Indian Expat Society: The Netherlands

Major reforms have recently taken place in the Dutch healthcare system. A new single healthcare insurance system (basisverzekering) was introduced at the beginning of 2006, replacing the old two-tier system. Everyone in the Netherlands is now legally required to hold the same basic health insurance package, although this can be supplemented by additional optional packages.

In general, the legal obligation to have the basic medical insurance package applies to all residents of the Netherlands, regardless of nationality, unless they are on a temporary residence permit or student permit. However, foreign students and people staying temporarily in the Netherlands are required to hold some form of health insurance as a condition of entry.

The coverage provided by the basic insurance package is subject to ongoing review and change by the government. It generally includes most general healthcare costs, but does not currently cover the cost of dental treatment for adults, some maternity and post-natal care and physiotherapy. Children under the age of 18 are automatically covered by their parents' basic health insurance package, and also receive coverage for dental care.

Individuals can buy their basic insurance policy from any of a number of insurance companies (zorgverzekeraars) who all legally have to offer the same basic package, and which also offer additional supplementary cover at higher cost. The annual premium for the basic cover is in the region of €1,115 to €1,250, and a tax allowance is available against this for people on low-incomes.

In general, there is a natural, non-interventionist approach to medical and maternity care in the Netherlands, reflected in the reluctance of doctors to prescribe drugs unless absolutely necessary, the general practice of giving birth without any pain relief and the high proportion of home births. Additionally, doctors tend to volunteer much less information to their patient's about their conditions than is normal practice elsewhere, and there is far less preventative health screening than in many other western countries; it is not usual for women to have annual pap smears, for example. Some non-Dutch nationals living in the Netherlands reportedly find this relatively relaxed approach to healthcare a source of concern. On the other hand, the medical care that is available in the Netherlands is generally of a very high standard with excellent facilities and advanced specialist treatments available.

Alternative treatments, such as homeopathy and acupuncture, are very popular in the Netherlands and the cost of these can sometimes be covered by health insurance.

Primary healthcare in the Netherlands is provided by neighbourhood GPs (huisarts). Within your area of residence you are free to choose your own GP, and can obtain details of those in your area from the Yellow Pages, listed under "Artsen – huisartsen" or from the town hall, or by asking friends or other personal contacts for a recommendation. Once you have registered with a GP, however, it can be difficult to change to another, without a very good reason. Some GPs may refuse to take additional patients because their lists are full, but most people manage to find a family doctor within a short distance of their home.

Patients are normally required to make an appointment in advance to see the GP, although it is common practice for them to allocate a regular time each day for short telephone or walk-in consultations (inloop spreekuur) for minor ailments only, on a first-come, first-served basis. Regular appointment times usually last around 10-15 minutes, and it is sometimes necessary to wait several days for a free slot. GPs rarely make house calls in the Netherlands.

Some GPs require their patients to pay at the time of the consultation and will provide a receipt with which to reclaim the money from their insurance company; others will send a regular invoice to patients which can be forwarded to the insurers or payment, or will send this to the insurance company direct.
If a doctor writes a prescription for medicines, this should be taken to a pharmacy (apotheek), where such medicines are dispensed and where computerized systems are often used to record details of patient's drug history. Pharmacies also sell a range of non-prescription drugs along with many other health-related products, including alternative medicines and nutritional supplements.

Outside the GP surgery opening hours, a recorded telephone message will usually provide contact details for an on-duty doctor or the medical advice service (doktersdienst). For medical emergencies or first aid requirements, it is possible to go straight to the First Aid department (Eerste Hulp bij Ongelukken, or "EHBO") of the local hospital. In serious medical emergencies the emergency number 1-1-2 can be called for an ambulance service.

If you need specialist treatment or tests you are not allowed to approach a specialist direct in the Netherlands, you need a referral note from a GP. The majority of specialists work within hospitals; there are very few private specialist clinics. Waiting times for specialist appointments vary a lot between different specialist areas, but in some cases may extend to months.

