The Netherlands has an extensive social security system, which is seen as one of the proudest achievements of Dutch society. In recent years, major reforms of this system have placed tighter controls on the way its laws and programmes work in practice. Other recent measures have been designed to tackle long-term sickness and create employment.
Each citizen of the Netherlands should be able to play an equal part in society. Some people need help in doing so: the elderly, young people, ethnic minorities and addicts, for example. Welfare policy is designed to give them that help. This is mainly the responsibility of local authorities, who have begun to focus on neighbourhood problems. They try to help neighbourhoods become vibrant communities where everybody feels at home.
Society is changing - which in turn requires changes to welfare policy. For instance, the Netherlands has an ageing population, 28% of whom will be 55 or older less than ten years from now. Almost half of those now aged 55 to 65 have already stopped working. So for social and economic reasons, the government is trying to reduce this figure and give older people more opportunities to work. The government is also tackling youth unemployment by funding job creation and on-the-job training. And there are many other examples of current welfare policy. By encouraging municipalities to provide more childcare, the Netherlands has moved closer to the standard of other West European countries. The government gives support to parents if they have problems raising their children or if their children risk falling behind in their development. It helps the long-term unemployed tackle problems ranging from debt to psychological problems. And under the new Equal Treatment Act, it will soon be doing even more to help the disabled overcome discrimination and integrate into mainstream society.
Ethnic minorities account for 9.4% of the population. This group includes people from the Netherlands Antilles and Aruba (both parts of the Kingdom of the Netherlands), Suriname, Turkey and Morocco, and many others who have come to the Netherlands as either migrant workers or asylum seekers. Between 1971 and 1997, the number of people belonging to ethnic minorities grew from 200,000 to 1.5 million. Integration does not come easy. Turks and Moroccans, for instance, are five times more likely to be unemployed than ethnic Dutch people. The government is trying to improve their position with extra training and extra incentives for companies to employ them. In 1998, it set up the Taskforce on Minorities and the Labour Market for senior businesspeople, trade unionists and policymakers. New immigrants now have to attend courses in Dutch language and society. They can also receive help finding jobs.
There are two types of social insurance: national insurance and employee insurance. The first are social insurance schemes which cover all residents of the Netherlands, as well as foreign residents who work and pay taxes in the Netherlands, who - if they wish - may continue with voluntary cover after they leave the country. Dutch national insurance legislation is implemented by the Social Insurance Bank, which manages the insurance funds and is regulated by the Ministry of Social Affairs. The General Old Age Pension Act (AOW) entitles Dutch residents to an old-age pension from the age of 65. A full old-age pension is built up over 50 years, from the age of 15 to 65. For each uninsured year, it is reduced by 2%. Four-fifths of those entitled to an old-age pension also have some other form of pension. The Surviving Dependants Act (ANW) provides benefit for those who have lost a spouse, partner, or one or both parents. The surviving dependant must have been born before 1 January 1950, be classified as at least 45% unfit for work, or have at least one unmarried child younger than 18. The amount of benefit depends on income. The General Child Benefit Act (AKW) helps parents or guardians pay the costs of raising children up to the age of 18 and the Exceptional Medical Expenses Act (AWBZ) provides cover against serious medical risks not covered by public or private health insurance funds.
All employees must be insured under the Sickness Benefit Act (ZW), the Unemployment Insurance Act (WW), the Health Insurance Act (ZFW) and the Invalidity Insurance Act (WAO).
This scheme insures employees who are partly or entirely unable to work for medical reasons. Since 1 March 1996, employers have had to pay their employees sick pay equal to 70% of their wage in the first year of sickness, more if laid down in their collective agreement, and at least as much as the minimum wage for which the employee would normally be eligible. The employee himself may have to bear the cost of the first two days of sickness, but if so, it must be stipulated in his contract, the employer's regulations, or their collective agreement. In many cases, employees are entitled to 100% of their wage in the first year of sickness. They may also be entitled to sick pay if they donate an organ or become sick during pregnancy or childbirth. Employees on maternity leave are entitled to at least 16 weeksí sick pay equal to 100% of their wage, beginning four to six weeks before the due date. Employers are only required to pay sick pay to employees with a permanent contract. Those who are not entitled to sick pay are, however, often eligible for sickness benefit. This includes temporary employees and those who lose their job during the first year of sickness. The scheme also acts as a safety net for those with work but no formal contract, such as homeworkers and trainees.
