible. Recent international assessments identify shortages and retention problems among nurses, an ageing medical workforce and a physician density below the European Union average. Belgian hospitals also maintain a comparatively high bed supply, while day surgery and shorter stays are becoming more prominent. These trends support a reconsideration of how permanent acute capacity is organised. They do not, by themselves, determine which site should retain which function (OECD & European Observatory on Health Systems and Policies, 2025).

Positive health and patient-centred care

The report draws on “positive health,” a conception associated with the capacity to adapt and manage physical, emotional and social challenges rather than defining health solely as the absence of disease. This approach shifts attention from isolated clinical interventions to functioning, resilience and the patient’s own objectives (Huber et al., 2016).

Positive health has an affinity with capability-oriented philosophy because both ask what people are effectively able to do and be. The resemblance should not be overstated. The report does not develop a capability theory or specify a list of essential capabilities. It uses positive health mainly to justify integrated care, shared decision-making, prevention and attention to the patient’s broader life situation.

Its model of autonomy is therefore relational rather than atomistic. Patients are not depicted simply as consumers choosing among interchangeable institutions. Their agency depends on information, continuity, trusted professional relationships, coordinated services and practical support. Central triage and differentiated referral may restrict immediate institutional choice while improving the chance that a person reaches an appropriate level of care. That limitation can be justified, but only when triage is reliable, transparent and open to review.

The World Health Organization’s (WHO) framework for integrated people-centred health services similarly links quality and efficiency to participation, equity, community engagement, accountable governance and coordination across sectors. Integrated care is not achieved merely by moving services out of hospitals. It requires institutional relationships that prevent patients from being abandoned between levels of care (World Health Organization, 2016).

The Quintuple Aim

The report presents the Quintuple Aim as its explicit compass: improved population health, good patient experience, affordability or efficiency, professional wellbeing and equity. The addition of equity to earlier versions of the Triple and Quadruple Aim reflects the recognition that aggregate improvements can conceal systematic disadvantages for particular populations (Nundy et al., 2022).

The framework is useful as a checklist, but it is not a decision procedure. It does not explain what to do when objectives conflict. Concentrating emergency care may improve professional staffing and clinical readiness while worsening geographical access. Maintaining a small maternity service may support proximity but produce difficulties in staffing or maintaining competence. Increasing local day care may improve patient experience but require investments that reduce short-term efficiency.

A philosophical framework must therefore specify either a ranking of values or a fair procedure for resolving conflicts. The report does neither explicitly. Its recommendations reveal an implicit ranking: safety, clinical quality and workforce sustainability receive priority; affordability supports that priority; proximity and institutional continuity are protected where they remain compatible with it. Equity is invoked as a cross-cutting requirement but is not translated into equally binding criteria.

Reconstructing the argument

The report’s principal argument can be reconstructed as follows.

Premise 1: Demographic change, technological development, rising care complexity, financial pressure and workforce scarcity make the current organisation of Belgian hospital care increasingly difficult to sustain.

Premise 2: The present landscape disperses scarce personnel, infrastructure and permanent on-call capacity across too many sites and functions.

Premise 3: For at least some complex, urgent or technically demanding services, sufficient activity and concentrated professional expertise improve safety, quality and continuity.

Premise 4: Many routine, planned, diagnostic and follow-up services do not require a complete acute hospital and can be provided through day-care sites, local medical facilities, intermediate care and stronger primary care.

Premise 5: A legitimate hospital system must jointly protect clinical quality, affordability, patient wellbeing, professional wellbeing, accessibility and equity.

Premise 6: Differentiating institutional roles can concentrate functions that require scale while retaining appropriate local care.

Premise 7: Mergers, integrated governance, central triage, adjusted financing and a transition fund can make that differentiation operational.

Intermediate conclusion: Belgium should replace the expectation that each general hospital site provides a broad range of acute services with a system in which sites perform distinct, coordinated functions.

