Leuven, Belgium

Leuven is located in the Vlaamse-Brabant province of the region of Flanders, Belgium. For the purposes of this research, the Functional Urban Area (FUA) includes the municipalities of Leuven and Herent in its core; those of Bertem, Bierbeek, Holsbeek, Lubbeek, Oud Heverlee, Boutersem and Rotselaar in its periphery; and those of Aarschot, Bekkevort, Tielt-Winge and Glabbeek in its commuting area. In 2020, the FUA had a population of 258,089 people, of which 102,275 (almost 40%) lived in the Municipality of Leuven.

Unfortunately, despite their importance in terms of labour market and housing dynamics, Functional Urban Areas in Belgium have no administrative role. Therefore, any further data is only available at the level of the Municipality of Leuven (Leuven from now on) or at the regional level of Flanders.

Leuven is closely linked to the metropolitan area of Brussels, especially in terms of housing and commuting dynamics. It is one of the common residential destinations of wealthier households that move out of the chaotic capital in search of a smaller and more liveable environment. What makes this mismatch between home and work location possible - and even attractive - is the very generous system of subsidies that reduces commuting costs to near zero for those traveling with public transport or a company car  ^[ 1 ] . Indeed, in Flanders 2,781,288 people commuted in 2018, of which nearly 2.5 million within the region itself. ^[ 2 ] .

Both the age and nationality distribution of Leuven’s population reflect its role as an international university city and technological hub. Indeed, in 2020 young people aged 15 to 29 counted for 25% of the population, a figure that grows to 40% if we count people up to the age of 40, considerably higher than the Flemish average. According to an estimate by the Municipality, in the 2017-2018 academic year, over 55,000 students were enrolled in one of the university programs in the city, and if the student population is included, Leuven is the most densely populated city in Flanders ^[3] .

With regard to origin and nationality, in 2019 19.2% of Leuven’s inhabitants had a non-Belgian nationality, while 33.6% had a migration background (the same figures for Flanders were 9% and 22.6%). Of these, the vast majority (66%) has a non-EU origin.

The country is organized as a federal state with three levels of political power, each with their own parliament and government: The Federal Government, the three Communities (the Flemish Community, the French Community and the German-speaking Community), and the three Regions (the Flemish Region or Flanders, the Walloon Region or Wallonia, and the Brussels-Capital Region).

The Federal State retains exclusive policy responsibilities in the fields of justice, defence, federal police, social security, public finances, nuclear energy, and state-owned companies; as well as partial control over public health, home affairs and foreign affairs.

Communities have control over policy relating to culture, education, use of language, health policy, and social assistance (youth services, social welfare, immigration assistance).

Regions have responsibilities in the fields of economy, employment, agriculture, water policy, the environment, public works, energy (excluding nuclear), housing, transport, and spatial planning. They also exercise control over Provinces and Municipalities, the more local administrative levels.

Overlaps are present also in terms of responsibilities, and each level has a say in multiple policy fields with regard to specific aspects.

Leuven falls within the Flemmish region and Flemmish community.

The prevalence of highly specialized and technologically innovative labour market sectors means high salaries for many (international) professionals working in Leuven, and this is reflected in the higher average income in Leuven compared to Flanders and Belgium - €21,403 per year per person, in 2018 - as well as in the high share of tax returns above €50,000 - 22.2% in 2018. Despite its wealth and growth, Leuven also shows patterns of socioeconomic inequality along educational and ethnic lines.

Regions are responsible for all educational policy, including educational programmes and content. However, the educational system largely works in the same way in all regions, with differences mainly found in school programmes and management.

In Belgium school is free and mandatory between the ages of 5 and 18, and at the age of 14 pupils need to choose between four different educational tracks: the general one - leading to tertiary education, the technical one - in the best case leading to professional bachelor, the vocational one - leading to the labour market, or the arts one - of negligible size. While theoretically equal, the tracks carry a hierarchical weight, with the general education track being much more prestigious than the vocational one ^[ 4 ] . In Flanders, the permeability between the different tracks is low - once students end up in the vocational track there are hardly any opportunities for them to switch to a higher track - and downstreaming is much more frequent than upstreaming.

