There is a big difference between the trust internationals have in Dutch healthcare compared to the trust that Dutch people have in their own health care, research has shown. 39 percent of internationals do not trust that the doctor knows best here. In addition, that lack of confidence has a negative impact on the choice of whether or not to settle here permanently for 37 percent. One fifth of this group even says they are actively looking for another place to settle with (one of) the motive(s) being Dutch healthcare.
Robert Hazenberg, co-founder of SGE International: “A painful development when we look at how much money is invested by companies and universities to get those people here in the first place. You don't want them to go away because of something like this. Why do they not yet have that trust in our doctors? And how can we ensure that it changes?"
Image of Dutch healthcare
A paracetamol helps fight anything and everything, whatever you visit the doctor for. This is often mentioned when you ask about associations with Dutch healthcare. Master’s student Embedded Systems from Romania, Silviu Stanimir: "I once called the doctor about a problem and the answer was: "How much paracetamol did you take?" .... "Okay, try a double dose." That was not what I was hoping for to solve the problem.”
Internationals want more attention, more checks and easier access to healthcare. Velichka Georgieva, sports instructor at the Student Sports Centre: “I have never managed to make an appointment here quickly. Sometimes I cycle to the practice and negotiate there to get a consult, as if I am doing business."
Different cultures experience ‘being ill’, differently. Where Dutch people wait a while and only then go to a doctor, many other cultures are used to intervening faster with medication because the flu, for example, is seen as more serious. Not necessarily physically, but due to its consequences for work or education, for example. This results in friction with our reluctance with regard to checks, medication and preventive testing.
The Brazilian Bárbara Dias felt that too: “My mother died of breast cancer and shortly after I moved here, I got a very sharp pain in my breast. My father freaked out and asked the doctor for a check-up. The doctor spoke as if my father was totally unreasonable. And I assure you, he wasn't. He just asked for a check-up, never raised his voice. He stood by my mother's side during her treatment, so he knows the symptoms very well. And the doctor was so dismissive. I thought that was very rude.”
Stanimir also agrees that the expectations of internationals are higher in terms of checks: “The first time I went to the doctor here was for a strained muscle around my abs. It was very painful, like the pain of a knife, and I realized that I had to have it checked. First you start googling, which makes it worse and makes you go crazy. The consult consisted of the doctor touching and pushing my skin a little. I expected a more thorough examination. There was no check in the form of a scan or a blood test or something similar. Then I decided that from then on, I would go to the doctor in Romania. There I know how everything works and where I have to go. I speak the language there and it is cheaper as well. Sometimes I just book a trip home with two purposes: vacation and a health check.”
The so-called ‘Worried Well’
Doctor Anneke Dalinghaus: “We have a democratic system here: every patient gets the same amount of time. Sensible and economical. Expats who come here are often young and highly educated. They are, in general, in good health, but often feel insecure and worried and prefer a CT scan from head to toe to make sure. The so-called ‘Worried Well’. Of course you can go along with it and do all kinds of checks, but the chance that you find something you were not looking for can reach up to 40 percent! The question is then whether you not only unnecessarily increase unrest, but also the costs and risks that come with each check.”
Dalinghaus prefers to talk about well-being rather than health. "Well-being is much broader. This does not just concern physical health, but also mental health, someone’s social role and social embedding. Like making your own choices and learning to be resistant to stress. Our system is therefore very different from many other systems in the world, which I have also seen up close. I have worked in Venezuela, Ireland and Norway and gained a lot of experience there with other systems and cultures."
Bárbara Dias grew up in Brazil, where there are both public and private hospitals. “I was fortunate enough to use private hospitals. The public ones aren’t too great, but the private ones are good. We are well looked after there, better than here I must say. I have great respect for the Dutch, but I don't understand their healthcare system. What I miss here in the Netherlands is a caring environment. It often seems that the doctors just want to finish quickly and move on to the next patient. They also don’t do extra examinations, even if the patient asks for them, which I sometimes find worrying. I understand that doctors have years of experience and training, but I don't think you should ever dismiss a patient’s emotions or knowledge.”
What happened to the white overcoat?