Final conclusion: The hospital landscape should be organised around university hospitals, regional general hospitals, local medical or day-care centres and intermediate care hospitals, with minimum requirements for acute hospitals, concentrated emergency services, integrated governance and a staged implementation process.

The inference from Premises 1–6 to the intermediate conclusion is persuasive. If personnel and expertise are scarce, some form of role differentiation follows. It would be irrational to treat every historical institution as inviolable when clinical practice, population needs and workforce conditions have changed.

The inference from the intermediate conclusion to the report’s exact thresholds is much weaker. Nothing in the Quintuple Aim, positive health, solidarity or integrated-care philosophy entails that a regional acute hospital must have exactly 150 justified acute beds in the first phase, 180 in a later phase, or a specified total number of recognised beds. These are administrative proxies requiring an independent empirical justification. The report calls 150 acute beds an absolute minimum, but its modelling relies on site-level data from 2025 because comparable earlier data were not available and describes its own results as indicative. It identifies thirty-nine sites below that threshold as candidates for transformation (Expertgroep Hervorming Belgisch Ziekenhuislandschap, 2025, pp. 45–47).

The original report also proposed a future threshold of 600 births per year for maternity services. The June 2026 interministerial principle proposal removed that criterion. This political revision does not prove that the criterion was scientifically wrong. It does show that it lacked sufficient evidentiary or political durability to survive the first major round of intergovernmental negotiation (Interministeriële Conferentie Volksgezondheid, 2026, pp. 4–6).

Several hidden assumptions also sustain the argument. The first is that structural scarcity should be addressed mainly by concentration rather than, for example, stronger retention policies, different professional roles, technological support or larger public investment. These alternatives are not mutually exclusive, but the report does not compare them systematically.

The second is that hospitals converted into local or day-care sites will remain financially and professionally viable. This depends on new financing, reliable referral arrangements, sufficient diagnostic capacity and the willingness of professionals to work across sites. Without those conditions, “local care” could become a rhetorical substitute for the disappearance of meaningful services.

The third is that primary care, home care, rehabilitation, ambulance services and intermediate care will have sufficient capacity before acute hospital functions are reduced. Yet several of these sectors fall partly outside the report’s scope. Belgian integrated-care policy is already constrained by divided responsibilities and fragmented governance. Hospital reform that proceeds faster than the development of surrounding services could shift rather than solve coordination failures (Martens et al., 2022).

The fourth is that institutional mergers generate substantive solidarity. A single legal entity, management structure and budget may facilitate cooperation and personnel deployment. It may also create larger bureaucracies, weaken local accountability and concentrate negotiating power. Legal integration is neither a necessary nor sufficient condition for clinical integration. The report treats it too readily as evidence that cooperation will follow.

From philosophical principle to practical rule

The report translates its principles into policy through several mechanisms.

Clinical beneficence and nonmaleficence become concentration rules. Complex and urgent care is directed toward institutions capable of maintaining permanent expertise, staffing and infrastructure. Twenty-four-hour specialised emergency departments are associated with regional acute hospitals, while central triage through the 112 and 1733 systems is intended to direct patients to an appropriate service. This is a defensible application of the duty to prevent avoidable harm, provided that travel and triage risks are included in the assessment rather than treated as external issues (Expertgroep Hervorming Belgisch Ziekenhuislandschap, 2025, pp. 39–41).

Stewardship becomes minimum-scale requirements, reduced duplication, expanded day care and the repurposing of hospital resources. The four-part typology is the key institutional expression of this principle. Regional acute hospitals retain a broad range of permanent functions. University hospitals add academic and highly specialised responsibilities. Local medical centres provide consultations, diagnostics, day treatment and selected planned services without the full permanent infrastructure of an acute hospital. Intermediate care hospitals address patients who no longer need acute treatment but cannot yet return home safely (Expertgroep Hervorming Belgisch Ziekenhuislandschap, 2025, pp. 32–36).