Leuven has the highest number of highly educated people per square kilometre in the whole country ^[5] , and Leuven's colleges and universities are attracting more and more students: one fifth of all Flemish students study in Leuven ^[ 6 ] . However, the city also suffers from important educational inequalities. Not only Leuven’s tertiary education, but also its schools attract a high number of pupils from neighbouring municipalities. In secondary schools, non resident students make up almost two thirds of the student population. Unfortunately, this means that there is a shortage of places, particularly for the most popular schools.

Research shows that educational inequality occurs along parental education, socioeconomic and ethnic lines, and it is reproduced across generations ^[ 7 ] . In Flanders, a high average level of performance is combined with a high level of educational inequality ^[ 8 ] , with students from low socio-economic and migration backgrounds performing consistently worse, and consequently having structurally fewer opportunities in the labour market, than those with a higher socioeconomic status ^[ 9 ] .

What language is spoken at home, and how that impacts fluency in Dutch, is one of the most important indicators of educational disadvantage. In Leuven, 41.5% of children born in 2017 did not have Dutch as a home language- 30.4% of preschoolers, 21.6% of elementary school pupils and 17.9% of secondary school students. In Leuven 27.8% of young people who do not speak Dutch at home leave secondary education without a diploma, compared to only 5.6% of those who do speak Dutch as their home language ^[ 10 ] .

Another feature of the Flemish school system is the relatively high rates of grade repetition compared to the OECD average. Grade repetition rates are much higher for students with a migration background than for natives, highlighting how Dutch language proficiency plays a large role in educational inequality ^[ 11 ] . Indeed, in the 2015-2016 academic year, 10.2% of primary school pupils with Dutch as their home language and 31.4% of those with another home language had repeated at least one year of schooling. In secondary education, the gap only increases: 30,7% of native Dutch speaking students experienced repeating a grade against 65,9% of those with another native language ^[ 12 ] .

Similarly, although formal choice of which educational 'track' to follow happens at 14, often pupils are de facto pre-selected in two main streams at the beginning of secondary school, when they are 12 ^{[ 13 ][ 14 ]} . Again, students with lower educated parents are systematically more likely to end up in the lower tracks, as do students with a low socioeconomic status and a migration background.

School segregation in Flanders is particularly high, due to the absolute freedom of parental school choice. This, together with the fact that secondary schools often only offer one track, helps to explain large performance differences across schools ^[ 15 ] . As a result, disadvantaged students tend to be highly concentrated, which hampers their learning without clear benefits for their better-off peers ^[ 16 ] .

More than 6% of 18–24-year-olds in Flanders do not have a secondary education diploma and are not in education or training, a figure lower than the OECD average. It is not surprising that students with a migration background, those with a home language other than Dutch and those with a lower socio-economic status - three characteristics which often overlap - are overrepresented in this group.

The share of early school leavers in secondary education in Leuven had been decreasing gradually until 2016, but it has increased again in the last few years (11.7% in 2016 to 6.1% in 2019). In 2017, 38.2% of early school leavers in Leuven were still unemployed after one year of dropping out of school, while the share of unemployed one year after graduation was 35% for low-skilled secondary school graduates, 13.2% for medium-skilled and 4.2% for high-skilled young people.

With regard to gender differences, young women fare comparatively better than young men. Not only do they have higher educational attainment - in 2019 55.2% of young women aged 30 to 34 had completed higher education compared to only 40.2% of young men - but the percentages of NEET and early school leavers are much lower for young women. Indeed, in 2019 the share of NEETs among girls was 8.6% compared to 10.1 % for boys, and only 6.2% of girls dropped out of school compared to 10.5% of boys.

Finally, the share of upper-secondary students enrolled in vocational education (VET) is high in Flanders, and although 83% of 25-34-year-olds with an upper secondary or postsecondary non-tertiary vocational qualification are employed, a relatively high share of them ends up not in education, employment or training (NEET) ^[ 17 ] .