Hazenberg: “It can sometimes be difficult to understand how a foreigner has so little trust in our system. We are doing a good job, right? Yes, that is true, but the experience can be different for people with a different cultural background. An American Muslim woman opened my eyes about this topic. She said: "I was used to a doctor in a white overcoat with all kinds of diplomas on the wall behind him. Such a person prescribed me a maintenance dose of antibiotics. Then I see a ‘huisarts’ here in the Netherlands, whom we call a GP, a general practitioner, which is actually a ‘basic doctor’ if you translate that back to Dutch. That is already a level lower than our doctor. A ‘huisarts’ is actually a specialist: after completing his diploma in basic medicine, he continued to study and specialized to become a ‘huisarts’. So the expat thinks he will be confronted with a doctor of a lower level than at home and will also see a person in a casual outfit with an empty wall behind him or her. And that person will then tell you that you have to stop taking the maintenance dose of antibiotics.’ Now that’s kind of hard to swallow."
Doctor Dalinghaus also notices the internationalization of the region at Lidwina practice in Eindhoven: “You see more people with a different cultural background and different ideas about healthcare. Certain questions and expectations show this change. Internationals sometimes ask to have a smear taken by a gynecologist. In the Netherlands, that is not the job of a gynecologist. So I tell them. It means that the doctor often first has to explain something about why healthcare is different in the Netherlands than in their country of origin. An introductory chat is a good opportunity for such a talk."
“It is important to bond with the patient so that he or she accepts such comments from me. Then at a certain point you can also start a conversation about other things that have to do with living in another country with a different culture. We can learn something from them, but they can also learn something from us. It is the art of give and take."
Stanimir agrees: "It's easy to say ‘oh, the doctors here don't speak proper English,’ it is also true that we internationals come here and do not speak Dutch. I sometimes feel guilty about that. I've been living here for five years now, so I'm really trying to learn the language. At work I always tell my colleagues to speak Dutch with me, so that I can improve my language skills."
“The desired improvements in the field of healthcare are two-fold: I would like a little more attention, more thorough checks and easier access to a specialist. But the awareness of both sides also needs to improve. So that doctors understand that internationals have different backgrounds and different habits. And that internationals gain more knowledge about how Dutch people go to the doctor and how the system works. Knowledge about insurance and what is covered, what is not, how the (mandatory and voluntary) own risk and the own excess work, et cetera.”
Georgieva noted that the doctor also uses the internet during the consult: “The doctor googles what you have and shows it to you on the screen (www.thuisarts.nl, ed.). I was stunned.” This may seem to internationals as if the doctor needs Google to make a diagnosis.
Yet this also has a useful function in communication with internationals. Dalinghaus endorses this: “We have had standards, agreements and protocols in the Netherlands since the 1980s on how we are supposed to treat certain diseases. In addition, we invested a great deal in properly informing patients. www.thuisarts.nl is an example of this. Doctors work according to those NHG standards when they see a patient and give advice. The standards state how you should treat, when you must refer to a specialist, etc. If you have to appear before the Disciplinary Commission, they always check whether you have followed the standards and if not, why you deviated from them. This system is often unknown to people from China or India. When I get internationals for a consult, I always show them this (page of thuisarts.nl with a clinical picture, ed.), in their own language with Google Translate. That can help give just a little more insight if there are language barriers."
A special healthcare center for internationals
We have had SGE International in Eindhoven for a few years now. A healthcare center focused on bridging the gap between Dutch healthcare and internationals, taking into account their cultural background, language and expectations. Hazenberg: “I have been involved from the very start of the founding of SGE International. We noticed that the growing international group of residents had different needs concerning healthcare, than the Dutch. Our professionals speak the English language. In addition, we allocate more time (20 minutes instead of 10 minutes) for the patient than is the case with a regular doctor. And yes, that costs more money and is an investment for us. Our employees have completed a culture-sensitivity training at KIT, the Royal Tropical Institute. Approximately 95 percent of our patients are internationals and 5 percent is Dutch. We now have around 5,000 patients (March 2019) and another 200 are added every month."
