Proposition 54K2652

Projet de loi portant modification de la loi relative à l'exercice des professions des soins de santé, coordonnée le 10 mai 2015.

General information ¶

Submitted by

MR Swedish coalition

Submission date

Aug. 25, 2017

Official page

Visit

Status

Adopted

Requirement

Simple

Subjects

doctor access to a profession public health

Voting ¶

Voted to adopt

CD&V Vooruit Open Vld N-VA MR

Voted to reject

LE PS | SP ∉ PVDA | PTB

Abstained from voting

Groen Ecolo PP VB

Party dissidents ¶

• Muriel Gerkens (Ecolo) voted to reject.
• Olivier Maingain (MR) voted to reject.

Contact form ¶

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Discussion ¶

March 15, 2018 | Plenary session (Chamber of representatives)

Full source

I am referring to the written report.

Mr. Speaker, Mrs. Minister, colleagues, when I stand here and think about the subject on which I will immediately give a brief explanation, I get a huge sense of déjà-vu. That may not be so strange. After all, I have held the same speech here many times and it will not be different today. I myself have been working on this dossier for ten years, first behind the scenes as a spokesman, together with Mr. Louis Ide, from the opposition, and in the past years here, from the majority. Ten years ago, and now I truly hope, colleagues, that it will be the last time.

It was a rough path, but we got hit. After twenty years of unwillingness, all imaginable delaying manoeuvres, and a lot of speech, there is before you a draft to vote that finally straightens a decades-long gap-growth, based on a balanced and fair agreement within this government. But above all, and that is sometimes forgotten in this discussion, based on the common will of this majority to keep the health care and therefore also the body quality and affordable.

Some colleagues will tell you immediately and undoubtedly how scandalous this agreement is; how the French-speaking interests are unacceptably violated by it; how medical care can no longer be guaranteed in the south of the country; how the contingentation, which they never de facto applied, has in some miraculous way yet made that there is today a shortage of doctors in French-speaking Belgium and how the N-VA plays a community game on the cap of the French-speaking students. You will hear this immediately from the colleagues, but I will not go into it too closely: it comes.

The reality, dear colleagues, cannot be more different than that. But well, I can answer a hundred times that the assignment to less popular regions and to sub-specialities has since become a competence of the Communities and that this is applied consistently and successfully in Flanders. I can say a hundred more times that today’s deficits can still be hard to put on the contingent that has never really existed in the south of the country, and that not we have made it a community story, but the PS. Federal, it voted twenty years ago to introduce the quota in this country, then for twenty years to refuse to do at community level what had to be done, in particular to introduce an entrance exam.

This resulted, on the one hand, in frustration on the Flemish side for all Flemish students who could not start the training and on the other hand had consequences for the future certainty of the French-speaking students who were told for years that there was nothing to fear. The PS would ultimately ensure that the ghost of the contingentation would disappear. Dear colleagues of the PS, I actually have a solution to that, and that is called confederalism. However, if the account shifts with it, such an attitude is already a little less interesting for certain parties, which I have learned in the meantime.

I have rejected those curved reasoning so many times in the committee that I do not have the illusion here that I will be able to convince my colleagues this time. So I come to the design itself.

When the quota was introduced at the end of the 1990s, it was not for nothing. At that time there was a huge overflow of doctors in our country, with overconsumption and overcrowded halls. This also resulted in less quality training. Limiting the number of RIZIV numbers that could be awarded annually to graduates was necessary to continue to guarantee the quality and affordability of health care. I hear the words quality and affordability there sound very often but when it comes to it, they don’t like to work with it.

The rest is actually history. In Flanders, we have immediately introduced an entrance exam since the introduction of this quota. Approximately 4,000 students participate each year. Only a minority can pass through. In itself, that is not a problem because everyone knows why it is so and everyone is in favor of that decision. How bitter is it, however, for those Flammers to see what has been happening on the other side of the language border for twenty years now? I cannot describe it better than with the words after nous le déluge. Somebody will solve it someday. This is what you have told the students and us for a very long time.

The account for the reluctance of the French-speaking parties to introduce an entrance exam in their Community is, of course, federal. That is, of course, a large part of the problem. This is cynicism at the top. When then Minister of Public Health Onkelinx didn’t think better about having a law passed to allow students who graduate today to pick up the RIZIV numbers of the future, I thought to see the end in this file for a moment. Then, however, we still had to come to the discussion with which we hope to conclude this today, about the solution that this government has found. Every delayed manoeuvre has passed the review here, on the shameless end. Dear colleagues, however, this agreement cannot be touched.

It is very clear and it remains clear: there is finally an entrance exam in French-speaking Belgium and it will continue to be. That entrance examination will also have to be efficient and lead to a limitation of the influx, as in Flanders. The overload of doctors that has been built up over the last twenty years will finally have to be paid off. The distribution of the RIZIV numbers between the two counties, which will be determined annually by the Planning Committee for the whole kingdom, will be made from now on the basis of the only correct criterion, in particular the population number.

With this agreement, we make it possible for the French-speaking students who are now in their training to fully begin the profession. I do not expect a thank you for it, but you can be grateful for it. However, we also put an end to the flawed growth and the harmful consequences for our health care.

Our group will therefore fully support this project.

Mr. Speaker, Mr. Minister, I know that I will not convince and that it is too late. I will be concise. But I would like to reaffirm the basis of the convictions of my political group in this matter. Whatever you say, this issue is, in our opinion, community-related.

Inami numbers allow doctors, dentists, after a long and difficult training to exercise their profession in the service of the community.

This is a community dossier, Mrs. Minister, in which you have plunged, from the beginning of the legislature, harassed by your majority partners who want, once again, to harm – this is in any case our way of seeing things – the accessibility for all to health care in our country and especially in certain regions. I will return to this point.

Your hard work in this file began at the beginning of the legislature when you decided to impose on the Federation Wallonia-Brussels the introduction of an entrance examination for access to medical and dentistry studies, under the penalty of not granting, you said, INAMI numbers to students on course. It was and we denounced it at the time, an unacceptable hostage-taking.

After various rebounds that I will not recall, the entrance examination was therefore put in place and demonstrated its effects last September, unfortunately. I would like to recall it, because it goes, in my opinion, against the freedom of access to studies. The future good doctors are not necessarily those who pass this type of examination at the exit of secondary education. We were able to witness a number of tragedies experienced by these students.

In 2016, you decided to set quotas for the year 2022, without taking into account the opinion of the Planning Commission which clearly considered it necessary to revise the key in favour of the Wallonia-Bruxelles Federation. You yourself spoke of a political agreement away from the evidence-based medicine you advocate so much, from quotas eventually invalidated by the State Council due to illegal deadlines that you did not respect.

Finally, the apotheosis, the cherry on the gift, this bill presented as a balanced agreement within the framework of the INAMI file received an opinion more than Assassin of the State Council, an opinion on which your government sat without swinging!

No objective reason justifies the positions taken in this matter and ⁇ not the health needs of our citizens. Your positions are inconsistent, incomprehensible, intolerable. This is the opinion of my group, which I do not lack to share, but not only because the State Council does not say anything else regarding the text that is submitted to us today. According to the Council of State, "not only does such a system appear inconsistent with regard to the respective consideration of criteria at the national level and at the Community level, but also, more fundamentally, it can result in a decline in the medical supply in one or another Community in relation to the needs of its inhabitants, as they would have been evaluated by the said commission." Considering its interests seriously damaged, the French Community Commission (COCOF) has initiated a procedure in conflict of interest.

I could explain the argument again, numbers in support. I will thank you to quote all these numbers that we have already heard hundreds of times. We know what a conflict of interest represents in this parliament, we know how meetings take place and above all how they end: there is no worse deaf than the one or the one who does not want to hear. Again, we advocate that the very content of this type of consultation may be revised, but this is another debate.

I come to the bottom, very briefly. This bill significantly modifies the contingent system for the exercise of medicine and dentistry, without taking into account the needs of the whole population, without taking into account the realities of the field, experienced on a daily basis. For many years, the Commission for Planning of Medical Supply has played a key role in fixing quotas and the distribution key between the Communities, carrying out an increasingly sophisticated work, taking into account the evolving needs of medical care and the demographic and sociological evolution of the occupations concerned.