The policy against educational inequality (Gelijke Onderwijs Kansen - GOK) that came into effect in 2002 in Flanders is generally considered to be the main instrument to counteract the inequality of opportunity in Flemish education. Among the measures taken was the granting of extra resources and teaching time to schools with a certain percentage of disadvantaged pupils. In 2018 an evaluation of the GOK policy was carried out ^[ 18 ]  that showed a limited effect of these measures. Indeed, in the 15 years the policy has been in place, educational inequality has slightly decreased, but not to the desired extent. The report highlights a responsible use of financial resources towards tackling the two most persistent sources of inequality - namely the low Dutch proficiency and low socioeconomic status - but at the same time it warns that the GOK policy is still too often implemented inefficiently. Indeed, schools - which in the Flemish system are given farreaching autonomy - often do not implement good quality programmes due to the lack of specific and clear guidelines and insufficient investment in teacher and school team training and expertise.

In terms of recent policy, the 2012 Enrolment Decree, which was further amended in 2018 to include an algorithm to assign students to schools based on their preferences and other criteria of fairness ^[ 19 ] , appears to be decreasing segregation, at least among newly enrolled students (Frank & Nicaise, 2018). However, due to political disagreement, proposed reforms of the tracking system have not gone through ^[ 20 ] .

In an attempt to decrease inequalities of opportunities from an early age, since 2011 the City of Leuven partnered with local primary schools to offer economically accessible childcare for after school hours (KinderKuren programme). Children are engaged in additional learning activities that stimulate their development, in the same school they attend in the morning, while parents have time to work. Costs are contained (about €1.80/hour) and the hourly rate ensures as much flexibility as needed. Moreover, there are additional discounts for low income families and families with multiple children enrolled in the program.

The Buddy Project shares a similar objective of improving learning skills, but it is aimed at both primary and secondary school students and it is free. Pupils can have one or two weekly sessions with a “buddy”, either a trained volunteer or a professional, who will help them with homework and give them extra support. A “buddy” can be recommended by the school or requested by parents or students themselves. The Buddy Project started in 2007 as an initiative of the Leuven Alderman for Education and various education partners, including the teacher and welfare training departments of three universities (KU Leuven, UC LeuvenLimburg and VUBrussels), which encouraged their students to act as buddies through internships. Currently, all secondary schools in Leuven participate in the Buddy Project, together with a number of primary schools, for a total of more than 450 “buddies” and over 00 students.

With regard to early school leaving, the Internal Pupil Coaching Programme (Interne Leerlingenbegeleiding) in Flanders, implemented in 2015, provides additional funding to schools who request it for the purpose of relieving teachers of part of their teaching duties or hiring specialised staff (a psychologist, pedagogue or social worker) in order to provide extra care for pupils in need ^[ 21 ] .

In order to improve the employability of VET graduates, since 2019 Flanders implemented a decree on dual learning, with 87 new study programmes where students acquire most of their training (60% or more) in the workplace and the rest at a VET school or at a training centre. One important component of the new model is an online tool called Werkplek Duaal, where firms can sign up to provide accredited apprenticeships ^[22] .

Finally, the SOM - Samenleving Onderwijs Leuven network brings together all educational actors in Leuven, from preschools to adult education. Both individual educators and institutions are involved and all Leuven schools are involved alongside the local educational consultation board and the Municipality of Leuven. SOM’s objectives are to increase pre-school participation, reduce school drop-out, promote the development of talent and competences, promote cultural diversity as a value, and increase wellbeing and involvement of teachers and parents as well. These objectives are pursued through workshops and initiatives in schools, as well as open meetings for all educational actors. .