As in the case of GPs, specialists will charge patients at the time of their consultation and provide a receipt with which to reclaim the payment, or will send an invoice at a later stage to the patient or direct to their insurance company. A copy of the referral note from the GP will also usually be required by the insurance company.

All dental services in the Netherlands are provided by private clinics, most of which consist of a single dentist and their assistant, although there are some joint dental practices which also include dental hygienists. Dental charges are relatively high in the Netherlands, and cannot be reclaimed under the basic insurance package, except for children under the age of 18. Dental services are tightly regulated by the government, which sets the charges for different dental procedures and ensures that the standards of dental care are consistently high. Dental specialists such as oral surgeons, periodontists and orthodontists generally work within hospitals in the Netherlands, and a referral from a dentist is usually required in order to see a specialist.

The Netherlands has a large number of hospitals offering excellent medical care, which include eight university hospitals, as well as a number of hospitals which are run by community or religious organisations. Traditionally, all hospitals in the Netherlands have offered the same range of specialist services, but under the new reformed healthcare system, the government is encouraging hospitals to specialise in particular areas of treatment. Although all hospitals offer the same high standards of care, the University hospitals, where medical research is conducted, often have the most up-to-date facilities and use the most advanced medical techniques.

When you first visit a hospital to see a specialist or to have treatment, you will be required to complete a questionnaire about your medical history and various lifestyle factors, and your personal details will be registered on the hospital's patient database. A hospital registration card (ponsplaatje) containing identification details will be issued to you and must be shown at reception each time you visit the hospital.

In some cases, if your condition is serious or requires urgent surgery, the specialist will recommend hospitalization or refer you straight to the emergency department. In other cases, however, you may have to wait some time, even months, for a hospital appointment for some types of surgery or other treatments.
Most hospital accommodation in the Netherlands is in shared rooms or wards of up to six patients, and may be mixed-gender. Often, beds are equipped with private televisions and phone lines, although you will be charged for the use of these. Patients are required to take their own nightwear, toiletries and other personal requirements for a residential stay in hospital.

There are children's wards in all hospitals and also a number of special children's hospitals, which provide more facilities to keep children entertained while in hospital or to help them keep up with school work during their stay. Some of the children's hospitals and children's wards have accommodation for parents to stay overnight with their children if required.

Visiting hours vary between hospitals, and are usually strictly enforced.

The Dutch have a very natural approach to childbirth; around 30% of babies are delivered at home, reportedly the highest percentage in the western world, and the use of pain relief during labour is extremely rare. This approach is based on the belief that pregnancy is not an illness and does not merit medical treatment unless complications arise. The high proportion of home births may also be related to the fact that medical insurance in the Netherlands does not cover the full cost of having a baby in hospital unless this is necessary for medical reasons.

In the Netherlands, midwifes (verloskundige) are the mostly commonly used primary carers for women throughout pregnancy, childbirth and the post-natal period. It is fairly uncommon for gynaecologists or GPs to provide this service, although this can be requested if the pregnant woman has strong preference for this type of care. GPs also look after women during pregnancy in some remote areas where no midwife is available. Midwifes are fully-trained medical professionals and usually work independently or in small teams. They are listed in the Yellow Pages or can be recommended by a GP or another personal contact.

Pregnant women should register within the first two months of their pregnancy with a midwife, who will at this stage provide a pregnancy confirmation note (zwangerschapsverklaring) which will be needed to determine eligibility for maternity leave and benefits. The midwife will also take full details of the medical history of the pregnant woman and her partner at the initial consultation, and will ask the woman whether her preference is for a home or hospital birth, although it is possible to change the delivery plans at any stage in the pregnancy.