Solidarity becomes regional responsibility, shared personnel, integrated budgets and the proposed reinvestment of savings. The report argues that resources released through rationalisation should remain within healthcare and proposes a transition fund, partly financed by redirecting historical components of hospital funding. Its indicative proposal of approximately €130 million annually for five years is intended to support personnel measures, temporary double running, infrastructure and equipment (Expertgroep Hervorming Belgisch Ziekenhuislandschap, 2025, pp. 59–60).

Professional wellbeing becomes a reason to concentrate on-call duties and scarce expertise. This is not a secondary employment issue. A system that formally maintains services but cannot staff them reliably creates risks for patients and moral distress for professionals. The report is right to place workforce wellbeing inside its definition of quality rather than treating it only as a human-resources concern.

Relational autonomy becomes shared decision-making, care coordination and case management. Patients are expected to participate in decisions, but they are also routed through more structured pathways. Autonomy is thus interpreted as meaningful involvement in appropriate care, not an unrestricted right to demand every service at the nearest site.

Federalism and subsidiarity become a common interministerial framework implemented through federal and federated competences. This arrangement reflects Belgium’s constitutional reality, but it also creates the possibility that common principles will be applied unevenly. The June 2026 proposal leaves federated entities substantial responsibility for deciding the future role of individual sites while maintaining common categories and criteria. This may be politically necessary. It also requires unusually clear public justification if neighbouring sites or populations receive different treatment.

Procedural justice appears in the proposed publication of indicators, staged implementation and future evaluation. These elements resemble Norman Daniels’s principle of “accountability for reasonableness,” (A4R) under which priority-setting decisions should rest on publicly accessible reasons considered relevant by fair-minded participants, include mechanisms for challenge and revision, and be effectively regulated (Daniels, 2000, 2008). The report satisfies the publicity condition only partially. Its broad reasons are public, but the derivation and weighting of specific thresholds are not sufficiently transparent. It proposes revision after evaluation, but it does not establish a clear appeal procedure for affected communities or institutions.

The normative centre

The normative centre of the text can be described as sustainable solidarity under conditions of scarcity.

“Solidarity” means that good healthcare remains a shared social responsibility rather than a commodity distributed principally according to purchasing power. “Sustainable” means that solidarity must be organised in a form that can continue to function with limited personnel, money and infrastructure. “Under conditions of scarcity” means that public authorities cannot avoid choices simply by affirming every desirable value simultaneously.

The report’s practical core standard is therefore: provide care as locally as is consistent with safety and sustainability, and concentrate it when permanent competence, infrastructure or staffing cannot otherwise be guaranteed. This is a form of constrained population-level consequentialism. Institutions are judged by their expected contribution to health outcomes, access and system continuity, not by historical status alone. The consequentialism is constrained because the report also recognises equity, solidarity and patient participation as moral requirements.

This standard is stronger than cost minimisation. The report repeatedly states that efficiency may not be pursued through a loss of quality and proposes reinvestment rather than simple budget extraction. Its main concern is the opportunity cost of maintaining dispersed acute structures: scarce professionals assigned to low-volume permanent services cannot simultaneously serve higher-volume regional functions.

At the same time, the report is less egalitarian in its operational details than in its stated principles. It accepts that some populations will travel farther and that some communities will lose acute functions. Such inequalities may be justified if they produce safer care and if burdens are compensated. The report does not provide a sufficient theory of compensation. It lacks firm commitments concerning transport support, mobile services, public transport, accommodation for relatives, digital inclusion or protection against the economic effects of repeated travel.

The normative position could also be described as conservative reformism. “Change to preserve” reassures stakeholders that the objective is institutional adaptation rather than ideological rupture. This is persuasive political framing. It invites agreement from actors who support the solidaristic system but disagree over the existing hospital structure. It also conceals some of the distributive conflict. What is preserved at the system level may be experienced locally as a significant loss.