And, today, you take away, Mrs. Minister, this main role, to give a role of figure to this commission. This is not surprising, as you had already ignored his opinions and expertise in the past. You will tell us that the Planning Commission will continue to evaluate the needs of the country, as is the case now. Yes, but you clearly take away the care of proposing a sharing between linguistic communities. The work of distributing the national quota between French and Flemish speakers will in the future be reserved for the Court of Auditors alone.

It will make a distribution according to the size of the population of the Communities. We will do mathematics at the expense of socio-demographic needs, and that do not take into account the differences between the Regions. This is the main criticism we make to the text.

These are mathematics and magic formulas, because the issue of the Brussels Region had to be solved. To calculate the number of Dutch and French-speaking inhabitants of the Brussels Region, dear friends who exercise responsibilities within this Region, we found a criterion at least particular. This is the proportion of students in the Netherlands-speaking and French-speaking primary and secondary education, compared to the total number of students. I am talking about magic formula, be careful because the State Council has said that it does not perceive – an elegant style formula – the link between the number of students in compulsory school attending respectively the Dutch-speaking and French-speaking schools, on the one hand, and the distribution of the certificates of contingentment of candidates medical specialists by Community, on the other. I can’t see the link either. It is also noted that the number of students attending Dutch-speaking schools is not representative of the number of Dutch-speaking students living in the Brussels Region. I would like to mention the State Council.

Mr. Speaker, I thought I would let Mr. Frédéric go to the end of his reasoning, but I would like to make a small clarification.

The criteria of the schools that have been chosen can always be discussed. But what is certain is that when we look at the negative differential that he might assume, we speak, for students who will start their specialization in 2024, of twenty doctors. In the meantime, we will still have 14,486 doctors working in Wallonia and 5,553 in Brussels. There will be 20 doctors out of 5,353. These figures should be relativized. In the meantime, we have found a solution; I will return to it in more detail in my speech.

I thank Mr. Thiery for his courage.

The [...]

Allow me to continue!

I just say that is extremely courageous. This is unconvincing, but I have admiration for you, Mr. Thiéry, because it is always you who must take on indefensible strikes, to support the plans of the three Flemish partners of the majority who, in your daily and extra-parliamentary activity, have never really supported you. I admire this conviction. I would even offer you a drink at the bottle. (The Hilarity)

And more seriously. We will not argue.

Mr. Frédéric, I also admire your argument, simply because you really believe what you say. Of course, we will never agree, but what is certain is that we have found a solution in the interests of all. Without this, there would be no number issued in 2017 until 2020 and beyond.

Thank you for defending the majority for this argument. We will not make a fight of numbers, because the numbers I have and which have been mentioned every time, according to the text you are going to vote today will ensure that there are about 100 general physicians fewer per year in the Walloon Region and in the Brussels Region. These are the numbers. But we will not agree on the figures.

To conclude and not monopolize the tribune, I would also like, Madam the Minister, to recall that your project implements a famous negative smoothing that, in a certain way, punishes the ugly Francophone who have formed – it has just been said – more doctors and dentists in the past than they were allowed to train. As this government has always desired, it is therefore the future generations who, from 2024, will compensate for these surplus INAMI numbers in a context of shortage. I will remind you and I will come back.

For my group, Mrs. Minister, there is an obvious thing in this case. This is precisely the need to re-examine the system of contingentation, a purely and simply aberrant system. And, in this case, everyone should obviously avoid taking responsibilities.

And you, instead of removing it or at least adapting it to the realities, you are manipulating it to make it an even more disastrous system, a system that only meets the requirements of your majority partners, disregarding the reality of the field, disregarding the different regional needs, disregarding the need of patients, the quality and accessibility of our profession.

And the reality is that of the shortage of general doctors, specifically in some municipalities of Wallonia and, specifically, in the rural environment from which I come. It is also the shortage at the level of certain specialties, which results in waiting times to get an abnormally long appointment and all studies converge to say that this shortage will only accentuate in the coming years.

I just said I ⁇ ’t do it anymore, but it’s stronger than myself. I will try again. (Mr. Frédéric is looking for the translation)

Look at my mouth. Maybe you can read it.

The shortages in the sub-specialities that you experience today in Wallonia, in French-speaking Belgium, the shortages in certain regions are there without ever having any influence of contingentation. Why do you have them today? Because you do not use your community authority that should ensure that it is delivered to regions and sub-specialities; something that Flanders does.

Therefore, stop holding the people every time the argument that the deficits would have arisen from the contingentation at the federal level and that the solution would be here, because that is simply completely incorrect.

Mrs. Van Peel, I thank you for your speech, applauded by the majority.

The [...]

Everyone has the opportunity to express their beliefs, and I respect it.

The [...]

I wanted to come here, Mrs. Onkelinx, be calm! This is the last reality I wanted to insist on.

Foreign doctors who come to work in our hospitals are not bound by the contingent. I would like to remind you that at present, more than 40% of doctors with an INAMI number are nationals of a Member State of the European Union.

Finally, Belgian students who will complete their training abroad return home without fear of being trapped by this contingent. It remains incomprehensible that a Belgian student – and we have also submitted an amendment in this regard – is not treated equally as a foreign student in terms of the conditions for access to a specialization. For my group, the selection must be fair, and people with a foreign degree must therefore be subject to the same criteria for admission to a specialty by universities.

As I announced, I’ll spare you the numerical quarrel: we’ve had enough commissions exchanges, as well as in the media, about this.

Madam the Minister, Flemish and French-speaking majority, you have thus decided to install a real community imbalance in terms of health care supply. At no time have you worked in favour of a federal public health policy. This is not the first time you are being accused of it. Tomorrow, the accessibility of our health care will be clearly less good in Wallonia and Brussels than in Flanders. We regret it bitterly. We will continue to oppose it and will of course vote against this text.

Mr. Speaker, Mrs. Minister, dear colleagues, I also did not intend to enter into a polemic because, as often here, in the plenary assembly, we are only repeating a number of arguments and elements that have been discussed long in the committee. It can be said that in fact, here we are faced with a problem that dates back almost twenty years.

I will begin by referring to what recently said Professor Jean-Jacques Rombouts, who is the former dean of the Faculty of Medicine of UCL and who was a historical actor in the case of contingentation: "The toelatingexamen was set up in the Flemish Community in 1997. Soon it will be 20 years. This was the end of a long reflection in which I participated as president of the UCL School of Medicine. The primary objective was to improve the basic level of incoming students, so that medical studies can be liberated from science upgrading to devote more time to human and social training for future doctors.” I only see that an agreement was reached during this period. The Dutch-speaking – I only see it – respected it, which was not the case for the French-speaking. I regret it.

Madame Onkelinx, saying that I do not know my dossier, I let you listen to what I have to say! What is certain is that historically this case is chaotic. We have never found a solution to solve the concern that successive health ministers have never solved until today. This problem, whether we like it or not, has always been detrimental to our students, especially by the fact that the French Community has been misleading for years before introducing the filter at the beginning of studies, with as a consequence an enthusiasm of medical students in our faculties that did not correspond to the planning set by the federal.

The establishment of a filter at the entrance of studies is indispensable, not only to regulate the medical offer but above all to guarantee the quality of the training. Quality training requires adequate and suitable infrastructure, a guaranteed number of internships and patient-bed learning. At the time, it was necessary to take into account students who had successfully completed their studies, the opposite would obviously have been unacceptable. Therefore, the positive smoothing mechanism was introduced, allowing to extract INAMI numbers into the quota for future years. This is the problem we are currently facing. As a result, there were no more INAMI numbers left for all those who succeeded in 2017, 2018, 2019 and 2020. Today we inherit this.

It was – and it is still – unacceptable to deny access to the profession to our successful medical students. So the government has done the necessary and sought a comprehensive solution in the matter. I am joining Mr. Frédéric. We all have our own view of the situation. You disagree with the proposal here. We have found a solution to enable the issuance of INAMI numbers for all these future doctors between 2017 and 2020, taking into account the 2018 double cohort. The government agreement, you know. I will explain this in six points.