The Unemployment Insurance Act insures employees younger than 65 against the financial consequences of unemployment. A person is eligible for unemployment benefit for six months, as long as he or she has been employed for at least 26 of the 39 weeks immediately preceding the loss of his or her job. The amount of benefit is at least 70% of the minimum wage, but may depend on previous earnings. To be eligible for earnings-related unemployment benefit, a person must have been employed for at least 52 weeks in at least four of the five calendar years immediately preceding the year in which he or she loses his or her job. Those eligible receive earnings-related benefit from six months to five years, depending on how many years they worked. Those who are still unemployed once their earnings-related benefit comes to an end are eligible for unemployment benefit equal to 70% of the minimum wage for another two years. If a person aged 57 or older loses his job, he will be eligible for this benefit until his 65th birthday.
The Health Insurance Act (ZWF) covers the costs of medical and paramedical treatment, hospitalisation and some dental treatment. The scheme is implemented by several public health insurance funds. It also covers the costs of medical appliances, medicines, dressings and rehabilitation. It offers health insurance to most welfare benefit claimants and employees whose annual wage is below a certain amount.
The Invalidity Insurance Act (WAO) aims to help sick or disabled people find work as quickly as possible and insures employees younger than 65 against loss of earnings as a result of long-term incapacity for work. The legislation was amended with effect from 1 January 1998. A person is eligible for invalidity benefit if he has been classified as at least 15% incapacitated for acceptable work after a waiting period of 52 weeks. This period is the maximum for which a person is entitled to receive sick pay from his employer. Invalidity benefit is paid for five years. If a person wishes to continue receiving it, he must re-apply at least three months before the five years are up. The amount of invalidity benefit depends on the claimant's degree of incapacity for work, age and earnings. There are seven categories of invalidity, varying from 15% to more than 80%. A benefit percentage is linked to each category, varying from 14% to 70%. Invalidity benefit also comes in two stages: loss-of-earnings benefit for a maximum of six years and afterwards follow-up benefit. Since 1 January 1998, the Invalidity Insurance Act has also applied to civil servants. In that same period, the government has introduced compulsory invalidity insurance schemes for the self-employed and young disabled people: the Invalidity Insurance (Self-employed Persons) Act (WAZ) and the Invalidity Insurance (Young Disabled Persons) Act (WAJONG). The Invalidity Insurance (Self-employed Persons) Act covers people such as freelance workers, clergy, managing directors who are also major shareholders in their companies and spouses or partners who also work in a family business. The amount of invalidity benefit depends on the claimant's degree of incapacity for work and his or her income in the previous year. But since the earnings of the self-employed often vary widely from year to year, claimants may, if they wish, claim loss of earnings equal to the average annual amount earned over five years. The self-employed are required to take out WAZ cover. The amount of benefit is equal to at most 70% of the minimum wage. Women with WAZ cover are entitled to 16 weeks of maternity benefit, up to the minimum wage level. The Invalidity Insurance (Young Disabled Persons) Act provides minimum benefit to young disabled people; that is, those who are incapacitated for work on their 17th birthday or become incapacitated after that date and studied for at least six months in the previous year.
Other legislation provides supplementary benefits to families with incomes below a certain minimum. Most of this legislation is implemented by local authorities. Its centrepiece is the Social Assistance Act (ABW). People with too little income to provide for themselves are eligible for social assistance. If they have some other income, such as a maintenance allowance from an ex-spouse, their benefit will be reduced accordingly. Under the Services for the Disabled Act (WVG) local authorities provide transport, wheelchairs and housing services (such as alterations) for the elderly and disabled. It is intended to help them stay independent as long as possible.
Recent legislation makes it easier for disabled people and the long-term unemployed to get back into work. The Disability (Reintegration) Act encourages companies to employ disabled people by covering them against the financial risks and paying the cost of adapting the workplace. It also offers additional job opportunities for the disabled. TThe Jobseekers Employment Act (WIW) helps the long-term unemployed (with or without a disability), benefit claimants and unemployed people under the age of 23 get back into work faster. The WIW also funds work placements and training to improve job opportunities for the unemployed and it provides single parents with childcare and out-of-school care for children younger than 12.
