Analysis Looking to Europe

The Netherlands: regulated competition behind the dykes?

BMJ 2009; 339 doi: (Published 07 September 2009) Cite this as: BMJ 2009;339:b3397
  1. Gert P Westert, professor of health services research 13,
  2. Jako S Burgers, senior researcher2,
  3. Harry Verkleij, senior researcher3
  1. 1Tilburg University, PO Box 90153, 5000 LE Tilburg, Netherlands
  2. 2Scientific Institute for Quality of Healthcare, Radboud University Nijmegen Medical Centre, Netherlands
  3. 3National Institute for Public Health and the Environment (RIVM), PO Box 1, 3720 BA Bilthoven, Netherlands
  1. Correspondence to: G P Westert gert.westert{at}

    In 2006 the Netherlands introduced a set of healthcare reforms aimed at improving the efficiency of the country’s health system and getting better value for money. Dutch society, in common with that of many other European countries, is ageing and healthcare costs are expected to peak in 2040. The Dutch ministry of health thought that change was essential if the system was to contain costs and continue to provide equitable access to good quality care. The reforms have attracted much interest, not least in the US, because the Dutch are trying to make private insurance work for public benefit. We describe the reforms, explain why they were introduced, and discuss early evidence of their effect.

    Spur for health reforms

    The seeds for the 2006 reforms were sown in the late 1980s. In 1987 a committee, headed by the chief executive of Philips, Wisse Dekker, reported that the system lacked efficiency.1 The Dekker report pointed to a lack of cost awareness among consumers and providers and a fragmented funding system, with lack of alignment between the publicly and privately funded parts of the system. It also concluded that rigid governmental regulation inhibited flexible organisation and thwarted innovation.

    Before the reforms, around two thirds of the Dutch population was covered by social health insurance, which was financed through fixed income based contributions; enrolment was mandatory for everyone under a certain income level. Most of the rest of the population (those on higher incomes) had to take out private insurance to get access to the same healthcare services. In the Netherlands most services are delivered by private providers and access is open for all, irrespective of type of insurance.

    Quality of care

    Health expenditure in the Netherlands as percentage of gross domestic product has been running close to the average in the first 15 European Union countries.1 It …

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