Healthcare System & Market
The Netherlands is situated in Western Europe and borders the North Sea, Germany and Belgium. It covers an area of 41 543 km2 and has a population of 16.4 million (2008), the majority of whom (80.4%) are native Dutch. The Netherlands is a wealthy country and is among the world’s top 20 in terms of total gross domestic product (GDP) and among the top 10 in terms of export volume. Key drivers of the Dutch economy are financial and commercial services. The Dutch political system is a parliamentary democracy with a bicameral parliament consisting of a Senate and House of Representatives.
Organisation and regulation
A major health care reform in 2006, introduced after almost two decades of preparation, has brought completely new regulatory mechanisms and structures to the Dutch health care system. The reform introduced a single compulsory insurance scheme, in which multiple private health insurers compete for insured persons.
Health insurers can negotiate to a certain extent with health care providers on price, volume and quality of care; and are allowed to make a profit and pay dividends to shareholders. They are obliged to accept new applicants and they are not allowed to differentiate their premiums according to the risk profile of the applicants.
The government changed its role from direct steering of the system to safeguarding the process from a distance. Responsibilities have been transferred to insurers, providers and patients. The government controls the quality, accessibility and affordability of health care. The establishment of new “watchdog” agencies in the health sector aims to avoid undesired market effects in the new system.
Furthermore, in long-term care as well, increased competition among providers of outpatient services is changing the system considerably. The delegation of responsibility for domestic home care services to the municipalities has resulted in more diverse care arrangements.
In the Netherlands, 8.9% of GDP was spent on health care in 2007. Between 1998 and 2007 the expenditure (in constant prices) increased in real terms by 38%. The Dutch health insurance system is divided into three so-called compartments.
The first compartment consists of a compulsory social health insurance (SHI) scheme for long-term care. This scheme provides for those with chronic conditions continuous care that involves considerable financial consequences and is regulated in the Exceptional Medical Expenses Act (Algemene Wet Bijzondere Ziektekosten, AWBZ). The AWBZ is mainly financed through income-dependent contributions. A complicated cost-sharing system applies to individuals using AWBZ care. The care is provided after a needs assessment and the provision of care is organized via care offices (Zorgkantoren). Care offices operate independently, but are closely allied to health insurers.
The second compartment also consists of a SHI system covering the whole population for “basic health insurance”. Basic health insurance covers essential curative care tested against the criteria of demonstrable efficacy, cost-effectiveness and the need for collective financing. The scheme is regulated by the Health Insurance Act (Zorgverzekeringswet, Zvw). All Dutch citizens contribute to this scheme in two ways. First, they pay a flat-rate premium, the so-called nominal premium, directly to the health insurer of their choice. Second, an income-dependent employer contribution is deducted through their payroll and transferred to the Health Insurance Fund. The resources from this Fund are then allocated among the health insurers according to a risk-adjustment system. A “health care allowance” should partly compensate the lower incomes for their health insurance costs.
The third compartment consists of complementary voluntary health insurance (VHI), which may cover health services that are not covered under the AWBZ and Zvw schemes. Prevention and social support (including certain home care services) are not part of the SHI or VHI, but are mainly financed through general taxation.
WHO Netherlands Healthcare review
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