Belgium as a whole withstood both the 2008-2009 Great Financial Crisis and the 2011-2012 Euro area debt crisis relatively well, quickly recovering in terms of employment and overall growth ^[ 23 ] . The effects of the new Covid-19 crisis are still unclear, but reports point towards a good resilience of the labour market, particularly in the case of Flanders, also thanks to the large investments made by both the federal and the regional governments, although the highest price in terms of income loss is paid by the most vulnerable groups - the young, the migrants and the low-educated ^{[ 24 ][ 25 ]} .

The Leuven economy is doing well, with an annual growth rate of more than 3% since 2009, and the tertiary and quaternary sectors dominate the local economy and account for over 90% of employment in Leuven. In particular, the non-commercial services and knowledge-based economy employ nearly 50% of workers in Leuven, compared to 33% in Flanders.

Generally, unemployment rates in Belgium are low compared to OECD levels, and unemplyment showed a general upward trend until 2015 (from 6.6% in 2008 to 8.5% in 2015), followed by a slow but steady decline (from 7.2% in 2016 to 5.4% in 2019), albeit with great fluctuations. Unfortunately, long term unemployment is particularly high and persistent, accounting for nearly half of all unemployment ^[ 26 ] . In addition, there are significant regional differences in unemployment rates across the country but Flanders fares substantially better than the national average (3.5% against 5.4% in 2019).

Leuven performs slightly worse than the Flemish average. Indeed, in 2019 the employment rate in Leuven was 71.1%, slightly below the Flemish average of 75.2%, while the unemployment rate was slightly higher than in Flanders - 6.9% versus 6.0% - although it has been falling in the last decade. Just like at the regional level, unemployment figures are worse for young people (16%), for people with low levels of education, and for people with a migration background, particularly if non-Western. Instead, in Leuven unemployment rates for women are lower than for men. In 2019 only 5.8% of Leuven women were unemployed compared to 7.8% of men, a difference that has been consistent since 2012.

The labour market in Belgium is amongst the most protected in Europe. Indeed, a system of collective negotiations between trade unions and employers across most sectors ensures high minimum wages, fair labour relations, as well as protection in case of collective dismissals ^{[ 27 ][ 28 ]} . For this reason, the proportion of workers with temporary contracts remains low, and nine out of ten employees enjoy a permanent contract. However, since 2014 there has been a steady increase in the number of temporary contracts.

Further, about 17% of workers are self-employed, a figure higher than in other OECD countries, and which continues to rise. The popularity of self-employment is probably due to the relatively good social protection conditions, with good pension, sickness and maternity leave provisions ^[ 29 ] . In addition, more than a quarter of employees work part-time, well above the OECD average.

One of the main labour market problems in Belgium is the large share of inactive working age population. The 64.5% employment rate for those aged 15 to 64 years is lower than the OECD average of 68.6%, and the share of youth not in employment, education or training (NEET) was in 2020 (7.3% in Flanders, 11.3% in Brussels and 11.7% in Wallonia).

employment dynamics vary greatly according to age, education level, gender and ethnic background. Indeed, youth unemployment is a major concern, in particular for those with low levels of education and those with a foreign background. In Flanders in 2019, the youth unemployment rate (15-24 years old) was 9.5%, almost three times the general rate for the region. The same figure for low-educated youth was 16.6%, and 11.3% for youth with a non-EU migration background. Similar dynamics are at play also for the 25-29 age group.

People’s migration background is a fundamental determinant of their likelihood of being employed, and of the quality of their employment, and this not only applies to first-generation immigrants, but also to their descendants who, despite being born and raised in Belgium, continue to face serious difficulties in accessing the labour market and obtaining better paid 'white collar' or stable public sector roles. This gap results from a combination of factors, namely low educational attainment, inadequate work-skills, discrimination and imperfect knowledge of the native language(s) ^[ 30 ] .

Not surprisingly, young people and people with a non-EU migration background are overrepresented in temporary jobs.