First: we have decided to fix 2023 doctor quotas in accordance with the opinion of the planning committee. This commitment has been respected: there will be 607 for the French Community, against 492 so far. So there is an increase of 215 doctors, contrary to what I have heard.

Second: the decision to award additional certificates, counting the double cohort of 2018, provided that there is an effective entry examination on both sides of the language border. This was what was initially requested but which was never respected at the French-speaking level.

The government also kept its promise by promulgating in the summer of 2017 a royal decree that allowed all those students who were finishing their studies to receive their certificate. The Government respects its commitments as long as the entry examination is still applicable.

Third: the decision to distribute federal global quotas taking into account demographic thresholds so that all young people on both sides of the linguistic border can have equal chances of becoming a doctor. This link has never been made before, although it makes sense, given the quota corresponding to the number of people per year who can start their internship to become a general physician or specialist.

Fourth: the decision to transfer the competence to set the allocation key for global federal quotas to the Court of Auditors. This is in order to objectivize the distribution and make it transparent. The authority and experience of the Court of Auditors in this matter cannot be questioned.

Fifth: the decision to fix the surplus and definitive shortage of doctors at the end of the smoothing period 2004-2021, in accordance with the methodology proposed by the Planning Committee.

Sixth: the decision to launch the reduction of surnames and the clearing of missing ones in 2024.

I have to say a word of negative smoothing, which could be blamed on us. There are two elements to be taken into account, which have been the subject of thorough negotiation. If we look at the total number of doctors, the surplus number of French speakers was set at 3,167 units. As part of the negotiations under this government, a new interposed calculation approach was implemented and this surplus number increased to 1 531. Why Why ? Because it was taken into account the loss after studies, among other things, of foreign doctors who return home. Therefore, in terms of overnumerous doctors, it remains half of what was originally planned.

As part of this negative smoothing, there is no longer a question of a duration of 7 years, but rather of 15 years.

Finally, I don’t understand why I hear that every year, 100 graduated doctors fewer will get their number. These are not the numbers we have. That is why we disagree. It was decided to never be able to descend below 505 numbers, a number higher than the 2015 quota, which was 492. These figures are also based – it is fundamental – on the figures provided by the Planning Commission.

Mr Thierry, I interrupt you.

We will say it once and the egg will be peeled. What is your reasoning? You say, “Thanks to us, it is no longer 492 but 505 doctors a year. But what you forget every time to say, and it is irritating, is that the Planning Commission had identified a need, on the French-speaking side, not of 492, not of 505, but of 607.

The delta that my colleague mentioned just recently is not the delta with what was done a few years ago. The challenge is to adapt to health needs. The health needs, which were identified by the Planning Commission, are 607 on the French-speaking side; 505, that is actually 102 doctors fewer per year. Over the years, this represents a lot, especially since there is a reality that we are all facing, in Flanders in some places, in Wallonia and in Brussels, for certain types of shortages.

Thank you, Madame Fonck, for your intervention.

I would also like to remind you that the principle of negative smoothing must be taken into account in your calculation. And if we are forced to make a negative smoothing, it is because there have been shortcomings before.

We can discuss it as long as we want, it is simply because the rules have not been followed before that we are obliged to go through this system over the next 15 years.

It is unfair!

No, this is not unfair, Mr Maingain! What is wrong is that you have not followed the rules from the beginning.

I understood very well that, somewhere, one does not want to recognize the mistake that was made by not putting a filter at the entrance. In the meantime, this mistake has been made. This is why we find ourselves in the current situation and we must, in order to fulfill our commitment under the agreement, proceed to a negative smoothing. This is what happens!

The [...]

Madame Onkelinx, we are not going to argue! If you had found the solution ten years ago, we ⁇ ’t be there!

The [...]

No No No No No No No No. You never found the solution. Otherwise, we ⁇ ’t be discussing this here!

Mr Maingain, I know very well your position and especially this willingness to always say: "We defend French speakers." All the doctors.

And the patients?

But of course, patients, who are at the heart of the debate, in order to be well treated, must be able to resort to doctors who have been properly trained and who are qualified. Through this project, we are moving in that direction.

What about doctors coming from abroad?

I’m going to talk about foreign doctors.

Mr. Thiéry, the Planning Commission states that, given a whole series of criteria on which I will return, we need a minimum of 607 doctors per year on the French-speaking side. And you say, “No, it’s a scandal, you have to smooth out, you have to hurt.”

But during that time, there are three times more who come back every year from abroad. And you tell us, as I heard from the mouth of a colleague just recently, to pay attention to payability: there is absolutely a need for 100 doctors less on the French-speaking side. But there are 300 who come during this time from abroad. And for those, there is no problem with payability!

Years go by and let them happen. When you are offered to make a contingent that can be justified in relation to European regulations, you refuse to do so on the grounds of the free movement of diplomas. What about the freedom to choose his profession and the freedom to settle as a doctor? You forget them. You are defending free movement.

You justify your decision with questions of public health, payability, quality of care, and you say that it is necessary to contingent. So hold this argument and contingent in Belgium, the foreigners and especially the Europeans! Or then your contingent is absurd and makes no sense.

You explain that we must punish Belgians on every side of the language border! I will not make it a community affair. But you would rather tell young Belgians, both Dutch- and French-speaking, that they cannot do medicine for budget and other issues while Europeans are settling in their place. This, for you, is not a concern of payability and health care! This is the world of the "absurd" version government MR-N-VA-CD&V-Vld!

Mrs. Fonck, Mrs. Onkelinx, you react quite emotionally. I find your outrage nice, but where was that outrage for twenty years, when so many Flemish boys and girls had failed each year or had succeeded, but simply could not start their studies? Twenty years! Explain that to the parents. On the French-speaking side, on the other hand, everyone could start with the studies. Where were you?

I know where you were. Take a look at the case of the Chineseists in which it was also said for years that one should take an exam after the studies if there were too many graduates. Flemish boys and girls have for years, after four or five years of study, had to take an exam to get a RIZIV number, until the first year that there were too many French-speaking graduates and at that point the exam was cancelled by you, Mrs. Onkelinx. That is your outrage!

Mr. Speaker, like many of us here, I believe that in medical matters, we need planning. This is obvious! For the quality of health care, so that there can be specialists in each discipline and to allow accessibility wherever we are in this country, we need to work on planning. The problem is not in planning. Intelligent planning is needed.

We are told that there was a planning, a contingent that was respected on the Dutch-speaking side but not on the French-speaking side. It has been proven in the past that this was not true. When you decided to take an entrance examination to the Flemish Community, this was never based on contingent numbers. You know it because, despite the entrance exam, you were beyond the numbers of the contingent. The figures prove it. It was not an examination to comply. It was an entrance exam. It does not matter! But you were also, to a different extent than on the French-speaking side, beyond the figures that had been given by planning.

To return to the shortage, during the last legislature, one solution was to say: let us no longer do contingent in the shortage professions, while considering that, overall, it was obviously necessary to continue the planning work. There was an agreement in first reading on this decree that enabled to resolve a number of problems. This decision was the subject of a scream from the N-VA who was then in the opposition! French speakers, including the MR at the time, believed that the N-VA was wrong. We are now under the new legislature and the MR thinks the N-VA is right. That’s why I talked about “carpet strategy.”

I say and repeat that the solution you bring is obviously bad.

I come to my last argument. At the beginning of the legislature, the minister had promised that, for her part, she would respect the opinion of the Planning Commission, including French and Dutch speakers in charge of studying the dossier and examining the peculiarities of the subregions. The planning committee submitted a proposal. And what did the government do? He rejected the conclusions. When you ask the Minister, what does he answer? “What do you want? If it is not to provide proof that a community problem has arisen and that the MR as well as the Open Vld – who had said that it would respect the Planning Commission – have accepted the arguments of the N-VA based on the principle “it is to take or to leave”, I do not understand anything!

Therefore, I regret that, in this case, you have not taken into account not only the interests of doctors, but also those of patients from all corners of the country, and that you have purely and simply accepted the demands of a party whose trade fund is only community-owned.

