Volume 4 / Issue 5 / 2009 - Features

Dutch Health System Remains Europe’s Top Ranked


Tosh Sheshabalaya,


For the second year in a row, the Netherlands has been judged to have Europe’s best healthcare system, according to the annual Euro Health Consumer Index. With a strong performance across all evaluation categories, the Dutch scored an even larger margin than the previous year (when 3-5 countries were clustered close to it at the top). Denmark, edged out of top slot in 2008, was in second position this year. Though it remained at the top of the league in terms of providing access to information and enforcing patient rights, it fared weakly on the issue of waiting times.


One interesting finding: The Netherlands has shown a rise in healthcare spending to the highest per capita levels in the European Union (excluding Luxembourg, or non-EU members Norway and Switzerland – all of whose per capita GDPs are far higher than the EU average).


The annual Euro Consumer Index, the fifth so far, provides a “user-focused, performance-related” comparison of health services in 33 European countries. The Index, traditionally based on evaluating criteria such as patient rights, waiting times, outcomes, range of services offered, and access to medicines, introduced the criterion of e-health last year - essentially, in terms of electronic medical record usage and healthcare data exchange; this year, it added a new sub-criterion under the e-Health rubric: e-solutions for communications to patients.


The Netherlands was singled out by HCP due to recent reforms, which have led to a central, strategic role for the patient/ health consumer. The reforms blend competition for funding and provision within a regulated framework. This separates financing of hospitals from their operation, and removes decision-making from amateurs and transfers it to professionals. Alongside, information tools (such as Kiesbeter – covered in a previous issue of Healthcare IT Management) support active choice among consumers.


Indeed, the above recipe is more or less a model for countries in the top quintile of rankings.


HCP said its league table serves as ‘a reality check’ for governments who can use the data to benchmark themselves against Europe's best-performing health systems.


HCP is critical of countries with GP gatekeepers, requiring patients to visit family doctors before accessing specialist health services. This leads to longer waiting times and does nothing to reduce costs. It is in this respect that accessible information on hospital performance and greater patient choice together lead to improvements in the efficiency of healthcare delivery.


Ironically, one of the countries that relies fairly heavily on GPs as gatekeepers is EHCI’s top-ranked Netherlands. Not surprisingly, the country shows a relatively mediocre performance in terms of waiting times and access.


As mentioned above, in 2009, the EHCI added ‘solutions for communications to patients’ as a new metric. However, the choice of making online comparisons of hospital outcomes is so far confined to a handful of EU countries; apart from the Netherlands, they include Germany, Denmark and the UK.


In the near future, the wider availability of such data will become an increasingly important issue, after patients travel across European borders for treatment, in line with the new EU directive on patient mobility.


According to the EHIC and other research, healthcare in Europe is improving each year. However, public perceptions of health services remain poor in several EU countries (not least Spain, Ireland and Greece), despite better EHCI scores.


Given below is an analysis by Healthcare IT Management of the performance of different countries by key EHCI category:


Patient Rights and Information

Sub-criteria: Healthcare law based on patient’s rights, patient organisations involved in decision making, no fault malpractice insurance, right to second opinion, access to own medical record, physician registry, Interactive 24/7 helpline, cross-border care finance from home, provider catalogue with quality rankings.


Leaders: Denmark, followed by the Netherlands.

Good Performers: Austria, Finland, France, Iceland and Slovenia.

Losers: Bulgaria, Czech Republic, Greece, Spain.


Waiting Time for Treatment

Sub-criteria: Same day GP access, direct access to specialist, major non-acute operations in less than 90 days, cancer therapy in less than 21 days, CT scan in less than 7 days.


Leaders: Albania, Belgium, Germany and Switzerland, followed by Austria, France, Iceland and Luxembourg.

Good Performers: Cyprus, followed by Greece, Hungary and the Netherlands.

Losers: Portugal and the UK, slightly behind Finland, Spain and Sweden.



Sub-criteria: Heart infarctus case fatality, infant deaths, ratio of cancer deaths to incidence, preventable years of life lost, MRSA infections, rate of decline in suicide, % of diabetics with hihj HbA1c levels.

Leaders: Sweden, followed by the Netherlands, Norway and Iceland.

Good Performers: Finland and Iceland, followed by Germany, Italy and Switzerland.

Losers: Albania, Bulgaria and Slovakia.


Range and Reach of Services Provided

Sub-criteria: Equity of healthcare systems, cataract operations in elderly, infant 4-disease vaccination, kidney transplants per capita, inclusion of dental care in public health system, rate of mammography, payments to physicians.


Leaders: Belgium, Luxembourg and Sweden, followed by the Netherlands.

Good Performers: Czech Republic, Denmark, Finland, Norway and the UK.

Losers: Bulgaria, slightly behind Albania.



Sub-criteria: Prescription drugs subsidy, layman-adapted pharmacopeia, novel cancer drugs deployment rate, access to new drugs (time to subsidy).


Leaders: Denmark and the Netherlands, followed by Austria, Germany, Spain and the UK.

Good Performers: Ireland, Slovakia, Sweden and Switzerland.

Losers: Albania, Bulgaria and Lithuania.



Sub-criteria: EPR penetration, e-transfer of medical data between health professionals, lab test results communicated directly to patients via e-health solutions, on-line booking of appointments by patients, on-line access to check how much doctors/clinics have charged insurers for, e-prescriptions .


Leaders: Denmark and the Netherlands, followed by Croatia, Iceland, Sweden and the United Kindom.

Good Performers: Austria, Finland, Macedonia and Norway.

Losers: Greece, slightly ahead of Albania, as well as Belgium, Cyprus, Czech Republic and Slovakia.


[The nascent/emerging status of e-health is indicated by a much lower rate of divergence between the leaders, losers and the median].


The origins of the Euro Health Consumer Index (EHCI) date back to 2004, when Sweden’s privately-owned Health Consumer Powerhouse (HCP) introduced an index comparing Swedish county council responses to the care consumer (Vårdkonsumentindex - VKI). The success of the VKI led to Swedish authorities developing their own set of indicators for performance comparison, significantly improving transparency in the healthcare system.


HCP extended the concept to a pan-European level in 2005 with its first Euro Health Consumer Index (EHCI). Indices of performance in specific healthcare needs (diagnoses, illness groups, care needs) are an added in offering in its mission of “strengthening the position of the healthcare consumer.”


There is, nevertheless, an issue of semantics involved in the indices, and rankings. HCP takes great pains to point out that EHCI does not measure the best healthcare system, but rather the most consumer-friendly one.

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AuthorTosh Sheshabalaya, For the second year in a row, the Netherlands has been judged to haveEurope’s best healthcare system, according to the annual

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