Georgieva agrees that the language is important to gain trust. Her first doctor did not speak English very well, which caused communication problems. “That makes me have less trust and the doctor may not understand why something is important to me as a patient. Like with contraception. I wanted contraception that is non-hormonal. So I asked my doctor, but she said the pill is the most widely used option. I said I didn't want hormones, but she prescribed the pill anyway."
Health checks, antibiotics and health tourism
Hazenberg: “We always try to be aware of what is going on and how we can respond to that. For example, we regularly see people with a maintenance dose of antibiotics prescribed in their home country. That is a no go here. We do not want maintenance doses of antibiotics in the Netherlands for a good reason: the resistance of bacteria grows this way and if you really need the antibiotics, they will no longer work. But you also have to realize that if you do not first gain the trust of a patient, you will not be able to have them voluntarily stop taking them.”
For example, in his home country Romania, there’s a high usage of antibiotics, Stanimir knows. “I am aware of the difference in antibiotic use here. I like to be prepared and have some at home in case I need them, because it's hard to get them here. But I will not use them for a regular cough, only for a real infection. In Romania it is easier to get hold of antibiotics. We are one of the top users of antibiotics in Europe, which is not good. But public awareness about the effects of antibiotic use is increasing in Romania. My mother is a pharmacist, so I am aware of the risks of using antibiotics."
Hazenberg: “Many internationals are used to so-called health checks. We regularly get requests for those in the practice. Just a full body annual preventive check to be sure that everything is ok. We don't do that in the Netherlands. In fact, the full body scan is not even allowed here, it gives a false sense of certainty. For specific target groups, however, we do have breast examinations, colonoscopies and smears once every few years. We will try to accommodate the people who ask for those health checks. What can we offer that also fits within the framework of our policy? It really is a recurring theme among internationals, so we cannot ignore it."
We regularly see people with a maintenance dose of antibiotics prescribed in their home country. That is a no go here
Hazenberg: "Many countries do not have a ‘huisarts’ like in the Netherlands; someone goes directly to a specialist there. In the Dutch healthcare system we work with primary and secondary care, in which a general practitioner also has a kind of gatekeeper’s function for the specialists. The GP also has his own gatekeeper in the form of a doctor's assistant who is seen as yet anoter difficult obstacle to get the desired care.”
Georgieva noticed that too. “Calling often takes a really long time. There are many people waiting in figurative line. Sometimes I cycle to the practice and negotiate there to get a consult, as if I am doing business. When I ask for help, I want help quickly, not: ‘let's see how it goes and come back in ten days if the problem remains’. I never managed to get an appointment here quickly. I once said that I was super worried and about to go on vacation. And that worked, which is very sad. I had to exaggerate the issue to get an appointment faster, and I still didn't get one the same day, but within three days," Georgieva says.
Calling often takes a really long time. Sometimes I cycle to the practice and negotiate there to get a consult, as if I am doing business
Georgieva: “The doctors themselves are polite and kind in my experience. Unfortunately I had to deal with language barriers a few times that could make it problematic. For example with the problem with my ear. I got a nasal spray for that. That didn't make sense to me, because my nose wasn't blocked at all. The doctor couldn't explain in English why I got the spray and I didn't trust it so I decided not to pick it up at the pharmacy. Maybe, had the explanation been clear, I would have."
All doctors expatproof
Dalinghaus has a different view on providing care to internationals. “I am familiar with SGE international as a practice for internationals, but I don't really believe in that. I don't think you should put all internationals together in a practice. You can better use that money to make all doctors ‘expatproof’. If the expat goes to the doctor in his or her neighborhood, a broader interest of well-being can be served more easily. I know my neighborhood and the initiatives. That can help with local integration. At SGE international, expats from all over Eindhoven come to the practice. Integration is easier close to home, preferably in one's own neighborhood. That is why I would rather invest in care for other cultures in every district of Eindhoven than concentrate it in one center in the city. But the patient can make his own choice of course."
Hazenberg thought it was important to see whether the efforts of SGE international actually paid off. “We repeated the The Hague research in our practice, with the limitation that it only involved 200 participants and one doctor, but it nevertheless gave hopeful results. 72 percent of the respondents said they trust our doctor."