Mijnheer de voorzitter, op some banken laaien de emoties hoog op.

Mrs. Onkelinx, I know that you have tried to find an agreement in the previous government. You have gone very far and you have fought with the strength that we know you. But that did not work. I was looking for a solution with Mr. Marcourt, whom you know well. It wasn’t easy for him or me, but we found a solution, which I respected. I gave an INAMI number to students who were in training, while his project of setting up an entrance exam for French-speaking students was not ⁇ ined. I was patient, as always.

When you say it’s a community file, it’s true. In fact, in Wallonia, for years and years, too many doctors have been trained. The double cohort will bring you a large number of doctors to your hospitals and your communes. This is an opportunity, but it cannot continue. For this reason, it was necessary to have a contingent to prevent that, in six or seven years, there would be a plethora of doctors, which would not be good for the quality of education or public health.

This solution was accepted by the government, the discussions were not easy, but I think it is necessary for students who are still in training. If they do not have access to the profession after five or six years of study, it will be serious. You, too, were looking for a solution, which was not the same as mine. And I think this issue deserves a consensus within the government.

I would like to send a further message regarding the shortage. Indeed, there are truly regional disparities and significant differences between the subregions of the same Region. This clearly highlights that it is not the numerus clausus as such that is responsible for the insufficiency of medical offers in certain areas, it is the lack of attractiveness of the profession of general physician that poses a problem, at the university, first, even though it has been found, lately, that the trend was being corrected. Hopefully this will be the case again soon.

I would also like to point out that there are other circumstances to be considered, for now. In fact, the profession becomes feminine, if I can express myself that way. There is a willingness of doctors to adjust a time range, possibly to make fewer guards to allow for a higher quality of family life. These elements must, of course, be taken into account.

The [...]

You are absolutely right, Mrs. Fonck.

As for foreign doctors, I would like to remind you that, contrary to what has been said, foreign doctors are out of quota, unless, of course, they do their studies in Belgium.

Ms. Fonck, we had a discussion in the committee concerning Romanian doctors. I hope that you now have numbers that allow you to know whether it is rather Belgian doctors who are going to study in Romania to not enter the quotas. I hope you have the numbers. As far as I am concerned, I have them, but we will hear your point of view on this matter soon.

I will not expand much more. I think this debate is extremely sensitive. The text under consideration has been the subject of very intense discussions in the committee and it is still the case today. But once again, I would like to remind you that if a solution had been ideal, if a solution had been known, it would have been put in place, already a few years ago. It is because we have not found any solution so far, it is mainly because it was necessary to find a solution for the doctors who came out in 2017 and the future doctors, in any case on the French-speaking side, that we found a compromise that is, contrary to what I have heard, absolutely not to the disadvantage of one and the other, but that takes into account a historical situation that had to be addressed. This is the reason why the compromise that this bill constitutes does not disadvantage, as it has been said or as it is understood, French-speaking doctors. We will therefore support this project, which is now under vote.

Ladies and gentlemen, I will be brief.

I think a lot has already been said. Let me be clear: my party will support this bill, not because it is ideal, but for us it is a balanced agreement that ensures that many of our concerns are addressed.

We had two principles for years.

First, we must provide legal certainty for young people, regardless of their place of residence. If they start studies, they should also be able to access further specialization and the labour market after those long studies. This has always been our goal. Young people cannot be left in this uncertainty.

Second, there must be equal treatment, regardless of the place of residence of those young people. They should all have the same rights, but also the same duties when they get access to those studies.

We also know that this uncertainty was not created by the federal level. We also know that this equality has not existed until today. We hope that it will come with this bill.

In the discussion there are three important substantive arguments for us that we also see finalised in this bill.

First, there is an effective filter in both regions. We are pleased that it has been introduced. This filter will also produce results. Colleague Frédéric, you referred to the fact that an entrance exam could sometimes lead to inferior doctors, to a weakening or to a lower quality. We are also convinced that there were many good doctors among the students who failed to pass the entry exam on the Flemish side. However, you should not focus on the federal level as the Communities are competent for the filter that is the entrance exam. They may determine the criteria for the entrance examination. I notice that in Flanders the exam has been adjusted several times in recent years. It was adapted because it wanted to test not only young people on their knowledge, but above all also on their competencies and skills. You have this in your hands. If you find that the result is insufficient, the Communities have the power to make adjustments based on the exam. Our first major, substantial argument, the filter, which is there now.

Secondly, it was extremely important for us that there would also be an arrangement for both the deficits and the surpluses. In relation to the deficits, there is a good arrangement, which will enter into 2024. I would like to point out that it is also necessary to take side-by-side measures regarding the deficits so that the deficits on the Flemish side can be quickly addressed.

A third aspect that has always been important to us and that often has disappeared to the background due to the emotions in the debate, is the sufficient number of internships. This was also discussed with the communities. Adequate attention should be paid to internships, both in terms of financing and in terms of deployment outside the university hospitals. There are currently agreements being made with many general hospitals to accommodate the double cohort and to monitor the quality of the training of all those young people.

Our three conditions for this bill have been fulfilled. CD&V would like to support this bill today.

Much has already been said, but I would like to summarize briefly.

What we see today is a generous compromise. For example, this bill gives the Welsh students who have started with the study of medicine the guarantee that they will receive a RIZIV number. This bill also guarantees the viability of the French-speaking medical faculties, even if it is shortened to the contingent of French-speaking doctors.

This bill provides a solution to a problem that lasts 20 years. Surpluses will be eliminated and deficits will be supplemented, allowing the balance agreed at the end of the last century to be restored.

The purpose of this bill is not to harm one or the other, but to safeguard the quality of medicine.

There can be much discussion about the calculations of the Planning Committee, but one should also know that every estimate is just an estimate. However, it is impossible to say that a lot of parameters were not taken into account here.

For the distribution of the federal contingent among the Communities, we effectively take into account the population. I think there can be no more fair, more objective distribution key.

Mr. President, Mrs. Van Peel said that she has been following this dossier for ten years. I know it for 20 years now. It is indeed a difficult dossier, but I will be more serene in my discussion.

To begin with, I will point out a few positive points.

This bill is the result of a very long discussion. In 1996 the first agreements were made. What is the plus point? Today, the nose is in the same direction. That in itself is a merit.

As other colleagues have said, this design involves a regularization, which was needed. It is also a fair regulation.

The purpose of this bill is to establish for the future the mechanisms by which the quota is implemented year after year in an equal and rigorous manner.

In recent years, we have seen that this in Flanders has produced a number of results that, in terms of the regulation of the health professions, have been positive in two areas. First, to address the shortage of general doctors — which I have also experienced, to ensure that there are sufficient general doctors. Second, for accent shifts in specialists, because there are too many for one specialty, resulting in overconsumption, and too little for the other specialty. These subquotas can fix something. So far the good news.

I come to a number of pain points and negative points.

There are a number of missed opportunities. It is very important that a spread policy can be linked to such contingentation. I know that this is with the Communities, but with this bill, a number of issues have not been resolved. Currently, for example, there are too many hospital beds, especially in Brussels. International research shows clearly that strengthening primary care needs to be accompanied by the courage to withdraw a number of hospital beds, in order to avoid a suction effect. Another possibility to be missed here is to strengthen the first line and introduce an equilon.

Another pain point, the last one I will talk about here, has been quoted by many speakers. The indicators of the Federal Planning Commission are good, they have evolved over the years. We now have 25 indicators that properly take into account the needs. It is therefore a very missed opportunity that this has not been passed on to the Communities. When I hear the emotions, the concerns and the opposites, it is mainly about the fact that in Brussels a strange criterion has been installed for enrollment in schools, with population numbers, and so on. The Federal Planning Commission has a good way of working. It seems to me quite logical that this is the criterion to be applied everywhere, including in the Communities and in Brussels. We also submitted an amendment on this subject. My colleague Muriel Gerkens will explain it.

The Ecolo-Green Group will abstain from voting on the bill.

My colleague will also give an additional explanation.

