Editor’s Note: Health Affairs has published several articles that shed light on the Dutch health system, including Universal Mandatory Health Insurance In The Netherlands: A Model For The United States?, by Wynand P.M.M. van de Ven and Frederik T. Schut; Alain Enthoven’s interview of the Dutch Health Minister, Ab Klink; and the analysis of health care in the Netherlands and six other developed countries by Cathy Schoen and her colleagues at the Commonwealth Fund. The Schoen article is extensively cited by the Dutch Health Care Performance Report, which Gert Westert discusses in his post below.

The Dutch health care system is considered a possible model for the United States. Potentially attractive features of the system are: universal mandatory health insurance from private insurers; the ability of enrollees to change health insurance annually; and the ability of insurers to selectively contract with particular health care providers.

Given the recent international focus on the institutional arrangements that characterize the Dutch system, the actual performance of health care in the Netherlands is of great interest to all considering adopting bits and pieces from the Dutch system.

In 2004 on the Dutch government commissioned an independent agency of the Dutch Ministry of Health to assess the system’s performance every two years. The Health Care Performance Report (DHCPR) monitors the accessibility, cost and quality of the Dutch health care system, using roughly 100 indicators. The second report, for which I was lead editor, was released recently and is available in full in English. I outline some of its most interesting findings below.

Accessible for everyone?

The Netherlands has an accessible health care system. Confidence in the affordability of necessary care is high, and few people forgo visiting a doctor because of costs.

The Dutch health care system obliges everyone living in the Netherlands to be insured against health costs. Hence, a basic package of health care is accessible to everybody. At 8 percent of total payments, out-of-pocket payments in the Netherlands are below the OECD average of 20 percent. In 2007, the percentage of people who said they did not visit a doctor because of costs in the Netherlands was only 1 percent, comparable to the United Kingdom’s 2 percent and much lower than the 12 percent and 25 percent of people who did not visit a doctor because of cost in Germany and the United States, respectively.

The use of care varies only slightly with respect to educational level and ethnicity when differences in health are taken into account.

Sufficient personnel?

Between 2004 and 2006, the number of vacancies per thousand jobs in the health care sector increased by 42 percent. One-quarter of these are difficult to fill.

In 2007, 56 percent of nurses and caring personnel thought that there were enough personnel to guarantee safety (38 percent for nursing homes), whereas in 2004 that figure was 70 percent. If this unfavourable trend of increasing personnel shortages continues, serious accessibility and safety problems will occur in the near future.

The labour productivity has increased in recent years. In geriatric care the labour productivity, measured on the basis of days and hours of care, rose by 1.4 percent per year between 2000 and 2005.

Concerns about expenditure?

Health care expenditure has risen by about 5 percent per year since 2004. This rate of growth is comparable to that in the neighbouring countries, but since 1990, the health care expenditure per working Dutch person has constantly been above the EU-15 average.

The Dutch health care expenditure expressed as a percentage of the gross domestic product was 9.4 percent in 2006. This figure for the Netherlands is lower than that in Belgium (9.8 percent), France (10.8 percent) and Germany (10.3 percent), but higher than in Denmark (8.7 percent) and the United Kingdom (8.9 percent). In the US this percentage is 15, much higher. Canada is close to the Dutch figure: 9.3 percent.

Quality: average or excellent?

Compared to other wealthy countries, the Netherlands does not particularly excel in terms of the quality of health care provided. Although many types of care are of high quality and quality has increased, the overall picture is average on an international scale. The Netherlands is one of the five wealthiest countries in the Eurozone and so, quite understandably, expectations regarding quality of health care are high.


In the area of prevention, the Netherlands scores highly when it comes to screening and vaccination. However, the results are less favourable with respect to the promotion of a healthy lifestyle. Doctors are quite haphazard in providing their patients with specific recommendations about lifestyle. Canada, the United States and Australia, for example, all score significantly higher for this aspect.

Curative care

Only a small percentage of patients in primary care are referred by GPs to secondary care. Since 2001, this percentage has risen slightly, but the Dutch GP is still cautious about referring. In about two-thirds of cases, Dutch GPs prescribe medicines according to their own professional guidelines.

