This paper consists of an analysis of the concept of empowerment—which is often defined as a key issue in health care—at the macro, meso, and micro levels by focusing on health care reform in Belgium. Three research teams collected data and combined them in an inductive secondary analysis. Our preliminary results demonstrate that patient empowerment does not always encompass the same scientific reality. At the macro level, this concept is linked to the authorities’ wish to support at-home care for chronic patients. At the meso level, the role of caregivers in maintaining patients’ autonomy, but also the social conditions of their lives, is a salient component of empowerment. At the micro level, individual and personal features such as identity can influence patient empowerment and behavior in the health care system. This cross-level research suggests that patient empowerment is not sufficiently clearly defined at each level of the care production chain, which could impede the reform of health care. This paper underlines the polysemy of a concept viewed as a milestone in European health care policy and the necessity of a clear, collective definition to operationalize and implement it.

When analysing public policies, an implementation gap is often attributed to unclear or irrelevant goals, implementers’ disobedience and/or the numerous layers of government involved. This paper focuses on the multi-layer problem, wondering whether aspects other than the number of layers have an influence on the implementation gap in federal contexts, for example, the layers’ degree of autonomy or the competencies ‘allocation. It addresses the following research question: from an organizational point of view, to what extent does federalism, as a specific institutional configuration, influence the constitution of an implementation gap as part of a public policy implementation process? This research focuses on the implementation of public policy in the Belgian health sector intended to integrate care for chronic patients. It highlights the blockages that may occur in a multi-layer federal country like Belgium, showing that federalism can become dysfunctional if the allocation of competencies was made in an incoherent manner.

In 2015, the Belgian Health Ministers launched a plan intended to evolve towards an integrated care system for chronic patients. This plan is implemented through pilot projects involving local actors. Therefore, the researcher raised the following research question: how does the use of pilot projects as implementation instruments structure the collaboration between parties involved in a pilot project? The term “pilot project” refers to a collaborative work method coupled with an experimentation purpose. This is further developed in the paper via a literature study. This qualitative research draws on interviews, focus groups, direct observation, and a documentary analysis. During the two first phases of the process, field workers had to create multidisciplinary local consortia and write an application file describing the project they would implement during the third phase, which raised challenging collaboration issues. Many people learned to work together over time, progressively overcoming the traditional fragmentation of care. They met regularly, understood their respective roles, and dealt with controversies through negotiation to reach an agreement on a common project. In conclusion, the researcher shows that, thanks to its characteristics, the pilot project instrument supports the development of collaborative care networks; in this example of community-based integrated care networks.

De Winter; Implementing an Integrated Care System for Chronic Patients in Belgium: a Co-creation Process future. Pilot projects appear to be tools supporting the development of "community-based integrated care" [2]. Lessons learned: Building multidisciplinary projects entails that local actors reach an agreement on their common vision and goals, which is a challenging task. This implies dealing with controversies by meeting, understanding their respective roles, exchanging ideas, negotiating and overcoming their personal interests. Becoming a group, a community aware of its existence is a task in itself, which takes time. Besides, co-designing health care with local actors brings unpredictability to the process: the result of local actors' reflections can be different from the authorities' expectations. Limitations: Nineteen pilot projects submitted applications. For practical reasons of feasibility, this research focuses only on two pilot projects and, more specifically, on the application file co-construction process of these pilot projects. Suggestions for future research: The selected pilot