Mr. Minister, I will first make an introduction that will remind you of my speech from recently, as well as others that I have already made to your address and some colleagues. We are faced with decisions to be made, which are linked to the health and public health policies we want to lead. This is the goal we all pursue right now! What does it mean to have a vision, a public health policy? This is obviously taking time to assess health care needs in relation to existing supply, population characteristics, and by analyzing how the caring force behaves and composes on the ground.

It also takes into account the specifics of the territories and areas. A city with hospitals and rest homes does not have the same needs as a rural area where there is virtually no institution. Ambulatory needs, specialized doctors will be different, depending on whether the ambulatory or hospital model is treated. All these elements are important. These are those that I would like to be taken into account when evaluating the health care offer that best matches the coverage of needs.

I address Mrs. Minister, but also Mrs. Onkelinx, who was Minister of Health, and to whom I also encountered at certain times. In 2006, I submitted a first text, which Ecolo-Groen reposted in 2008, 2010, and in 2014. This text suggested that all these criteria should be used. Some criteria of population characteristics are taken into the work of the planning committee now, but this is all recent.

These criteria relating to the characteristics of the population consisted of saying: "Let's leave these basins of care, those territorial units that make sense. Let us evaluate with the actors who are on the spot the needs covered or not and let us bring back to the National Planning Commission what we will need in terms of health professionals, in this case doctors or dentists! From there, we will be able to determine the number of professionals or doctors we will need in the next three or ten years and continue that exercise.”

The territorial dimension, the basin dimension of care has never been accepted or taken into account. This is still an issue that is not included in this bill. We really think it’s a mistake because that’s what we’re talking about when we say that we need as many healthcare providers or doctors.

At the same time, Ecolo, in the French Community, has also filed proposals for decrees to organize health studies otherwise and to say that rightly, there are all those who are interested in these studies and then, there is the orientation. This can be done toward medicine or toward any medical specialization. It can be done after a certain number of years to the nursing care, to other types of specialties or professions. The idea was not to sacrifice students, not to sacrifice citizens or young people in a choice but instead, to guide them taking into account their abilities, preferences and the evolution of their profile.

When I hear what to do and why to do it, namely to repair something that has been decided in the past and the Flemish students we have sacrificed, I recall that it is the Flemish politicians who have sacrificed the students. There were other possibilities. You chose this one. We must accept the choices that were made, but there were ways to do otherwise. I think it is not too late to continue to reflect on how to make conciliable a willingness to offer care and the coverage of a need, on the one hand, and the training of those who will have to exercise that care, on the other. The contingents have gone from the belief that too many doctors would be too expensive.

It is said that there are many French-speaking doctors. Let us admit! French-speaking side care is not more expensive, proportionally, than care in Flanders. No one would dare to say, now, that it is based on the number of doctors that the costs of health care are calculated. and no!

Now doctors work less, because they want to enjoy their family life and they want to have a social and cultural life. That we need more doctors who work less does not cost a euro more to social security, since we pay benefits. There is a time when you also need to get out of beliefs, myths and finally dare to rethink situations, rest on the right questions and work together on solutions.

The planning committee has changed. We have welcomed the fact that from now on, the planning committee will take into account additional criteria: the socio-economic data of the population and the workforce of doctors in the field.

If there were a plethora of doctors in one region or another, the planning committee would take this into account, since it takes into account the workforce. It does not mean that it needs to be so much. If, despite this plethora, despite what has happened in the past, it tells us that we will need 600, it is that we need 600. There is no need to make corrections and remove for the future of people earned in the past. In principle, they took this into account.

Even in the logic and mathematical reasoning that underlies the decisions made in this project, there is something wrong. The real realities are not taken into account.

I have, together with my colleague, Mrs Anne Dedry, introduced an amendment. This does not aim to change the way the planning committee will assess the number of future doctors needed across the entire territory. But from the moment when this positive evolution has taken place with the consideration of the criteria of the population and the workforce, the distribution of doctors must also be thought of taking into account these criteria.

The Planning Commission – or the Court of Auditors – should be able to distribute these doctors according to the places where we need them more or less, based on these different criteria. At that time, a link with the needs will be established. The State Council says that all work has been done and that doctors are again distributed, losing the benefit of the work provided by the Planning Commission. If the will to satisfy health care needs really exists, this kind of amendment must be accepted.

Madam the Minister, a last word concerning those foreign students who come to practice in Belgium, after their studies, with a diploma that is not Belgian. We must be honest: they are there and if they immigrate, it is because we need this workforce. If they couldn’t earn their lives in our country, they ⁇ ’t come. They settle a little in Flanders and a lot in Wallonia. We do not take into account the reality enough. Among the foreign students who come to study in Belgium and who will therefore finish with a Belgian diploma, French-speaking side, many new doctors remain on our territory and do not leave, which is not the case on the Dutch-speaking side. I’m not saying it’s better on one side and worse on the other. I say that different realities exist, which have their importance in meeting health care needs. A Belgian public health policy must incorporate these dimensions.

My colleague Anne Dedry told you that our group would abstain. Personally, I will vote against, to concrete through my vote the criticism I have just formulated.

What I want to add to conclude is that this way of acting and of not taking into account the needs, the specifics of the Flemish, Wallon and Brussels, incorporates a detestable community dimension in the management of this case.

If our group abstains from this project, it is to show you that by taking negative community positions on the subject, you will not be able to divide us between Ecolo and Groen, we who are mobilized by a public health policy for the benefit of all!

Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker. It is specifically the fact that you prevent young Belgians from practicing medicine or dentistry.

You organize a system that ultimately prevents our young people, no matter where they come to Belgium, from practicing medicine or dentistry, and at the same time, a system that imports without any restriction from foreign doctors and dentists. It is a complete nonsense. But that is what you do. And this in two ways: both in what this bill contains, but also in what it does not contain.

First I will look at what it contains. One of the most appealing elements is that you decide, even though everyone – and, in my opinion, in almost all political parties – has praised in recent years the way in which the Planning Commission has used increasingly dynamic and precise cadasters on the actual workforce of doctors and dentists in Belgium, to move from a scientific logic, based on public health needs, to a political logic. What a political logic! This bill now establishes the distribution of the global quota between the Communities on the basis of the number of inhabitants, except for the Brussels-Capital Region where you use the famous criterion of the key "students".

Until now, the allocation had always been established by the Planning Commission on an objective basis of public health needs. Obviously, the figures she presented suddenly did not please some members of your majority. When objective conclusions are no longer pleasing, it is decided not to follow the Planning Commission anymore. And even, some members of your majority—not all, it is true—have found no better than to denigrate the work she had done.

I totally disagree with you. It is enough, by the way, to look at the work carried out for years by this body, but also its composition. I don’t have any friends, I would say. I turn by chance... An eminent elected member of the MR is a member of it. I believe that the way some members of the majority have royally denigrated the work of the Planning Commission is totally unacceptable, but also disrespectful. As some people ask who is the elected person I am talking about, I specify that it is Mr. Brotchi.

You told yourself that these numbers didn’t like and that you would have preferred other results. You then abandoned this scientific logic in favor of a political logic. Evidence-based medicine, Madam the Minister, should not only serve as a criterion when it matters to you, to prefer to other times a political logic. As this was not convenient to you, when it was necessary to distribute the needs among the Communities, you decided to leave the opinion and work done by the Planning Commission.

And then you asked yourself what criteria you would use in your purely political logic. For the Brussels-Capital Region, you have chosen that of the key "students".

So that, we know it! Healthcare is only from zero to eighteen years old! We will not take care of the health care of the four-year-olds and the elderly; we do not care! The State Council has not failed to strike the criterion for the distribution of the "students" key. In fact, it is totally alien to the problem of medical supply and medical needs. We swim in the most complete arbitrariness.

I wondered why you had chosen the key "students". There must have been a reason. Why this criterion? What motivates you? I tried to look and listen to the arguments you put forward and which, in addition, had no tail or head. I wondered why did they not take the same criteria for the Brussels-Capital Region as for Flanders and Wallonia? Since you did not want to rely on the Planning Commission, you could at least rely on the entire population.

I have nevertheless been searching and allow myself to remind you of this by addressing myself more specifically to my colleagues from the MR, a very small analysis of the distribution on the Brussels-Capital Region according to the criterion that is taken. In fact, by taking the "students" key on which you rely for this bill, the distribution in the Brussels-Capital Region is 83% French-speaking and 17% Dutch-speaking.