Evaluation and critique

Validity of the general argument

The report’s general argument is valid in a practical rather than deductive sense. If the current configuration cannot reliably maintain quality and staffing, and if some care can be safely redistributed, differentiation and concentration are reasonable responses. The report also avoids the crude position that centralisation is always beneficial. It combines concentrated acute care with local planned care, day treatment and intermediate facilities.

Its four-part typology is particularly useful because it separates the question of whether a site remains active from the question of whether it remains a complete acute hospital. This creates more policy options than a binary choice between preservation and closure. It can support negotiated transitions and reduce the symbolic threat associated with losing the hospital label.

Soundness of the empirical premises

The report’s diagnosis is broadly sound. Workforce pressure, changing clinical practice, shorter admissions, day treatment and the costs of maintaining permanent acute capacity are well documented. International evidence supports concentration for selected complex procedures, particularly where outcomes depend on team experience, specialised equipment and continuous availability.

The report overextends this evidence when generic hospital scale is allowed to stand in for service-specific quality. The relationship between procedure volume and outcomes does not establish that total acute bed numbers are an appropriate universal criterion. Beds are an input and an administrative category. They do not directly measure clinical competence, response capacity, case complexity, outcomes or population need.

The modelling also lacks sufficient sensitivity analysis. The report does not publicly demonstrate how results would change under different traffic assumptions, population projections, emergency-time standards, public-transport measures or combinations of outcome and access criteria. Its maps are useful decision-support tools, not proofs that one configuration is uniquely correct.

The Federal Council for Hospital Facilities (Federale Raad voor Ziekenhuisvoorzieningen, FRZV) made a similar point in its April 2026 response. It supported the need for deep reform and accepted the importance of balancing quality, access and efficiency, but requested greater transparency concerning the data and model. It also raised concerns about rural accessibility, transport poverty, financing and the relationship between reform and stronger primary and post-hospital care. The council considered the proposed transition funding insufficient and rejected the idea that the hospital sector should finance the transition from its own existing resources (Federale Raad voor Ziekenhuisvoorzieningen, 2026).

The Flemish Council for Welfare, Public Health and Family (Vlaamse Raad voor Welzijn, Volksgezondheid en Gezin) also broadly accepted the typology but criticised the absence of a complete integrated-care framework. It argued that decisions should be based more directly on current and future population needs, including demographic, epidemiological, socioeconomic and vulnerability indicators, rather than being driven mainly by historical structures and bed numbers. It also identified the exclusion of psychiatric and some rehabilitation care as a serious gap in a report claiming a population-based and integrated perspective (Vlaamse Raad voor Welzijn, Volksgezondheid en Gezin, 2026).

These criticisms are well founded. The report has a systems philosophy but a hospital-centred evidence base. It asks hospitals to become part of integrated care without fully modelling the services on which successful deinstitutionalisation and shorter admissions depend.

Hidden distributive choices

The report presents concentration primarily as a technical solution, but it is also a distributive choice. Benefits and burdens fall on different groups. Patients requiring rare complex treatment may benefit from expertise and better outcomes. Rural residents, people without cars, hospital employees, local physicians and municipalities may bear larger costs.

These effects cannot be assessed solely through net system benefit. Justice requires attention to the position of those who are made worse off. A policy may be efficient in aggregate but unfair if a small and already disadvantaged population bears a severe access burden for benefits enjoyed elsewhere.

The report’s equity language does not resolve this problem. It should specify at least three things: the maximum acceptable deterioration in effective access; the population characteristics that trigger additional protection; and the compensatory measures required when concentration imposes disproportionate burdens. Without such rules, equity can be invoked selectively after the main structural choices have already been made.

Participation and legitimacy

The expert group is professionally diverse, but the process was not a substitute for public deliberation. The report describes consultation with institutional stakeholders and the review of stakeholder documents. It does not present a structured process of citizen deliberation, patient co-design or direct participation by communities most likely to lose acute services.