With regard to gender, Belgian female unemployment and activity rates, although still worse than their male counterparts, have been improving in the past decade - respectively decreasing from 8.5% to 5.4% and increasing from 60.4% to 64.5% between 2007 and 2019, and similar trends are visible in Flanders. However, employment conditions are still very unequal. In particular, 45.2% of employed women work part-time compared to 11.5% of employed men. Even when working, women are more at risk of in-work poverty than men ^[ 31 ] , although the gender pay gap is improving. In 2019 the average hourly wage for women in Belgium was 5.8% lower than that for men, an improvement of about 4 percentage points compared to 2007.

The intersection of different vulnerabilities is evident in the employment rate gap between Belgians and non-EU citizens. Among men this gap in 2019 amounted to 17.6% - already very high - but among women the gap reached 39.1%, highlighting how women with a non-EU migrant background are largely left out of the labour market.

The high rates of long-term unemployment and inactivity highlight a need for more tailormade active labour market policies (ALMPs). Indeed, the implementation of this type of policies has been ‘reluctant and erratic’ ^[32]  and uneven across the different regions, as well as much less widespread and strict compared to other continental welfare states such as the Netherlands ^[ 33 ] .

Social security and unemployment insurance are controlled at the federal level while regions are responsible for ALMPs. Belgium is the only OECD country that offers time-unlimited income support for the unemployed, in a system that provides good protection against income loss due to joblessness. However, this system has become the subject of an intense policy debate in recent years, in particular about its ability to maintain strong work incentives. In 2012, a reform was implemented to make unemployment benefits decline more steeply over the duration of the unemployment period.

There is a skills mismatch in Leuven; the demand for low-skilled roles is decreasing, while the number of low-skilled job seekers is increasing, while demand for high- and middle-skilled profiles has increased while the number of applicants is insufficient ^[ 34 ] . It is not surprising then that approximately 74% of the jobs in Leuven are filled by people from outside the Municipality, while 50% of Leuven residents have a job outside Leuven, thus confirming the prominence of suburban living and the relation with the Brussels metropolitan area.

In terms of employment policy, the room of manoeuvre for the Municipality is relatively limited, as it can only implement local activation programmes based on Flemish policies and guidelines.

In Flanders, the Vlaamse Dienst voor Arbeidsbemiddeling en Beroepsopleiding (VDAB) is the public employment and vocational training service provider and the main implementer of ALMPs. In order to develop tailor-made activation programmes for the long-term unemployed, in 2018 the VDAB has started to use a statistical profiling model, called “Next Steps”, which estimates the probability of being unemployed for a period greater than 6 months through a machine learning algorithm feeding on the jobseekers’ socioeconomic characteristics, their labour market history and the “click data” on their job searching activity on the VDAB website ^[ 35 ] .

The VDAB is also in charge of the Flemish EU Youth Guarantee Implementation Plan since 2014, which builds on the 2007 Youth Employment Plan. Funding from the European Social Fund (ESF) and is supplemented by the Flemish annual budget for youth policy. Compared to the previous plan, the focus has shifted on preventing youth unemployment, in addition to tackling it. The main objectives are:

• to support youth in vulnerable positions,
• “tracking down” NEET youth, and
• strengthening the links between education and the labour market.

Measures focus on improving the availability and quality of work-based training, both through vocational education and through internships. In particular, the Individual Vocational Training (Individuele Beroepsopleiding) programme allows employers to hire a jobseeker and train them in the workplace for a limited period. The VDAB covers the wage and social security contributions and in return, if the training is successful, the employer is expected to hire the trainee on a permanent contract. The programme showed a high rate of success, with 90% of participants still working in the same company where they completed their training one year later ^[ 36 ] .

Moreover, the VDAB aims to involve young people in order to better direct policy action towards their needs. For this purpose, digital advisory Youth Panels are organized in cooperation with the Flemish Youth Council to discuss proposed measures.

In conjunction with the Flemish Youth Guarantee Implementation Plan, in 2021 Leuven launched the BOEST! your future project to provide better guidance to young people between 18 and 29 who have been unemployed for more than 6 months and who cannot find their way into the labor market due to their insufficient skill level. The project is carried out in collaboration with local NGOs and social partners. It aims at providing a tailor-made approach for the young person with the help of a permanent counselor who supervises the young person for as long as necessary to find the most appropriate training courses, internships and eventually jobs.

