the Netherlands

The Netherlands is one of the most densely populated countries in Western Europe with about 16.5 million. It is part of the Kingdom of the Netherlands which consists of The Netherlands, Aruba and the Netherlands Antilles. The Randstad, is the 6th largest metropolitan in the world holding 40 % of the total population. It consists of the four largest-cities Amsterdam, The Hague, Rotterdam and Utrecht together with their surrounding areas. However, the largest city is Amsterdam (1 million inhabitants) and the second largest is Rotterdam (about 600,000 inhabitants).

The total amount of physicians is about 51,000 (2003). This number is rather high, in comparison with other countries with the equivalent amount of inhabitants. The Netherlands has in average 5 GP´s per 10,000 inhabitants or about 8,500 GPs (2005 ) in total.

A general introduction to the health care system

The hospitals in The Netherlands have a vast majority (more than 90%) of privately owned organisations, which are mainly non-profit organisation. The government has strict control over the amount of hospitals built and on the size of the hospitals. The local governments are responsible for the organisation and distributing the health care budget.

The payment of health care is divided between three different fractions: taxes, co-payment (statutory insurance, private insurance, voluntary insurance supplements) and out-of-the pocket payments. In comparison to other countries, like the Nordic countries, the tax funding of public health in The Netherlands consist of a relatively small part of the payment of health care. The taxes paid for health care goes mainly to the funding of research of health .

In the Netherlands the primary care consists of GP practices which have certain patient-lists from the local area. The GP practices do all primary care and most referrals to hospital care go through these municipal practices. The local GP is also called the family physician due to the close patient-GP relationship created by this system. This, in addition, results in a relatively low referral rate to secondary care .

The health insurance policy

In 2006 a reform was introduced within the health insurance market with the aim to create competition between the insurance companies. From having an insurance policy which included a base insurance and a “top” insurance strategy, it now was transformed to a more competitive policy. As a result of this, health insurers have adapted their offered services to the needs of their users. Although they still are obliged to offer a standard insurance package, they are free to add supplements to the package to create their own competitive edges. Some critics argue, that although this new policy has created an increased freedom of choice with more offered services, it has also created an even larger gap between the low-income households to the rest. The reason is that half of the insurance expenditure is income-based and the other half is now based on the nominal premiums offered from each individual insurance company. The price of the later has substantially increased since the implementation of this new policy. The result of this change has been that the prices of health care insurance have risen with more than the double between 2005-2006

The role of the pharmacists

The distribution of pharmaceutical products is divided between local pharmacies and drugstore which sells OTC-products. Both the prescriptive pharmaceuticals and OTC-products are allowed to be sold at the pharmacies only after improvements by the Dutch government.

Due to the so called Pharmacist Act, a pharmacist is allowed to be the owner of multiple pharmacies. The result has been an increase in the number of pharmacies and a decrease in the number of staff/pharmacy.

For the pharmacists the advisory role has become more important during recent years - both for the patients and the local GP practices and the vast majority of all patients and GP´s are loyal to a specific pharmacy.

Future challenges and developments within the health care

One of the main concerns affecting the Dutch health care in a negative way is the increased size of the population above 65. The need for an increased amount of elderly care might therefore lead to problems in resources.

Another challenge facing the Dutch health care system is to solve the problem of the increased socio-economical gap of different minority groups . Some might argue, that the gap might increase even more as the need for private insurance supplements increases.

The increase waiting-list for inpatient care has long been a problem for the Dutch health care system and actions have been taken to decrease this problem. Some of the actions included more control over statistical figures, distribution of extra resource incentive based on performance of the health care services offered and educational campaigns. There have been some positive results with this implementation, where the amount of patients on the waiting-lists has decreased with about 30% between years 2000-2004

Belgium

Belgium has a total population of about 10.5 million inhabitants, which are divided between the French-speaking region Wallonia in the South and the Dutch-speaking region Flanders in the north. Greater-Brussels, is the capital of Belgium and has 1.7 million inhabitants. This makes the capital the largest city in Belgium. The second largest city is Greater-Antwerp with a total of about 950,000 inhabitants.

The country has a total of about 46,500 (2003) physicians from where 21,000 (2006) are GP´s.

A general introduction to the health care system

The health care in Belgium has a totally privatised system, with a vast majority of the hospitals owned by non-profit organisation. Decisions on the organisational structure and planning for the individual health care providers are the owners’ responsibilities, whilst the Belgian government does the budgetary and legislative control.

Most of the physicians in Belgium have their own practices or working in a team of physicians. To become a legal physician you must become member of the so-called “Order of the Physicians”. This is an independent body, which has a monitoring function with the aim to decrease unethical practices.

Unlike The Netherlands, there exist no referral rules between general practitioners and specialist or referral between hospitals. Instead all patients are free to contact specialist directly . The role of the general practitioner is therefore rather different from many other European countries, with focus on visiting patients at home. Although this has proven to be effective, actions are taken to follow the same policy as you see in The Netherlands.