This matters because hospital reform involves reasonable moral disagreement. People may disagree about how to trade marginal improvements in clinical quality against travel burden, continuity, local resilience or the social role of an institution. Scientific evidence can inform these choices but cannot determine the acceptable distribution of burdens. Justin Parkhurst’s concept of the good governance of evidence is relevant: policy evidence must be scientifically credible and used through democratically legitimate institutions, rather than treated as if technical analysis could eliminate political judgment (Parkhurst, 2017). Paul Cairney similarly shows that evidence enters policymaking through framing, institutional constraints, bounded attention and negotiation rather than through a simple transfer of facts into decisions (Cairney, 2016).

A stronger process would include regionally organised citizen panels, patient and disability organisations, primary-care representatives, professional organisations, labour representatives and transport-access experts. Their role should extend beyond commenting on a completed model. They should participate in determining the criteria by which site decisions are made.

Legal and institutional feasibility

The report acknowledges significant legal questions but does not resolve them. Its legal appendix is expressly preliminary, based partly on an oral explanation and presentation of the proposed model. It states that a full legal analysis will be required when the model is finalised. Financing was also outside the legal assessment’s scope (Expertgroep Hervorming Belgisch Ziekenhuislandschap, 2025, pp. 63–78).

This is not a minor technical omission. Hospital recognition, financing, emergency care, professional practice and infrastructure involve overlapping federal and federated competences. A politically agreed objective may still fail if responsibilities, deadlines, legal remedies and funding duties are ambiguous. Decisions that affect individual sites will also require consistent criteria to avoid arbitrary differentiation and prolonged litigation.

Metric substitution

The report’s central methodological weakness is metric substitution. It begins with a rich normative framework and ends with a decision model in which bed counts, travel times and institutional categories do most of the operative work. These indicators are measurable and administratively available, which partly explains their prominence. They are not necessarily the best representations of the values the report itself identifies.

A model aligned with the Quintuple Aim would include clinical outcomes, avoidable mortality, readmissions, continuity, patient-reported outcomes and experiences, staff retention, deprivation, disability, public-transport accessibility, emergency response times and unmet need. It would then disclose how these dimensions are weighted. The Federal Council’s recommendation to use outcome and process indicators, including patient-reported measures, points in this direction.

The report does propose future quality measurement, but that sequence is backwards for irreversible structural decisions. Outcomes and equity should help determine the configuration, not merely evaluate it after implementation.

The authors’ professional, philosophical and political background

The report is the work of a collective expert group rather than a single author. Its members include hospital managers, medical specialists, a general practitioner, a nurse and health-services researcher, academics in public health and economics, a health economist associated with the Belgian Health Care Knowledge Centre, and individuals with senior experience in healthcare organisations and public administration.

Peter Degadt previously led Zorgnet-Icuro, a major network of social-profit healthcare institutions. Guy Durant is a management engineer with training and academic experience in hospital management and public health. Johan Albrecht is an economist at Ghent University and a founding member and senior fellow of the Itinera Institute, a policy think tank. Carine Van de Voorde is a health economist associated with the Belgian Health Care Knowledge Centre. The group also includes clinicians with experience in general practice, internal medicine, haematology and hospital leadership, as well as nursing and integrated-care expertise (Expertgroep Hervorming Belgisch Ziekenhuislandschap, 2025, pp. 61–62).

Alda Greoli has the clearest direct party-political background. She served as a national secretary of the Christian Mutualities, advised federal Health Minister Laurette Onkelinx and served as a Walloon minister responsible for health. She has also been active within Les Engagés. Her career links mutualist solidarity, Christian-democratic social policy and executive government experience.

It would be irresponsible to infer the private philosophical convictions of individual members from these biographies. The report itself permits a more limited conclusion about its collective intellectual orientation. It combines the solidaristic traditions of Belgian social insurance and social-profit healthcare with public-health planning, clinical professional authority, managerial rationalisation and health economics.