The Flemish housing market is often characterized as relatively stable and static, with Belgium a typical example of a ‘nation of home owners’ ^[ 37 ] . However, even though these general features to a large extent still apply, trends such as gentrification and rising inequality are increasingly influencing Flemish housing developments. Indeed, gentrification has been taking place in several low-income neighbourhoods of the bigger Flemish cities. This process leads to the displacement of the private rental tenants with the lowest incomes ^[ 38 ] .

In Flanders around 70% of homes are owner-occupied. The private rental sector has a share of approximately 24%, whereas the social rental sector accounts for around 6% of the Flemish housing stock. In terms of geography, the highest shares of home ownership can be found in the more rural regions, whereas the cities are characterized by a relatively high, and often increasing, share of rental dwellings ^[ 39 ] .

Compared to the Flemish average, Leuven has less home ownership (68.9% in Flanders vs 6.4% in Leuven), and more private rent (25.1% vs 46.3%), but the proportion in social rental housing is similar (7.3% in Leuven vs. 6% in Flanders). As far as house prices are concerned, Leuven is clearly more expensive than the Flemish average, with the fact that Leuven is an attractive location for commuters who work in Brussels pushing up house prices in the city ^[ 40 ] .

Social rental housing in Flanders is provided by two types of organizations. Social Housing Associations (SHAs) provide 95% of the Flemish social rental housing stock. At the end of 018, there were 100 SHAs active in Flanders, which together owned 156,280 social dwellings. Social rental Agencies (SRAs) do not own their housing stock but rent it from private rental landlords. The SRAs orginate from the 1990’s and focus more than the SHAs on housing the most vulnerable groups. At the end of 2018, 48 recognized SRAs were active in Flanders, with a stock of 10,990 dwellings ^[41] .

House prices and rental prices have increased incessantly since 1996, even in the aftermath of the Global Financial Crisis, which did not have a very large effect on the Flemish housing market and economy. Over the last two decades, housing affordability for home ownership has more or less stabilized, whereas housing affordability in the rental sector (particularly in the private rental sector) has deteriorated. This may be an indication of an increasing income and wealth gap between home owners on the one hand, and tenants on the other (a so-called residualisation of the rental sector) and a consequence of intergenerational transfers, with home owning parents financially supporting offspring so that they can enter the home ownership sector as well.

Partly as a result of rental price increases, in 2018 around 37% of the social rental tenants and around 35% of private rental tenants lived in poverty: their income after housing costs is too low to cover necessary expenses ^[ 42 ] . Most of these people are either unemployed, sick, single-family parents and/or have a migration background. The rented sector also provides comparatively bad housing quality; older rental stock in particular is often of poor quality.

For young people with a low income, the home ownership sector is often out of reach. Although in principle the social rental sector should cater for these households, Flemish social rental dwellings are in short supply and waiting lists are long. Although official numbers are not available due to the fragmented management of social housing dewllings, it is estimated that more than 100,000 people are currently waiting for a social rental dwelling in Flanders ^[ 43 ] .

Some young adults, who cannot find an affordable home to buy in Leuven, move further eastwards, where house prices are lower. Commuting (which is heavily subsidzed) serves as a solution for solving housing needs. Together with a preference for suburban living and self-provided housing, and a lack of proper spatial zoning, this tradition has resulted in a large urban sprawl around Flemish cities, including Leuven ^[ 44 ] .

Since 2011, rent regulation, tenure security and housing tax policy, which used to be formulated at the federal level, have been the responsibility of the Belgian regions ^[ 45 ] . Moreover, the regions are also responsible for housing-relevant matters such as social policy, economic policy, spatial planning and land policy ^[ 46 ] .