If you take a criterion not more than zero to eighteen years but that of the population since it is the one that you have chosen over the rest of Belgium, several aspects can be used. I will mention two: that of the identity card and that of the tax return. The result accounts for the identity card: 92% of French-speaking and 8% of Dutch-speaking. And according to the tax declaration criterion: 93% of French-speaking and 7% of Dutch-speaking. But not ! You decided in the end not a somewhat logical or consistent criterion, no! You chose the criterion that allowed, in the Brussels-Capiale Region, to have the worst score for French speakers.

You had other criteria accessible, but you chose to take the criterion for which you told yourself that, in essence, it was not very serious. This does not correspond to the reality or the health needs of the population, but you take the most unfavorable criterion for French speakers and that has no sense in terms of the approach and logic in health. We are rarely in complete arbitration.

We are totally against the use of a political criterion in this case. Even for me, the key "students" or any other criterion has no logic in the Brussels-Capital Region. As a first option, we propose, by amendment, to continue the work carried out by the Planning Commission by giving it the responsibility to fix the quotas per Community according to the needs of each of them. We opt for a return to scientific logic and health logic. However, if you persist in your vision of taking a purely political criterion, we cannot accept that you take the most unfavorable criterion for French speakers, as you do at the government level. As a subsidiary of the Planning Commission, we therefore propose to take the criterion of the language of the identity card. Of course, this is not the best criterion. The best is the Planning Commission, but if you persist in a purely political logic, then you need at least one criterion to take into account the reality of the inhabitants of the Brussels-Capital Region.

You move from a scientific logic and public health needs to a political logic. But, in addition, your bill completely denies the existence of a shortage. The most appealing thing is that, in this bill, you deny the existence of certain types of shortages unilaterally. It is written black on white.

The bill, the exhibition, the comments to the articles, recognize the existence of certain types of shortage on the Dutch-speaking side. This does not pose any problem to me. On the other hand, it denies the existence of certain types of shortage on the French-speaking side, while objective elements are clearly present.

Some municipalities in Wallonia and Brussels are actually in shortage today, it is demonstrated. Is there, like on the Dutch-speaking side, a shortage for some specialties on the French-speaking side? Yes, it is demonstrated. The Planning Commission showed the pyramids of doctors' ages, where it is seen that a large number of doctors are close to the retirement age. And this phenomenon is more important today on the French-speaking side than Dutch-speaking.

This is not a problem for me that the shortcomings of the Dutch-speaking side are highlighted. But I find it shocking, dear MR colleagues, while you know the reality, that for some of you this happens even in your communes, that you have made the choice to write black on white that there was no shortage in Wallonia and in Brussels.

I explained what the Planning Commission had proposed with this figure of 607 doctors on the French-speaking side. I will not come back. I explained in committee everything that was not right in your bill, but there is also everything that it does not contain. You have never stopped justifying contingentation for issues of quality of care, but also for the financial balance at the level of social security.

I recently heard the word “payability”. A lot can be said about the relevance or not of this model. I heard a few weeks ago Mr. Brotchi tell me how much he was no longer agreeing on linking contingent to the financial sustainability component. But let’s leave this aside, I won’t go into this discussion.

What interests me more is that if you justify your bill by saying that it is absolutely necessary to contingent and that it is necessary to be effective on the contingent for issues of financial balance of social security, then it must concern all doctors and all dentists who settle and begin to exercise their profession. But this is not what you are doing since you decide to penalize and limit young Belgians while leaving, at the same time, the door open to all foreign doctors who come to settle in Belgium. We’re not talking about a few, we’re talking about hundreds every year. Of the French-speaking doctors who took an INAMI number and who settled, 40% are foreign doctors. And this is even more at the level of dentists: 50% of the INAMI numbers distributed in 2016 are to foreigners.

The [...]

Mr. Clarinval, choose your arguments better! Who set up a contingent because there was a flood of French in certain faculties, especially in the faculties that concern the health professions? Who could go fighting at the European level to get it? Who was able to move the way at the European level?

Fortunately, since today, with the non-residents decree, there is a limitation on admission to medical studies. I am not talking about this, but about doctors who have been trained at a university abroad, who arrive in Belgium, who settle there and who have an INAMI office number. This is where the concern is. In fact, either the contingent is justified for reasons of public health funding, or it is not. But if it is justified, it must be explained to me why every year several hundred foreign doctors, who will do curative and will cost the social security, will come to settle.

You all then invoke the free movement of diplomas: “Attention! Nothing can be done at the European level.” I totally disagree with you. I will take three minutes to explain it. This requires a mobilization and, Madam Minister, it is your job and your responsibility. This requires work and this requires placing the debate on the European square. I can already tell you today that ministers of health in other European countries have today the same reflection that I will explain to you right now.

You decide, through the contingent, to deprive a number of young people of the free choice of their profession. The free choice of the profession is a right to which the Constitutional Court has recognized constitutional value. You justify this restriction by preserving public health. The same reasoning can be ⁇ ined at the European level. It is true that a contingent of European doctors would deprive these young Europeans of their right to free movement, which was also enshrined by the Treaty of Rome. However, the European Treaties also allow violations of free movement if they are justified for reasons of public health. This is also what the Court of Justice and the Constitutional Court concluded in the introduction by the French Community of quotas for non-resident students, therefore non-Belgian Europeans, in veterinary medicine, but also in physiotherapy.

With your public health arguments, you should be able to justify these public health criteria in the same way for a contingent that would then also apply to European doctors. This stands the way at the European level.

It is not normal to continue to fall into a logic in which you reverse discriminate our youth against European youth.

If you consider that the European contingent does not hold the road, that it does not make sense and that it is not very serious for public health problems and this famous payability that you mentioned, it makes no sense to continue to exercise a contingent at us, in Belgium. This makes no sense! If we contingent all the doctors and dentists who settle in Belgium, what you already do, we must proceed in the same way at the European level. Otherwise, it makes no sense!

I did not give a lot of numbers. However, there are enormous amounts. I will only remember the figures for the last five years. In Belgium, between 2012 and 2016, a total of 3 069 Dutch-speaking doctors and 2 053 French-speaking doctors settled. These are not my numbers, they are those of the Inami. This is a fairly logical ratio. If we add to these figures the foreign doctors who came to settle in Belgium, there is no longer a 60/40 distribution. In order not to overwhelm you with numbers, I will only give you those relating to the year 2016. This is the last year for which figures are available. Four hundred and thirty-six French-speaking Belgian graduates received an INAMI number.

Six hundred and forty-six Dutch-speaking doctors received an INAMI number, according to the key 60/40. As for Europeans, there are 76 in the Flemish Community. It is true that they are far fewer, but the language is a factor that can explain this fact. In total, they are 727.

If we add the European doctors, on the French-speaking side, we are no longer at 436. There are 232 foreigners and there are 696 Belgian and European doctors who have settled in the French Community.

When foreign doctors are taken into account, the ratio of doctors receiving an INAMI number on the French-speaking side and on the Dutch-speaking side is no longer the same, namely 696 versus 727. On the other hand, if we only look at the Belgians, there are 436 French speakers (40%) and 646 Dutch speakers (60%).

Colleague Fonck, do you actually have a shortage or an excess of doctors in French-speaking Belgium? I hear you complain about the fact that there are too many foreign doctors, although I do not understand what you have against foreigners, but that many foreign doctors are a perfect solution, since at the same time you have been proclaiming for an hour that there are too few doctors in French-speaking Belgium. So be happy, or know what you want.

Madame Van Peel, by force of contingent, without taking into account the needs in the field of public health, you organize a real medical social dumping and you create a phenomenon of aspiration of foreign doctors. Before, it wasn’t like that. Go check the number of European doctors who came to settle in Belgium ten years ago: it had nothing to do with today’s. In fact, we are witnessing an air call every year.