After the initial consultation, the pregnant woman will visit the midwife for around twelve routine check-ups in total, from around the third month onwards, and increasing in frequency towards the end of the pregnancy. These will generally consist of consist of basic checks such blood pressure and the position and heartbeat of the foetus. Genetic screening and prenatal testing are not routinely conducted in the Netherlands, unless a woman is considered to be at particular risk of having a baby with a genetic disorder, which includes by definition all women aged over 36. Ultrasound (Echoscopie) is typically used to screen for foetal defects, along with various other medical tests. If an ultrasound examination is required, this will generally be carried out within a hospital as few midwife clinics have ultrasound machines.

There are a range of pre-natal classes for expectant mothers in the Netherlands, many of which are run by the Thuiszorg organization and delivered by qualified physiotherapists. Some of the classes are covered by medical insurance, although other private-run classes may have admission fees which are not reclaimable. The classes generally include exercises, breathing and relaxation techniques and advice and information about labour and delivery, while some offer more specialized techniques tailored to the needs of pregnant women, such as yoga. In some cases, partners are also able to attend or all of the sessions.

For a home birth, once labour has started, the midwife will come to the woman's home accompanied by a maternity assistant (kraamverzorgster) whose job it will be to assist the parents in looking after their new-born baby. If any complications arise during the labour or delivery, the woman will be transferred to hospital on an emergency basis. This is done routinely by many midwifes in the event, for example, of the baby being in a breech position. Under Dutch law, midwifes are not allowed to administer anaesthetics or pain-relief medication, so a transfer to hospital will also be required if pain relief becomes absolutely necessary. However, most women in the Netherlands deliver their babies without pain relief.

In most cases, hospital births take place on an outpatient basis, with women and their babies returning home within 24 hours, unless there are complications or a caesarean is needed, in which case an in-patient hospital stay of 5-7 days is typical. In the case of normal labours in hospital, it is typical practice for the mother and her partner to be left alone for quite lengthy periods until the actual delivery, with just occasional checks by the midwife or gynaecologist, but help and support is always available if needed. The midwife or doctor who delivers the baby is not always the same one who carried out pre-natal checks on the woman, as this will depend on who is on duty at the time of delivery.

If the new-born baby needs to stay in hospital for any reason, the mother is will normally be allowed to stay with them.

The birth of a baby has to be registered by law within three days, by someone that was present at the birth, usually the father. Registration must takes place at the gemeentehuis (town hall) in the town where the baby was born, not the town of the parents' residence, if this is different. If the parents of the baby are not married at the time of its birth, the father can legally recognize the child as his own at the time of registration or a later date, but the mother must also be present when this takes place, and this must take place in the family's town of residence.

There is an excellent aftercare programme (kraamzorg) in the Netherlands, in which insurance cover provides for a maternity assistant to visit the home of a new-born baby every day for up to a week after the delivery, whether or not it was a home-birth or hospital delivery, to help look after mother and baby, teach new parents how to look after their child, and even carry out light housekeeping duties, cooking or shopping for the family.

The midwife will usually visit two or three times during the week after the delivery to carry out medical checks on the mother and baby. On one of these visits she will carry out the heel-prick (hielprik) blood test on the baby, to check for the presence of various disorders. After six weeks of the birth, the midwife or gynaecologist will conduct a routine health check on the mother. Mothers are also encouraged to attend post-natal exercise classes, many of which are run by the Thuiszorg organisation, and which provide a good opportunity to meet other new mothers.

With the first 14 days after the baby's birth, the family will also be visited by a community nurse (wijkverpleegster) from the local Baby Clinic (Consultatiebureau), run in most areas by the Thuiszorg organisation, who will check on the baby and discuss any concerns that its parents may have. Following this initial check-up at home, regular visits to the Baby Clinic will be scheduled to check on the child's development, with 10 visits during its first year, and annual visits thereafter up to the age of four. The nurses at the baby clinic will check the height and weight of the child, conduct motor and cognitive development, speech, hearing and sight checks, and will carry out routine vaccinations. After children start school, they continue having regular health checks but these are carried out by the municipal health office (Gemeentelijke Gezondheidsdienst).