In Flanders, there has always been a strong fiscal support for home ownership. However, in recent years this support has become less generous and since 2020, fiscal advantages (Woonbonus) have been abolished for new mortgages. Support for home ownership now takes a more focused approach. For example, subsidized home ownership dwellings are provided in many Flemish municipalities, also in Leuven. These dwellings are developed under the supervision of the municipality and they are characterized by a selling price below the market value. Often, but not always, these dwellings are subject to income requirements and there usually is an age limit of 30 to 35 years.

Municipalities are responsible for the development of social and affordable home ownership housing within their boundaries, as well as for housing quality control and policy. Furthermore, they may coordinate the housing related activities of private and civil actors. The municipality of Leuven has a subsidiary (Autonoom Gemeentebedrijf Stadsontwikkeling Leuven - AGSL) which is responsible for the urban development and the implementation of the land policy of the city. In its housing development projects, AGSL reserves a limited share of newly built dwellings (stadswoningen) for lower-middle-income groups. Since 2010, these dwellings are offered at a below market price and they are primarily meant for first time buyers that have a connection to the city of Leuven. In order to prevent speculation, specific resale conditions apply to these dwellings. By 2021, 155 stadswoningen had been built ^[ 47 ] .

In the private rental sector, since 2014 AGSL has offered so-called starter dwellings (starterswoningen). These are affordable private rental dwellings for single or two person households. The starterswoningen come with an arrangement that allows the tenants to save a part of the rent that they pay. After some time, these savings can be used to buy a dwelling or a plot of land in the city of Leuven. By 2021, 40 starterswoningen had been built ^[ 48 ] .

Finally, prospective tenants that have been on the waiting list for social rental housing in Leuven for a long time can apply for the so-called Leuven rental premium (Leuvense huurpremie). Only households with children are eligible for this premium.

In Belgium, jurisdiction over health policy and regulation of the health care system is divided among the federal government and the regional ones. Federal authorities are responsible for regulating the national compulsory health insurance fund, the ambulatory care and the hospital budget, pharmaceuticals and their price controls, and health professions and patients’ rights. Regions are responsible for health promotion and prevention, organisation of primary and palliative care, maternity and child health care, mental health care, social services and community care; as well as co-financing hospital investment. Inter-ministerial conferences are regularly organised to facilitate collaboration between the different levels ^[ 49 ] .

There is a compulsory public health insurance system, financed through social contributions proportional to income. This system is implemented through sickness funds (all citizens are required to register to one), which receive a budget from the federal government to finance the health care costs of their members. The provision of care is based on principles of equal access and freedom of choice (of sickness fund, physician and care facility), and works predominantly with fee-for-service payment, in which patients pay upfront and get (partially) reimbursed by their insurance later. The compulsory health care insurance covers the costs of many healthcare services, and what is not (fully) covered is paid by patients themselves (out-of-pocket payments - OOP). Alternatively, Belgian residents can take out supplementary packages from their sickness fund or additional private insurance in order to reduce their co-payments and OOPs for services that are only partially covered or not covered by the compulsory health insurance.

Health inequalities are more marked in Belgium than in all other OECD countries ^[ 50 ] . Generally, those in a less privileged position in society have more frequent and more serious health problems: the better one’s socioeconomic status, the greater the chance of a longer and healthier life ^[ 51 ] . In particular, children and young people are highly impacted by the socioeconomic status of their parental household, since it determines their health habits and opportunities, as well as their access to healthcare.

In Belgium, socioeconomic inequalities are observed in all health indicators, including life expectancy, rates of disability, levels of mental health, rates of chronic disease and in behaviours associated with health outcomes (e.g. smoking, nutritional habits). The inequalities and have increased over time.

Leuven shows similar patterns in terms of health inequalities. In 201, almost three-quarters of Leuven residents reported feeling 'healthy' to 'very healthy'. More than twenty percent feel 'reasonably well', while less than 5% feel 'rather bad' to 'very bad' ^[ 52 ] . This high score is most likely related to the fact that Leuven has so many highly educated inhabitants. Indeed, highly educated people (81%) feel much healthier than those with a low level of education (58%).