Dear colleagues, who ne siégez pas en commission de la Santé, je vous dirai quand même que des agences spécialisées se sont installées en Belgique. Their objective is only to promote and allow the arrival of foreign doctors. You can give the names. Elles ont pignon sur rue en Belgique et vont recruter des médecins étrangers pour les amener ici, avec un package tout fait, c'est-à-dire les facilitations administratives, les diplômes pour lesquels toutes les démarches sont facilitées. Everything is realized. The contacts are also established directly with the hospitals. Allez voir sur les sites Internet, vous allez très vite les trouver!

Mr. Speaker, I had planned to say nothing. I have been listening to this debate for four years now and as the only survivor of the entrance exam in Flanders in the hemisphere, I may be able to add something to the debate.

It really disturbs me immensely that, for example, Ms. Fonck continuously complains about the freedom of choice for students. This freedom of choice has been lost by Flemish students for 20 years. The entrance exam is a must there, because it is the only way to start the studies. However, the free choice of a study is completely meaningless, if one subsequently, after completing his studies, has no job security. Then one may have studied for so long: if one graduates and does not find a job because there are too many doctors, then one stands there with his expensive diploma, and that may not be the goal you have for the French-speaking students.

I have a second comment. I understand your concerns about foreign doctors, really true, Mrs. Fonck. That could potentially become a problem in the future and should be monitored in both parts of the country so that we can keep a very close eye on it. However, you forget that Flemish and Wallonian students who graduate with us also travel abroad. As long as there are communicating vessels, the free movement of diplomas in Europe applies to everyone.

In addition, you say that there is a shortage of doctors, which I absolutely want to challenge. You have no shortage of doctors, but if you still have such a shortage, then you should actually receive those foreigners with open arms. This is what we do in Flanders: we lead foreign doctors to that particular subquota in which we doctors are lacking. They seem to fill our tricky professions. In fact, sometimes headhunter agencies are assigned to search for those people.

Finally, I have a final comment on the quota. You always forget that this is actually a blessing for the student himself. It gives oxygen to the training, ensures better quality, for more time at the patient’s bed, which should not be shared with hundreds of other students. It creates better doctors and that can only benefit all French speakers in our country who will receive better care. I really do not understand why you continue to oppose this.

Madame Fonck, one more word? No to ?

Yes, Mr the President. If I get back, I will go back. You know the song. For an hour, no. But if you want, it can be two hours!

To "release the debate in all directions" ... I don’t think I’m going in all directions, Mrs. De Block. Tell me what I’ve talked about here that has nothing to do with the bill. I listen to you. Go to! There have been accusations since this afternoon. You accused us of lying. You accused us of being blind. You accused us of being deaf. It started at 14h15. Now, if we add more, it will still be complicated. Do I, yes or no, in my argument on this text, say something that had nothing to do with the bill? Tell me !

Mrs. Fonck, since you have questions, I’ll ask you one too.

You claimed in a commission that Belgian doctors were going to study in Romania so that, upon their return, they could not return to the quotas to obtain their INAMI number. How many Belgian doctors will study in Romania, Ms. Fonck? I asked you this question in the committee. You never answered. I would like to have an answer today.

You say we treat you as a liar. We do not say that! I would never dare to say that. On the other hand, I think there are arguments you should avoid using because it can turn against you. Now, I am waiting for a clear answer to my question: how many Belgian doctors have done or are doing their studies in Romania and will return to Belgium to get their number?

If you have the names, it is perfect. I don’t have the numbers, but I have the numbers.

I don't know the names, but I can imagine who told you the numbers.

Yes or not, some of our students leave to continue their studies....Brouhaha

Let Mrs. Fonck speak!

We are not going to get out of it in this debate. (Brouhaha) by

I will give you a number. Do you know how many foreign doctors received an INAMI number in 2016? and 341. In the year 2015? by 380. In the year 2014? and 373. In the 2013? and 359. You can stay like this for a long time.

The problem with this issue is that I heard for the first time...

Madame Fonck, Mr Thiéry asks for the floor.

Madame Fonck, let’s be serious for a moment!

In the commission, you have claimed twice that Belgians were going to study in Romania. You said it. I have asked you twice who they were, or at least what their number was. You could never answer me. I will tell you why. In fact, I have the numbers, because I went to ask them in Romania.

There are names!

No, I have no names.

In short, for the year 2016-2017, 50 Belgian citizens continue their studies in Romania. The distribution in teaching cycles is as follows: three students in preparatory training, four in university studies with a bachelor’s degree, three in master’s university studies and a doctoral student. This means that, if this latter person succeeds, he is the only one who could return to Belgium with a doctorate.

Madame Fonck, you claim something and you clearly accuse us in the commission, saying: “This is what will happen: everyone will go to study abroad to be able to return to Belgium.” You give a false impression of what is happening in Belgium and that is not correct! This is the only thing I wanted to emphasize, but I understood that you did not know how to answer my question. This means that you use arguments that are false!

Did I say, in the commission, that everyone would go to study in Romania? and no. But, you know, it makes me laugh a little because we talk...

So much better! I am glad that you can laugh! Go and explain tomorrow to the young Dutch-speaking or French-speaking young people – no matter – that, in the end, one cannot continue to study medicine and that one must contingent a number X – I do not go into the details of the numbers – but that there are as many as you let come from abroad. For the first time, I hear a colleague from the majority say that it really is a serious problem that there are so many who can come to us.

They say, all of a sudden, that we are going to monitor. Regarding the figures, these are the official ones of the INAMI. I gave them just recently, going back on a few years, and no, I’m not going to repeat them now!

It’s not something that has happened once in the last six or seven years, it’s repeated every year. This is not about a small number, but, as I said before, it is about several hundred people. Monitoring is done. We need to stop turning around and say to ourselves that we will see in five years if it is always the same thing.

I am proposing by amendment and I have also submitted a bill on the same subject, to be able to introduce a device that contingents European doctors and dentists who come to Belgium and who request to obtain an INAMI number. As I explained recently, this can be largely justified in relation to the issues and even more in relation to the free movement at European level. Since you justify the Belgian contingent, you can do so at the European level with the same limitation and the same argumentation.

This is also your responsibility. You can’t stand with your arms hanging in front of something that repeats itself every year. I see that in a whole series of other Member States, ministers are waking up. You must also take your pilgrimage stick and put this file on the European Square. It is necessary to be able to recall what has been achieved regarding non-resident decrees, especially in the French Community, since one can build a solid legal argument that will allow to contingent the Europeans. If we do not, there is no logic in keeping the current system. If we decide on the continuation of the contingent in Belgium, it must also be done at the European level.

So we have submitted a whole series of amendments to your bill, both to redefine things by the Planning Commission and therefore in relation to a scientific logic and public health needs and not according to a political logic that is the one you have chosen.

They also aim to introduce a contingent of European doctors and dentists, in the same way as for Belgians, justifying it on the legal level.

As I told you, we also submitted a subsidiary amendment for the choice of the identity card in the Brussels-Capital Region, if you do not decide to follow the amendment on the Planning Commission which alone would decide on the distribution of quotas according to public health needs.

Dear colleagues, this issue is not finished. I dare hope that, in the future, we will be able to come together on a fight that can be common, logical and that can serve both the North, Brussels and the South. If we do not wake up tomorrow, the difficulties associated with the arrival of foreign doctors will be increasingly important everywhere in Belgium, even as we contingent our own. Mr. Speaker, could we not, at some point, work together on this extremely important topic.

Mr. Speaker, at this time, I will be brief, especially since many arguments have been put forward. However, some important data cannot be denied.

First, the Commission for the Planning of the Medical Offering, as it gathered representatives and experts from both Communities and worked on scientific basis, challenged the key arbitrarily fixed in its time of access to INAMI approvals at a rate of 60 % for doctors from universities of the Flemish Community and 40 % for the French Community. She herself proposed another key objectively: 56,5 % – 43,5 %. It is a data. Whether you like it or not, the experts of the two Communities agreed.

and two . To all those who say that there is a plethora of doctors on the French-speaking side and that it was wrong to let cohorts of doctors be constituted at a certain time, I note that the Wallon Health Observatory, according to a cadastre that has been established, considers that of the 262 Wallon communes, 123 already encounter a relative shortage of general doctors and 106 already suffer a shortage. A dozen municipalities are even considered to be in severe shortage with fewer than 50 generalists per 100,000 inhabitants. Furthermore, 40 Wallonian municipalities are at risk of falling into a shortage situation, given the advanced age of active doctors. If only one doctor takes his pension without being replaced, the municipality will then turn into a shortage situation.