Georgieva: “I heard at school that the EU health card from back home also applies here, but only for emergencies or the GP. So I decided to get a Dutch health insurance in case something should happen. For international students, this is not the first thing they think of when they come here. They feel that they will only be here for a while and do not need Dutch insurance. But it's risky, if you need something and it's not an emergency or primary care, it's not possible. I now have a Dutch insurance and the process became much easier. And as a student, you get the healthcare allowance from the government, so it's not that expensive."
TU/e works together with AON for (collective) insurances. Paul Dekker is an insurance advisor at AON and has weekly consultations at TU/e that internationals can visit to ask questions. “During my consultations I mainly get PhD and PDEng students. They are seen as employees here in the Netherlands and are therefore obliged to have a Dutch health insurance. This is not the case for students. European students have their EU health card that is valid here in the Netherlands for emergency care and primary care, such as the general practitioner. But this does not apply to secondary care (e.g. referral from general practitioner to specialist care). That is planable care and therefore only declarable if the (foreign) health insurer has given authorization for this."
“There is a special student policy for non-EU students. This offers the same coverage as the EU health card. A collective health insurance policy is also available for Dutch students via the TU/e. In the Netherlands, foreign students without a Dutch health insurance cannot simply use secondary care. If they get a(n) (additional) job, they are eligible to get a Dutch health insurance and then make use of that secondary care. Many do so. Good to know: an internship is not valid as ‘work’ to insure you with a Dutch health insurance company. That is only possible if your internship allowance is in total per hour (may also be combined with, for example, a compensation for rent) at least the minimum wage."
Watch out when you travel
The most frequently asked questions from students? "What if I go abroad?" and "How does the system work here?" Dekker answers. “Many foreign students are used to a system regulated by the government. Here we actually have kind of a private insurance. In addition, the concept of ‘own risk’ and ‘own excess’ is also new to many. As an answer to that first question, I always advise students to get proper travel insurance, or to include an additional module in their health insurance that fully covers medical costs abroad. If you only have a basic insurance, it covers healthcare costs at Dutch rates. (This also depends on which form of the basic insurance you have chosen.)
The costs in America, for example, are many times higher than in the Netherlands. That can be tens of thousands of euros that you have to pay yourself if you end up in a hospital there. You can prevent this with a travel insurance or extra module with the right coverage. When traveling abroad, also pay attention to the activities you plan to undertake while you are there and which activities are covered by your (travel) insurer. Your policy states this information. For example, it may be that ‘hiking’ is considered a dangerous sport and you are not covered if something goes wrong. So take a good look at the policy before you travel."
Preparation is half the battle when you fall ill in the Netherlands:
- Check for health insurances in the first week you arrive in the Netherlands, or even already back home. You may think that you can skip it because you do not need them at that moment. But if you fall ill it can be really problematic to not have one. Of course you’ll get the right care in case of an emergency, which is obliged by law here, regardless of your insurance.
But things like dental care, or secondary care such as psychological support are not simply included and they are not just reimbursed with a foreign health insurance policy. The choice between a contracted care policy and a non-contracted care policy determines your freedom of choice and there are all kinds of rules concerning reimbursement, depending on whether you have a basic insurance or also have supplementary modules. For example, dental care is not reimbursed as a standard and many treatments have an excess.
- Register with a GP as soon as you have arranged your accommodation and insurance.
- Consider a practice focused on internationals such as SGE International. There they take more time for you, the practitioners speak English and people are familiar with questions that frequently occur among internationals.
- Also register at a pharmacy so that the doctor can send a prescription there directly.
- Keep receipts of the pharmacy and preferably take a photo immediately. Sometimes you have to submit them to get the costs reimbursed.
- Trust that our doctors and specialists have up to date knowledge and lots of experience, even if there are no diplomas on the wall and not all of them wear a white coat. Our healthcare system is number 1 in Europe according to the Euro Health Consumer Index (EHCI).
Do you have questions about the healthcare system in the Netherlands or do you need help arranging your health insurance? Paul Dekker is present every Tuesday between 1 p.m. and 5 p.m. and every Thursday between 8:30 a.m. and 12 p.m. for a free consultation in Atlas 10.240 (an appointment is not necessary).