This composition is a strength because the proposal requires operational knowledge of hospitals, professional practice, financing and public administration. It is also a source of institutional bias. Most members are current or former healthcare insiders. The listed group does not include a moral or political philosopher, a dedicated patient or citizen representative, a disability-rights specialist, a transport-access scholar or a labour representative. Legal expertise appears in a separate preliminary contribution rather than at the centre of the model’s design.

The report’s philosophy is therefore applied rather than theoretically developed. Its use of the Quintuple Aim, positive health and integrated care supplies a normative vocabulary. Its use of Specific, Measurable, Achievable, Relevant, and Time-bound (SMART) objectives, Strengths, Weaknesses, Opportunities, and Threats (SWOT) analysis, numerical thresholds and Simon Sinek’s Golden Circle (Why, How, and What) reflects a managerial and strategic-communication culture. The result is pragmatic but philosophically under-specified. It knows which outcomes it wants but is less clear about the principles that should govern conflict among them.

Politically, the group’s composition spans several institutional traditions and reduces the appearance of direct partisan ownership. This helps coalition building. It does not eliminate political contestation because the principal conflicts concern territorial interests, employment, institutional status and the distribution of public investment rather than conventional left-right ideology alone.

Political suitability as a foundation for healthcare policy

The report is politically suitable as an expert blueprint and negotiating framework. It is not yet sufficient as the complete basis for binding legislation.

Its principal political strength is its framing. “Change to preserve” presents reform as a defence of the healthcare system rather than an attack on it. The nearby-where-possible, concentrated-where-necessary formula acknowledges both sides of the conflict. It does not dismiss local access, but it refuses to treat proximity as absolute. The four institutional types offer affected sites an alternative identity instead of describing reform solely through closures.

Its second strength is value breadth. Quality, access, affordability, professional wellbeing and equity are recognisable concerns across ideological and linguistic divisions. Actors can support the framework for different reasons. Clinicians can emphasise quality and staffing. insurers and public authorities can emphasise sustainability. local actors can defend nearby day care. patient organisations can invoke access and continuity.

Its third strength is staged implementation. Transition financing, phased criteria, an evaluation point and the possibility of site conversion reduce immediate political risk. Policy that visibly allows learning and correction is more likely to survive than an irreversible national blueprint imposed in a single act.

The report has also generated meaningful institutional convergence. On 24 June 2026, the Interministerial Conference on Public Health agreed on a principle proposal as a common basis for further work. The ministers accepted the need for reform, the broad hospital typology and the combination of local care with concentration. They renamed the local medical centre as a day-care hospital site, introduced greater flexibility for rural accessibility, deferred some higher thresholds to a later phase and removed the 600-birth criterion. Definitive political decisions were expected in September 2026. As of 27 July 2026, the proposal was therefore a negotiated framework rather than final legislation (Interministeriële Conferentie Volksgezondheid, 2026).

These revisions improve coalition viability. Rural derogations respond to territorial concerns. Removing the maternity threshold avoids an especially visible conflict. Deferring stricter criteria permits additional evidence and adaptation. Allowing federated entities to determine the destination of individual sites respects Belgium’s institutional distribution of powers.

The same revisions expose the weakness of the original claim that its thresholds were technically necessary. A criterion that can be removed or delayed through political negotiation may still be useful, but it should not be presented as the direct implication of scientific evidence. The June agreement shows that the reform is being shaped through a mixture of evidence, federal compromise and distributive bargaining.

Coalition support also remains conditional. The Federal Council for Hospital Facilities supports the need for reform but demands better data transparency, more adequate financing and stronger integration with surrounding services. The Flemish advisory council supports the direction but criticises the population-needs analysis and exclusions from scope. A minority opinion from the Belgian Association of Medical Unions warns against treating volume as synonymous with quality and stresses professional autonomy, outcome transparency and organisational flexibility.