Useful contacts and links:

Ministry of Health, Welfare and Sport
PO Box 20350
2500 EJ The Hague
Tel: +31 (0)70 340 79 11
Fax: +31 (0)70 340 78 34
Website: www.minvws.nl/en/

Zorgverzekeraars Nederland
Postbus 520
3700 AM Zeist
Tel: 030 - 698 89 11
Fax: 030 - 698 83 33
E-mail: info@zn.nl
Website: www.zn.nl

www.actiz.nl/home/home.do

www.tandarts.nl/

www.kiesbeter.nl/algemeen/default.aspx

Under the Work and Care Act, there are a whole range of provisions in the Netherlands to protect the health and safety of pregnant women and to help ensure that families with children can enjoy a good work-life balance.

While pregnant, women have a wide range of workplace-related rights. For example, if applying for a job, they are not required to notify prospective employers of their pregnancy, and they cannot be turned down for a job because they are pregnant. Employees cannot be dismissed while pregnant or within three months of giving birth, and if they are employed on a contract which ends during this time, they are entitled to receive unemployment and sickness benefits. Employers must also take measures to ensure that the health and safety of their pregnant employees and their unborn babies are protected, for example by exempting them from potentially dangerous work and by providing the employee with time and a suitable place to rest during working hours. There is no obligation on the employee to work overtime or on night shifts, up until 6 months after the birth of their child. Breastfeeding mothers must also be provided with suitable facilities, and a time allowance of up to 1/4 of normal working, for feeding their baby in the workplace.

Pregnant women must notify their employer, or social security office if they are self-employed, of the date when they plan to commence their maternity leave, at least three weeks in advance, providing a zwangerschapsverklaring from their gynaecologist or midwife which confirms their due date. They are then eligible for 16 weeks maternity leave during which they receive a benefit equivalent to 100% of their normal earnings, which is paid from the General Unemployment Fund (Awf). Pregnancy leave (zwangerschapsverlof) must commence at least four weeks and up to six weeks before the expected date of delivery, and the remaining time can be taken as childbirth leave (bevallingsverlof) after the birth of the baby, with a full ten weeks paid leave allowed if the baby was born later than the expected delivery date.

Women who have to leave work earlier in their pregnancy for medical reasons are also entitled to 100% of normal earnings while not working, whilst women who are unable to return to work after the birth for pregnancy-related medical reasons, can receive 100% of their income for up to a year. Those who opt to take more than the statutory 16 weeks maternity leave must apply to their local social security office for Voluntary Sickness Benefits Insurance. Mothers are entitled under Dutch law to temporarily reduce their working hours by taking parental leave (ouderschapsverlof).

Fathers have a right to paid paternity leave to attend the birth of their child and for two days leave which can be taken at any time within the following four weeks. They are also allowed paid time off to register the birth of the baby. Both mothers and fathers who have worked for their current employer for at least a year are entitled to take a specified amount of non-paid parental leave (ouderschapsverlof) to care for each of their own children or adopted or foster children, within a six month period at any time during the first eight years of the child's life. The amount of leave that can be taken depends on the number of hours usually worked and the duration of employment, and can usually be taken as up to 50% of normal working hours until the leave allowance is used up. Employers must agree to a request for parental leave which is made at least two months in advance, but the specific arrangements and amount of weekly leave to be taken must be agreed between the employee and employer. Some employers pay up to 75% of normal income for parental leave, but this is discretionary. All employees are also entitled to up to 10 days leave (pro rata for part-time employees) to care for a sick child, parent or partner, and receive payment during this time of up to 70% of normal earnings.

Under the General Child Benefit Act (Algemene Kinderbijslagwet - AKW) a regular benefit is paid to the parents of all children (including adopted or foster children) aged below 18, as a contribution to the costs of raising them. The payments are made on a quarterly basis direct to a registered bank account, and are based on the age of the child and the number of children in the family. The 2007 rates are €186.91 for each child aged 0-5 and €226.97 for those aged 6 to 11, while specific rates apply to children of each individual age between 11 and 18, depending on the family size.

