Demande directe (CEACR) - adoptée 2012, publiée 102ème session CIT (2013)

Convention (n° 130) concernant les soins médicaux et les indemnités de maladie, 1969 - Pays-Bas (Ratification: 2006)

With reference to its previous comments, the Committee notes the information and replies provided by the Government’s report for the period ending 30 June 2011, as well as the observations on the report communicated by the Netherlands Trade Union Confederation (FNV) in September 2011.

Part II (Medical care) of the Convention. Domiciliary visiting. Please indicate under which provisions of the Health Insurance Act care given by the general practitioners includes domiciliary visiting, as stipulated in Article 13(a) of the Convention.

Dental care for adults. The report states that dental care for insured persons aged 22 and over is limited to specialized surgical dentistry (oral surgery), the associated X-rays and dentures. People with an exceptional dental disorder, physical/mental disability or special dental problems resulting from medical treatment are entitled to complete dental care (subject to special conditions). The FNV points out that, as described, dental care is limited to oral surgery involving the jaw bone and performed by hospital-based oral surgeons and does not include essential dental care usually provided by dentists, such as preventive advise, check ups, fillings, root canal treatment, extractions, dental supplies, etc. These benefits are not covered by the Health Insurance Act, which, in the opinion of the FNV, is a violation of Article 13(e) of the Convention. The Committee points out that dental care mentioned in Article 13(e) forms part of medical care defined in Articles 8 and 9 as care of a curative and preventive nature afforded with a view to maintaining, restoring or improving the health of the person protected. This definition is obviously much larger than oral surgery covered by the Health Insurance Act and would normally include the dental treatments mentioned by the FNV. The Committee also points out that Article 13(e) covers “dental care, as prescribed”, which means as determined by or in virtue of national legislation (see Article 1(b)). In order to ascertain that the understanding of dental care in the Netherlands conforms to Articles 8 and 9 of the Convention, the Committee asks the Government to specify how the term “dental care” is defined in the national health care legislation and what medical acts and operations are included in the dental care for young persons covered by the Health Insurance Act.

Effectiveness of medical care. The Government stated in its report on the Convention that the care system in the Netherlands has been organized in a way that will reduce direct government involvement. This is achieved through the “functional description” of care covered by the insurance package. The Government lays down legal requirements only for the content and extent of coverage and the medical indications that trigger coverage. It is the responsibility of the care provider to decide who provides the care and where. According to the Government, the choice for having private insurance that assigns greater responsibilities to insurers who are allowed to make a profit makes it inappropriate for the Government to supervise the effectiveness of the way health insurance is operated. Therefore, the Government continues, the main objective in overseeing lawful performance of the health insurance is for the Government to ascertain whether the care insurer is fulfilling its obligation to provide insured persons with the services they are entitled to under the Health Insurance Act. The Committee points out that such limited supervision of the quality and effectiveness of the medical care provided by private insurers seeking to make a profit, and therefore interested in reducing the volume and cost of care, may pose a threat to fulfilling the obligation imposed on the Government by Article 9 of the Convention to ensure that the medical care conforms to the highest practicable standard with a view to maintaining, restoring or improving the health of the person protected. The Committee therefore asks the Government to explain whether the Health Care Inspectorate (IGZ), which is entrusted with overseeing the quality of public health, or any other public body has established a system of indicators measuring effectiveness of medical care and monitoring the health status of the population.

Participative management of the health insurance scheme. The Committee notes that in the Netherlands the administration of health insurance is not entrusted to an institution regulated by the public authorities, but is entirely in the hands of private insurance companies, which run it for profit. For such schemes Article 31 of the Convention requires the national legislation to prescribe conditions for the participation of the representatives of the persons protected in the management of the scheme. To promote its management on a tripartite basis, the legislation may also provide for the participation of representatives of employers and of the public authorities. Article 30(2) also requires the Government to accept general responsibility for the proper administration of the health insurance institutions and providers of medical services. In its report the Government states that the basic principle of health insurance in the Netherlands is that insured persons must be able to exert influence on the policy of the company that insures them. A care insurer’s articles of association must ensure that insured persons possess a reasonable degree of influence over the company’s policy. The Committee wishes to point out in this respect that reliance on the private care insurer’s articles of association is not sufficient to give effect to these provisions of the Convention, which require the right of the persons protected to be able to influence the company’s policy through participation of their representatives in the company’s management to be established in national law. Moreover, the Government carries the general responsibility for ensuring that the national health insurance scheme is managed in a democratic and transparent manner, with the proper participation of the trade unions and other organizations representing the persons protected together with the professional associations representing care providers and the medical profession. The Committee therefore asks the Government to supply full information on the application of Article 31 of the Convention in the Dutch health insurance scheme.

[The Government is asked to reply in detail to the present comments in 2013.]