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Chapter 8 | The impact of the crisis on the health system and health in the Netherlands
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for curative care and some mental health care (up to one year for ambulatory
and institutional mental health care). The role of the government has changed
from directly steering the system to safeguarding the proper functioning of the
health care markets.
2.1 Pressure prior to the crisis
Health care is one of the largest sectors in the Netherlands, as measured by the
size of its budget (29% of the total government budget in 2013) and by the
number of employees (about 1.4 million people worked in or contributed to
the health care sector in 2013) (Statistics Netherlands, 2013a).
The need to contain growing health care expenditure was already recognized as
far back as the oil crisis in the 1970s. Expenditure started to grow in the early
2000s (it grew from €46.9 billion in 2000 to €70.7 billion in 2006, an increase
of over 50%) (Statistics Netherlands, 2013a) and made the need to contain
costs even more pressing. Therefore, it is not a coincidence that one of the goals
of the 2006 reform was to reduce the total cost of primary and specialized care.
Regulated market competition in the three health care markets was introduced
and health insurers were given a more central role in contracting with health
care providers and purchasing care for their clients. It was hoped that the
competition would lead to an increase in the quality of care and a decrease in
prices. Hard budgets were replaced by payment mechanisms linking payments
with performance mechanisms, and complex systems to define and register
performance and reimbursement were introduced.
Health care expenditure continued to increase after 2006, reaching
€79.8 billion in 2008 (Statistics Netherlands, 2013b) or 10.2% of GDP
(OECD, 2013). Between 2004 and 2008, the growth rate of expenditure
increased from 3.5 to 6.8% per year. According to the estimations by the
National Institute for Public Health and the Environment (Rijksinstituut
voor de Volksgezondheid en Milieuhygiëne), half of the health expenditure
growth between 1999 and 2010 could be attributed to growth in the volume
of care (number of treatments) and in the number of treatment options,
driven by technological advances. In comparison, price increases accounted
for 35% of growth and population ageing for “only” 15%. Treatment
of mental health disorders, which includes care for people with a mental
disability or dementia, accounted for the largest share in the growth of health
expenditure, followed by treatment of diseases of the locomotor system and
connective tissue. In 2007, mental health disorders accounted for the highest
share of health expenditure (20% of total health care expenditure), followed
by cardiovascular care (9%) (Slobbe et al., 2011).