Although the Dutch government is encouraging the expansion of childcare facilities through incentive schemes and other policies, so that mothers can return to employment after childbirth, the provision is currently inadequate to meet demand and there are typically long waiting lists for most forms of day-care. Some childcare places are subsidized by municipalities, with parents paying an income-related contribution (ouderbijdrage), others are provided by or reserved by employers for the children of their staff, and joint-funded by the employer and employee. Some parents arrange for private childcare and cover the cost of this themselves, although payments may sometimes be set against tax.

Day-care is heavily regulated in the Netherlands, where municipalities are responsible for ensuring that all childcare meets minimum requirements regarding safety, cleanliness, insurance and numbers of babies or children allowed per carer.

There are a variety of forms of childcare (Kinderopvang) available, with the most popular being the 3,500 or so public day-care centres (Kinderdagverblijf) throughout the country, which offer places for babies and children between the ages of six weeks and four years. These usually open for a full day, five days a week, from around 8 a.m. to 6 p.m., with various arrangements possible in terms of the numbers of days or half days that children spend in the centre each week. They are heavily over-subscribed in terms of applicants, and waiting times of up to 18 months for a place are not uncommon. The charges to parents are dependent on family income, with families contributing a percentage of the cost of the subsidised care.

In addition to these public day-care centres, there are some private facilities in the main cities of the Netherlands which stay open round the clock, seven days a week and provide flexible child-care arrangements, but at significantly higher cost.

An alternative for young children not requiring full-time care is available in the form of pre-school groups (peuterspeelzalen), which are usually open in the mornings and provide a range of activities for 2-4 year olds, who usually attend once or twice a week. Typical costs for this type of facility range from €50 to €140 for two sessions per week.

Some day-care centres provide after-school and holiday care for older children, usually up to age 12. This is also provided by the Buitenschoolseopvang (BSO) and the Naschoolse opvang, with similar fees to those charged by the Kinderdagverblijf.

Childminders (gastouder or 'host parent') are also commonly used for daycare in the Netherlands. These typically look after up to 3 children, sometimes including their own. Usually the care is provided in the childminder's own house, but some provide care in the child's family home. It is advisable to use a childminder who is registered with the local Gastouderbureau, which regulates charging policies and childminder responsibilities. Typical charges are around €3 to €4 per hour. A variation on this is the Project arrangement, whereby a qualified nursery teacher looks after up to four children in a private home, usually for around €15 per hour.

Some parents choose to hire a person to live in and provide full-time care for their children. The options include a professional nanny, who has been specifically trained to look after children, or an au pair, typically a young girl from a different country, who wishes to gain experience of living in the Netherlands and is responsible for looking after the children as well as carrying out light housework. Both nannies and au pairs can be hired through specialist agencies, who will have checked their references and credentials. Au pairs usually receive accommodation and food free of charge, and are given pocket money, while nannies generally cost at least €1000 per month.

Useful contacts:

Stichting Kinderopvang Nederland (SKON)
Hoofdkantoor
Postbus 1246
3600 BE Maarssen
Tel: (0346) 55 95 00
Fax: (0346) 55 95 01
Email: info@skon.nl

Bezoekadres:
Energieweg 1
3542 DZ Utrecht
Website: www.skon.nl/

Ministerie van Sociale Zaken en Werkgelegenheid
Postbus 90801
2509 LV Den Haag
Tel: 070-333 4444
Fax: 070 - 333 4033
Website: www.home.szw.nl

Sociale Verzekeringsbank
Postbus 1100, 1180 BH Amstelveen
Tel: 020 656 5656
Fax: 020 656 5000
Website: www.svb.nl

Other useful links:

www.kinderopvang.pagina.nl
www.kinderopvang.net