The Dutch economy is doing well and the healthcare system reflects that. The government is increasing funding for health care and everyone is covered by health insurance. Still, developments in society and medicine make it necessary to adapt. Sometimes, people have to wait too long for the care they need. Life expectancy in the Netherlands is 74.6 years (men) and 80.3 years (women) but varies with socioeconomic status. Experts and policymakers are studying ways of helping disadvantaged people.
One important government objective is to prevent health problems and disease, or detect them at an early stage. Prevention measures, like vaccination programmes for the under-4s aim to increase healthy life expectancy, prevent early death and improve the lives of the sick and disabled. General practitioners have the largest role in prevention. Fighting infectious diseases is the job of local authorities, as part of their responsibility for protecting the public and for local public health care. Measures to safeguard food and consumer products follow EU directives, and the Health Protection, Commodities and Veterinary Health Inspectorate monitors compliance with them. Screening that incurs risks for the participants may not be carried out in the Netherlands without a license. Central government conducts nationwide screening programmes for breast and cervical cancer. Prevention includes measures to combat threats to health. Lifestyle, in particular, has a major influence on health. Various public and private organisations educate the public about exercise, smoking, alcohol consumption, safe sex and relaxation. Central government supports these campaigns and takes measures to discourage habits that threaten health. It also tackles health issues like pollution, road safety and working conditions.
Aside from preventive programmes and the promotion of good health, care is also crucial to public health. In the Netherlands care is provided by a large range of organisations and professionals who pursue their own policies within parameters established by central government. Quality and accessibility are the key concerns. Quality is regulated in several pieces of legislation governing professionals, care institutions, the relationship between care provider and patient and the forced hospitalisation of patients unable to give informed consent. Legislation giving patients and clients a say also contributes to the quality of care. Professional care providers are responsible for setting up and monitoring their own quality systems. The Health Care Inspectorate supervises this process.
Accessibility is not only about ensuring the proper geographical spread of care, but also about financial accessibility. Essential care must be affordable for everyone. Several statutory schemes exist to safeguard this. People with incomes below a certain level are compulsorily insured with public health insurance funds. Everyone else is required to take out private insurance. Some companies have collective insurance schemes with private insurers. For long-term care and nursing, the Netherlands has a compulsory insurance scheme to which everyone makes an income-linked contribution. Forty-five per cent of all expenditure on care goes to long-term care. There are various sorts of insurance covering hospital care, GP consultations and paramedical care, which together account for 52% of all expenditure on care.
The Dutch care sector spent about EUR 37.3 billion in 2000, and the budget has grown sharply in recent years. Part of this growth is necessary to finance the care needed by a growing, ageing population. And the costs of care are rising as a result of rapid advances in medical science. On top of this, patients have become wealthier and more assertive and demand higher standards of care. The government is trying to cut unnecessarily long waiting lists and to reduce the workload of care providers. In 1998, for the first time, the government and national organisations of care providers, patients and insurers got together at an early stage to make long-term agreements about how the extra money should be spent. The organisations representing care for the elderly, care for the disabled, curative somatic care and mental health care met to consider the choices that must be made, and undertook to respect the agreements. For its part, the government undertook to make an extra budget allocation for several years. This new administrative approach has the advantage of being comprehensive. Furthermore, it is based on patient demand instead of institutional supply, and provides financial security for a number of years. This frees up time and space that can be used for innovations in care provision.
In recent years the trend has been to allow people requiring long-term care to continue to live independently as long as possible, rather than placing them in institutions. Care is tailored to individual needs and often delivered in the home. Having a job or another regular activity is often essential for people to feel they are part of society. Care providers therefore try to offer this to their clients as much as possible, either using their own resources or by collaborating with the employment service, welfare agencies or industry. The government encourages this approach. For instance, all local authorities now have ìindication agenciesî which assess each applicantís personal situation and reach an independent and objective verdict on the care that is required. This care is then supplied in kind by the insurers. People who wish to retain financial control over their own lives can apply for a personal budget, a sum of money which they are free to spend on a care provider or care institution of their choice. At present the funding for personal budgets is limited, but this innovation has led to greater flexibility and a more demand-driven approach among established institutions.