The report’s persuasive framing has one serious vulnerability. The June ministerial communication states that no site will be forced to close, while the accompanying principle proposal lists cessation of activities as one possible outcome for sites unable to meet the criteria or convert to another function. These statements can be reconciled by saying that no centrally imposed automatic closure follows from the framework and that federated authorities retain choices. Politically, however, the distinction is fragile. Communities may reasonably understand the withdrawal of financing or recognition as coercive even when the formal decision is decentralised. Ambiguous reassurance risks damaging trust.

To survive a legislative process, the proposal needs six additions:

1. First, the government must publish a transparent population-needs model combining clinical outcomes, workforce feasibility, demographic change, deprivation, disability, rurality, public transport and emergency access. Bed numbers can remain one variable, but they should not function as the principal definition of institutional legitimacy.
2. Second, each site decision should be accompanied by a distributional impact assessment. This should identify who gains, who loses, the severity and duration of the burden, and the measures used to compensate disadvantaged populations.
3. Third, the federal and federated governments need a binding multi-year financing agreement. Hospital conversion cannot credibly be financed through uncertain future savings. Local day care, intermediate care, ambulance capacity, digital systems, workforce transition and temporary double running require investment before acute services are withdrawn.
4. Fourth, reform must be sequenced with primary care, home care, rehabilitation, mental healthcare and non-urgent patient transport. Removing acute capacity before those alternatives function would contradict the report’s own integrated-care philosophy.
5. Fifth, the decision process needs public-reason safeguards: published criteria, understandable site-level reasons, direct participation, an appeal or review procedure, and an independent evaluation capable of changing the model.
6. Sixth, legislation should contain explicit outcome, equity and workforce targets, together with a review or adjustment clause. The 2031 evaluation proposed in the June agreement is useful, but it must assess real patient flows and outcomes rather than merely whether institutions completed the prescribed conversion.

Conclusion

Veranderen om te behouden is a serious and necessary intervention in Belgian health policy. It rejects the politically comfortable assumption that preserving solidarity requires preserving every historical hospital function. Its central insight is correct: differentiated institutions can provide more equal and safer care than formally identical institutions that lack sufficient staff, expertise or activity.

Its normative centre is sustainable solidarity under scarcity. The report seeks to preserve universal, high-quality healthcare by concentrating functions that require scale and retaining local care where full acute infrastructure is unnecessary. This position combines public-health consequentialism, egalitarian solidarity, relational autonomy and stewardship. It is more defensible than either indiscriminate centralisation or an unconditional defence of the institutional status quo.

The report’s ethical pluralism is not matched by an adequate decision theory. It does not specify how quality, proximity, equity, affordability and professional wellbeing should be weighted. Its operative rules give priority to scale and workforce concentration, while equity remains weakly quantified and patient participation remains procedurally limited.

The empirical case for reform is stronger than the case for the report’s exact thresholds. Evidence supports concentrating selected complex and urgent services. It does not establish generic acute bed numbers as a sufficient measure of quality or population need. The report’s reliance on indicative 2025 data, private-car travel times and incomplete surrounding-sector analysis makes it unsuitable as the sole basis for irreversible site decisions.

Politically, the text succeeds as an agenda-setting document. It offers persuasive framing, a negotiable typology and a phased route toward structural reform. The June 2026 interministerial agreement demonstrates substantial coalition potential. It also demonstrates that the original model required modification before it could attract governmental consensus.

The proper verdict is therefore conditional. The report is suitable for building healthcare policy, but not for bypassing political judgment. It should guide legislation only after its thresholds are justified more transparently, its equity commitments are converted into enforceable protections, its financing is secured, and affected populations are given a meaningful role in the process. Its strongest idea is role differentiation. Its weakest move is to convert a plural theory of justice into a bed-counting rule.

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