This same difference can be found in several other health related indicators. People with a high level of education exercise more than those with a low level of education (31% and 25% respectively) while the share of residents undergoing cancer screening drops about 20 percentage points for people with a low socio-economic status.

With regard to mental health, about 7% of the people living in Leuven feel regularly to often sad, lonely or depressed, and 46% suffer from limited psychological problems, and 14% from moderate to heavy ones. In this respect too, there are remarkable differences with regard to level of education, gender, and age. Twice as many low-educated people (20%) as highly educated people (10%) report moderate to severe psychological problems. Women (17%) are more often confronted with psychological problems than men (12%), and 18-24 year-olds have a higher rate of moderate to severe problems than average (20%). Not surprisingly, those who work (10%) are less likely to have mental health problems than those who do not (19%).

Socioeconomic inequalities are also present in terms of accessibility to healthcare. In this regard, at least two factors need to be considered. First of all, while the mandatory public insurance virtually covers the totality of Belgian residents, it does leave out crucial vulnerable groups, such as undocumented migrants, asylum seekers, refugees, and the homeless ^[ 53 ] . Limited healthcare for these groups is provided by local Public Centers for Social Welfare, but often these people are not even aware that they have a right to urgent medical care, and cultural and linguistic barriers can also create obstacles to appropriate care ^[ 54 ] .

Secondly, affordability of care is not always guaranteed, despite the public insurance system. Indeed, for many services upfront OOPs can be very burdensome for low to middle income households ^[ 55 ] . Additionally, fee supplements, mostly for hospital bills, have become larger and more common since 2015. It is not surprising then that the level of unmet need for medical care is high in the lowest income quintile and has been rising since 2010. Between 2011 and 2016, the unmet need increased from 4.2% to in the lowest income quintile. The difference between the highest and lowest income quintile has also been increasing, and in 2016 it reached 7.4% ^[ 56 ] .

In particular, differences in mental healthcare are striking. Despite the higher need for mental healthcare among the lower-educated and the young, these are the groups that have the lowest number of consultations with a psychologist or psychotherapist. Possible explanations for this include the fact that until 2018 consultations with a psychiatrist or in a mental healthcare centre were only reimbursed for adults ^[ 57 ] . Since then, a maximum of 8 yearly consultations with a psychologist or psycotherapist can be reimbursed via the general insurance, but this is hardly sufficient, since mental healthcare generally requires long-term therapy.

Municipalities have very little agency in terms of healthcare policy, and, despite the ambitious objectives, the only initiatives that the Municipality can implement are related to preventive health campaigns in collaboration with health institutes and the promotion of networks of organizations that provide help to specific target groups (the elderly for example) or with regard to specific aspects of health.

In this regard, in early 2020 Leuven secured a Flemish grant of €100.000 for the Start Smiling project. The objective is to make oral care more accessible for vulnerable residents through a series of information sessions and free dental screenings in three neighbourhood health centers across the city. The project will last for at least 18 months, and is implemented in cooperation with local dentist practices, NGOs and community groups. Moreover, thanks to a collaboration with the UCLL university of applied sciences, a number of primary schools are receiving lessons about oral care and healthy nutrition.

Another interesting initiative is the  TEJO programme  which provides free psychological therapy sessions to youngsters between 10 and 20 years old. The sessions can be completely anonymous if desired, and the help can range from a one-off conversation to long-term therapy, according to the specific needs. The programme is run since 2010 by a non-profit organization through a system of “TEJO houses”, open door places where young people can find psychological help. Currently, there are 18 TEJO houses in Flanders and 1 TEJO house in the Netherlands with more than 600 volunteers.

Finally, as part of the local healthcare system financed by the Flemish Region, Public Centres for Social Welfare help vulnerable people with the necessary expenses for a dignified life, including some types of medical costs, such as costs for medications, purchase of glasses, dental prosthesis or hospitalization, in an effort to improve local access to healthcare. Each case is evaluated on an individual basis and the request for financial support is granted based on the level of socioeconomic vulnerability.