General practitioners act as ìgatekeepersî to curative somatic care. People with health problems generally turn to their GP first. Only if the GP is unable to arrive at a diagnosis, or is unable or unwilling to provide the necessary treatment, will he or she refer the patient to a specialist or paramedic. Plans exist to give GPs a similar ìgatekeeperísî role within mental health care. But GPs have many other tasks and responsibilities: coordinating the treatment of patients who are seeing one or more specialists; delivering preventive programmes; and prescribing medicines. To achieve all this, they have to collaborate with other care providers and institutions. For GPs with solo practices - now roughly half of all practices - achieving all these aims is well-nigh impossible. The policy pursued by government and by the national organisation representing general practitioners is therefore geared towards making local and regional groups of GPs responsible for cooperation. Change is also in the air in hospitals, which vary in capacity from about 300 to more than 1,000 beds. The number of beds and the duration of the average stay have both been cut drastically, allowing an increase in one-day admissions and outpatient treatment. New medical technology, the scope afforded by computer technology and organisational change now make it possible to provide more forms of hospital care at home. Some hospitals have outpatient clinics in smaller towns, so that patients do not always have to go to the main hospital in the area. Another trend is for hospitals and specialists to cater for the needs of relatively large groups of patients, for instance in outpatient clinics where women tested for breast cancer receive the results within 24 hours.
The government is pursuing a policy of cost control in order to keep medicines affordable in the face of annual price rises of 10% or more. This rapid rise in prices is jeopardising efforts to tackle other health care problems, such as waiting lists. In principle, patients can pick up prescribed medication from the pharmacist without having to pay. But the government has set limits on the remuneration available for certain groups of medicines for which equally effective alternatives are available. If the price of a particular medicine is above the limit, patients have to pay the extra themselves. The health minister decides which new medicines are to be covered by insurance and therefore eligible for reimbursement. The Medicines Act allows the government to set maximum prices, taking prices in neighbouring countries as a guideline. The government, GPs and pharmacists are joining forces to encourage doctors to prescribe carefully and economically. Electronic prescriptions should also improve efficiency.
The main goal of drugs policy is to prevent drug use and to limit the risks associated with drug use. The health, justice and interior ministries share responsibility for this policy. Different kinds of drugs pose different health risks. Dutch law distinguishes between hard drugs (e.g., heroin, cocaine and synthetic drugs) and soft drugs (hashish and marijuana). The war on international drug trafficking, through criminal investigation and prosecution, has the highest priority. Taking action against possession of small quantities of soft drugs for personal use has a lower priority. On these grounds, the ìcoffee shopsî that sell small amounts of hashish and marijuana (up to 5 grammes per person) are ìtoleratedî. That is to say, persons selling soft drugs are not prosecuted under criminal law, even though it constitutes an offence. This approach has been adopted to prevent users of soft drugs coming into contact with hard drugs. Coffee shops must obey strict rules. They are strictly monitored and face closure if they violate these rules. Between 25,000 and 29,000 people are addicted to hard drugs in the Netherlands (National Drugs Monitor Annual Report 2000). That figure is lower than in most other Western countries. Methadone supply programmes help addicts kick the habit and improve their health and lifestyle. Thanks to needle exchange programmes, the percentage of HIV patients who are intravenous drug users is relatively low in the Netherlands: 10.5%. The number of drug-related deaths in the Netherlands is relatively low (76 in 2000) compared to alcohol- and smoking-related deaths (3,500 and 24,000 respectively), as emerged from the Policy Document on Alcohol and the National Drugs Monitor Annual Report 2000. Some new developments give cause for major concern, however: the rise of new synthetic drugs, for instance. Firm action is being taken under criminal law to counter the production and use of these hard drugs. At the same time, new strategies for education and prevention are being developed. The Netherlands plays a leading role in research and on the basis of the findings, it is adapting its policy to reflect new developments. The cooperation among criminal justice authorities, care agencies and international bodies is excellent. The factors that make the Netherlands such an ideal place for legal trade unfortunately also attract trade in illicit products. The Port of Rotterdam is the biggest container port in the world, and it is impossible to thoroughly check every incoming consignment. Nevertheless, more drugs are being seized than ever before.