The health insurance policy

The statutory health insurance is the main financing body of employed and self-employed people and is income-based and covers the most important areas of health service. The private insurance companies have therefore, in comparison to other countries, not yet established a significant role. But due to a present reformation of the volume of services offered by the statutory insurance, the market share of the private insurance companies might increase .

The role of the pharmacies

It is most common for Belgian Pharmacies to be privately owned. The market is relatively free for pharmacies, two examples of this are that a pharmacist is allowed to own multiple pharmacies or have a joint venture with another pharmacy. However, the government have set up rules so that the there is an even geographical distribution among all citizens.

The role of the pharmacists in Belgium is quite different from the rest of Europe. For example, prescribed products are not only distributed from the pharmacies. Instead many physicians have the authority to sell prescribe medicines directly to their patients.

Future challenges and developments within the health care

Belgium has the highest percentage of elderly in proportion to the rest of the Western Europe. In addition, the younger population is decreasing every year. Thus, a transition towards an increasing need for health care for elderly patients and a decrease of need for care for a younger population might create a gap within the health care system.

The pharmaceutical expenditure has increased during the last years and is expected to have a negative effect mainly on the elderly in the future.

Despite the challenges that Belgium is facing in the future, it also has positive trends. One such trend is the very short waiting lists. Unlike many other European countries, patients can get help almost immediately and with uniquely high quality. Some argue that the health care system is much more efficient then other countries due to the “non-referral policy”.

Luxembourg

Although both Belgium and the Netherlands are seen as very small countries, Luxembourg is even smaller with an area of approximately 2,500 square meters. The country is about ten times smaller in comparison to both The Netherlands and Belgium. The figures of the total amount of inhabitants show the effect on this, with a total population of only about 480,000 inhabitants (2007).

The largest city in Luxembourg is the capital Luxembourg City, with a total population of about 75,000 inhabitants. In the metropolitan around the capital (which includes the cities: Sandweiler, Strassen, Hesperange and Walferdange), there are in total about 100,000 inhabitants.

Due to its low total population, there is a significance difference in the amount of physicians in comparison with the other two countries. Luxembourg has a total of 1,700 physicians from where 1,300 are GP´s .

A general introduction to the health care system

All hospitals in Luxembourg are built up by self-employed physicians and therefore with no interference of governmental rules. The owners of the acute-care hospitals are divided between non-profit organisation and local authorities.

The health care system in Luxembourg is unlike most of the other European countries rather centralised . The budgetary decisions for each individual hospital have to be made in dialogue with the Union of Sickness Funds, which is responsible for the distribution of the statutory insurances

Similar as with the primary care in Belgium, patients are free to go directly to a specialist instead of first to the general practitioner.

The public care offers much prevention – and screening tests for patients. Some examples are test to uncover HIV/AIDS, fertility diseases, cancer and diabetes. Vaccination is also offered free of charge.

As with many other countries, Luxembourg follows the trend of a non-active lifestyle, which can in time lead to illnesses. The public care in Luxembourg has therefore set up many actions to promote a healthier lifestyle. Some examples of actions are to increase the awareness of the importance of physical activities and healthy eating habits, as well as non-smoking campaigns.

The health insurance policy

The health insurance consists of the statutory and voluntary insurance. For the former, the profession is the deciding factor on which insurance to have and all prescribed medicines are to a vast majority reimbursed by the state .

The voluntary health insurance is divided between three different bodies: Mutual Aid Society, Caisse Médico-Chirurgicale Mutualiste (“Mutual Medico-Surgical Fund”) and the German health insurance fund. But due to the wide coverage of the statutory insurance, many people only have that insurance.

The role of the pharmacies

All pharmaceutical products in Luxembourg are imported from neighbouring countries and have to be approved by the Ministry of Health before entering the market.

The local pharmacies are the main distribution channel of these pharmaceuticals. To get hold of the prescribed products patients must pay the retail price and later on get it reimbursed by the statutory insurance. However, in some cases the drugs are directly given at hospital visits and the reimbursement is in that case the hospitals responsibility.

The government controls the amount of pharmacies in the country and the amount is determined by supply and demand. Thus, there are seldom situations where you see a substantial increase or decrease of pharmacies.

Future developments within the health care

With the “Health for All” – act that was created in the beginning of the 1990s, the authorities aimed to increase the overall health in the country. Some of the goals included a reduction of the amount of deaths due to cancer and cardiovascular diseases and increasing the knowledge of diabetes.

Many people in Luxembourg are seeking care from the neighbouring countries and are therefore putting pressure on the statutory insurance system to reimburse their costs also for medical bills from abroad. The problem with, what many argue to be an out-of-date system where a patient first must pay for the hospital visit and after that send the bill to the statutory insurance for reimbursement, is that it does not work effectively. Thus in the future, there might be some actions for improving this reimbursement system .

Another prediction concerns the amount of physicians in Luxembourg, which already have doubled in 20 years. To be a physician in Luxembourg is a very appealing due to specific economical advantages that you get. The amount of physicians is therefore expected to continue to increase. Although the health care in Luxembourg already is of high quality , you might argue that the increased competition among physicians might increase the quality of care even more.