From an international perspective the Netherlands occupies an average position with respect to curative secondary care. The Scandinavian countries (in particular Norway, Sweden, Finland and Iceland) score better than the Netherlands when it comes to hospital mortality within 30 days of admission (acute myocardial infarction, cerebral haemorrhage and cerebrovascular accident). The same picture is found for five-year survival in the case of breast, cervical and colon cancer.

Long-term care concerns?

Since 2003 the incidence of decubitus (bed sores) in nursing homes, residential homes and home care has decreased. In nursing homes the figure was 10.3 percent in 2003 and 6.9 percent in 2006. The percentage of malnourished patients has also decreased. In 2006, clients gave residential homes and care for the disabled a score of 7.8 out of 10 and nursing homes received an average score of 7.4.

Compared to other types of care, the ratings for nursing homes in particular were on the low side. Nursing homes scored particularly low in the provision of information (5.0) and patient participation. The availability of sufficient personnel is the most important point for improvement. Less than 4 out of 10 clients in residential and nursing homes indicated that a staff member “sometimes struck up a conversation in passing”.

Patient safety

According to a recent estimate, 5.7 percent of patients admitted to hospital experienced adverse events, 40 percent of which was considered to be avoidable. In a recent survey among the Dutch about safety in curative care, 5 percent of the respondents indicated that they had been subject to a medical error during the past year and 6 percent indicated that they had received an incorrect medicine or dosage. The hospital standardized mortality rate (HSMR) gradually decreased in the period 1998-2005, but the risk of mortality in the hospital with the highest mortality was still 45 percent higher than the average in 2005.

Coordination and cooperation between care clusters: substandard cluster quality

A medical home is important for a good coordination of care. For the Dutch that is the general practice, where 99 percent of the population are registered. The study by the Commonwealth Fund (CMWF) (Schoen et al, 2007) reveals that the vast majority of Dutch people have a medical home for medical care: the GP. In other countries that percentage is significantly lower. According to 93 percent of the Dutch respondents, the GP knows the patient’s medical background, which forms a good basis for a coordinating role. However, the Dutch GP is less active in coordinating care that is provided by other physicians and care providers. Also, the Dutch GP provides the specialist with less relevant medical information than in other countries.

Another recent Dutch survey revealed that about one in five patients with a specific condition (breast cancer, rheumatism, cataract) experienced either insufficient or a lack of coordination or cooperation between the health care providers involved. In 2006, 44 percent of respondents stated that they had confidence in the cooperation between health care providers.

After the system reforms in 2006

The system reforms – at the start of 2006 – have led to clear effects on certain aspects, but have still not resulted in demonstrable changes in the quality, accessibility and costs of care at the macro-level. The health insurer mainly purchases health care on the basis of price and is no more critical about the quality than was the case in 2004. At present, the quality of care is not transparent enough.

The system reforms in 2006 led to a lot of movement by insurance policyholders. One in five policy-holders switched insurers and the competition between health insurers was fierce from the moment the reforms were introduced. Premiums failed to cover the costs and the profit margins in the premiums were limited. This picture continued into 2007. In a short time, a strongly competitive market has developed to acquire more policyholders.

However, in 2006 and 2007 hardly any use was made of quality criteria for hospital care during the procurement of care. In the care procurement market no competition is visible yet with respect to the price/quality ratio. The prices in independent treatment centres are lower, although the causes of this are still not completely clear. In the freely negotiable part of hospital care (the B segment) the volume of care in particular is rising. Due to a lack of information about the quality of care, no statements can yet be made about trends in the quality of care in the B segment.

Information about the quality of the care must counteract market forces that are purely price driven. A lack of such information could lead to quality losing out to competitive prices. Although care users can independently gain some insight into the quality of care, they also need to be assisted by the health insurers who procure care on a critical basis. However, there is still not enough transparency concerning the quality of care.

Challenges For The Future

Eye catching challenges for Dutch health care in the years ahead are: further improvement of effective and safe care, emphasis on health promotion within the cure setting, adequate care coordination and improving longitudinality of care for patients, and attracting sufficient and qualified personell for especially long term care services.