In Brussels, the situation is no less worrying, ⁇ due to the ageing of generalists. Doctors aged 50 and over account for more than 50% of the activity in Brussels with two notorious exceptions: Schaerbeek and Molenbeek. The record is reached in Uccle where senior doctors take over 80% of the activity. Therefore, these scientifically established findings should be taken into account.

Your bill is discriminatory for the Brussels Region because you can try to justify this in any way whatsoever, the arbitrary key that was set on the basis of the number of students attending the schools has not only nothing to do with the subject being dealt with, but in addition it is known that it does not correspond to the sociological reality. What is the use of Mr. Calomne who boasts himself in the press to ask questions about the linguistic distribution between French and Dutch speakers in Brussels? He was the one who recently stated in La Libre Belgique the outcome of his parliamentary questions. At least, there is no statistics where the issuance of identity cards, tax returns, the number of doctors registered in the Order are taken; there is no statistics that gives a distribution of less than 92% for French speakers and only 8% for Dutch speakers in Brussels. This is a sociological reality that all those who are managers of the institutions, especially the Brussels municipalities, see.

Also, there is a 9% gap between the statistics that you have retained and the sociological reality of Brussels, which means that 106 000 inhabitants were not taken into account to calculate the contingent of doctors and dentists for the French Community and that they were paid in the quota for the calculation in favor of the Flemish Community. If one is based on the standard, held by the experts, of more or less 9,9 full-time equivalents per 10,000 inhabitants, since there are 106 000 French-speaking inhabitants that have not been taken into account, Mr Thiéry, this represents a differential per year of 107 doctors paid to the Dutch-speaking quota only because this majority decides to take a criterion totally unfavorable to Brussels French-speaking, on the basis of an inexisting distribution.

Mr. Piedbœuf, if you show me that there are 16% of Dutch speakers in Brussels, I invite you to take champagne with me! But you will be unable to prove it, because no statistics confirm this reality.

Therefore, I can only say one thing: this bill is not a bill that meets the expectations of the medical circles, contrary to what some claim. And when you see the protest of French-speaking students in medicine against this bill, you say that you are announcing to young French-speaking students who are destined for medical studies sad tomorrow because you are not going to meet their legitimate expectations and concerns.

Mr. Speaker, Mrs. Minister, colleagues, good morning, I would say, although we will not stretch it until early in the morning.

A thick congratulation, Mrs. Minister, because you have extended your neck and eventually submitted a bill. It has known many circumstances and made a difficult journey, but it is here today.

Positive to the draft law is that the problem of the imbalance will be addressed, which was allowed, after twenty years. Finally, entrance examinations will also be arranged in the southern part of our country. I am pleased that an enforcement mechanism is being built for the future.

Per ⁇ I get such an observation that I am not working on this dossier for a long time. I would like to admit that, but files can also be studied and a lot of questions can be asked. Also in this regard, I would like to give you a plunge. In fact, I have submitted several written questions and the extensive answers you give deserve to be called an answer, for which I thank you.

Some colleagues find your bill too strict, but for me it doesn’t go far enough and isn’t strict enough.

I have heard the previous speaker but my view is slightly different.

I first sprinkled with flowers, so now I can throw with the flower pots, Mrs. Minister. I’m not going to do that; it’s definitely a foolish joke at this late hour.

With this project, there is still a possibility to build surpluses. This can be done with KB. I have absolutely no problem with the fact that a deficit can be transferred or compensated, but that does not apply to build up surpluses. We know this problem from the past. The French Community has continuously exhausted future RIZIV numbers, and a surplus of doctors is the result.

Therefore, we have submitted a number of amendments and one of them now wants to ensure that one can compensate for a deficit but that one can no longer build a surplus.

What makes me very surprised is that the same calculation method has been used for years. The classic 60/40 distribution has been used for years. Just at a time of community standstill, this will suddenly change. The 60/40 ratio is released, according to some for the Brussels ratio. However, I would like to point out that the Brussels Act uses the 20/80 ratio.

By leaving that relationship now, I am quite afraid of the future, especially given the future Brussels negotiations. After all, if one releases the 20/80 rule now in the outlined framework, then one does not know what we are still waiting in the future, in negotiations about Brussels.

Therefore, the Community standstill is not respected. In that sense, we can say yes, but we must be very careful with everything that is happening now.

I understand the story. There will be an adjustment and suddenly a new method of calculation will be applied. And what is the explanation for this? They want to do it in a different way. But if the surplus is calculated now, then we will not come to a surplus of about 3 000 doctors, but to a surplus of only 1 531 doctors. The curious thing is that in 2015 the Planning Committee estimated the overcrowding of doctors in the French Community for 2017 at 1,136 doctors and for 2020 at 2,758. If the figures are extrapolated to 2024, the French-language overtal to doctors will be more than 3 000.

Suddenly, a different accounting method is used. The gun is shifted from shoulder to shoulder, which I cannot call otherwise than a victoire francophone.

Strange but true, the French speakers in this body of course see this completely differently. I hear them say that they should take into account a large number of foreign students. I would like to point out that they have already received 1,500 additional seats. If it were up to us, you would have to demolish 3,000 places instead of 1,500.

How does this new method of calculation occur? I find it very strange that this method of calculation was proposed at the time by colleague Onkelinx. She once said that the non-active RIZIV numbers should not be counted. That is what is happening now.

I therefore do not understand the French speakers because they go further in the reasoning of Mrs. Onkelinx. I don’t understand how one is so opposed to this because it would have been a different story had one had to demolish 3 000 places. There are only 1,531.

There is, of course, also the period in which this is decomposed. We are talking about about 15 years. Only from 2024 will be started with the decomposition and this will take up to approximately 2038 to work out the overtall. We find that deadline too long. That period should be reduced to 2030. It can be demolished a little faster than is now proposed.

There were no quotas for 2022. The quotas then fixed for 2023 have not yet taken into account the negative leasing. The surplus, now fixed at 1 531, was calculated for the period 2004-2021. This means that there will be no quotas until 2022. You can graduate as many people as you want.

The quotas for 2023 do not yet take into account a negative lease. The distribution is 58-42. I have the impression, Mrs. Minister, that there is likely to be a surplus for the years 2022 and 2023, and that this surplus is not yet calculated at the moment.

I am proposing an amendment to ensure that the surplus of those two years is also accounted for and depreciated, preferably by 2030, and not by 2038.

When I hear the colleagues talk about foreign degrees and contingentation, I advise them to be sure to look at the answers to my written questions. The Minister has given a clear answer.

As you can see, this plan is not going far enough for us. It could have been a lot stricter. We will not support the draft.

Mr. Speaker, very briefly

Many numbers have already been mentioned, and we have all been given almost a point-head of them.

I am very pleased that the system of contingentation will apply throughout the country, in order to align the need for care and the supply of care and to guarantee the quality.

Let me go back to the words of Mr. Maingain.

However, Mr Maingain, for the Brussels-Capital Region, it is not obvious to determine the number of inhabitants per community in a simple way. This is why the fixation will take place on the basis of the number of students in the Dutch-speaking and French-speaking primary and secondary education in the Brussels-Capital Region.

The number of students will be used to distribute the population figure of the Brussels-Capital Region between the Flemish Community and the French Community. The criterion for the number of students is the one provided for by the law of 23 May 2000 fixing the criterion referred to in article 39, § 2 of the special law of 16 January 1989 relating to the financing of the Communities and Regions.

This is a distribution key that was decided after the fixation, by the Planning Commission, of federal quotas.

Mr. Speaker, I think this is the right time to thank everyone who contributed to the debate, as well as those who did not. I also thank the services who have had a lot of patience with us in the Chamber Commissions and here.

It is a debate that has been raging for 20 years in the cenacles of the committees and in this hemisphere and I am pleased that we have reached an agreement within this government and that we have taken this step.