VIOLATIONS OF HUMAN RIGHTS
IN THE NETHERLANDS
HeRWAI analysis on the consequences of the implementation of the draft bill,
modification Health Care Insurance Law (31 249), on the access to obstetrician care for
uninsured and undocumented pregnant migrants in Amsterdam.
Master Thesis
February - July 2008
Author: Aniek Wubben (1759256)
E-mail: aniekwubben@hotmail.com
Organisation: Women’s Global Network for Reproductive Rights
Supervisors: Mrs. Otte and Mr. Wolffers
Master: Health Sciences with differentiation in International Public Health (30 credits)

First supervisor: Drs. C.C. Otte
Policy officer at the Women’s Global Network for Reproductive Rights
Second supervisor: Prof. Dr. I.N. Wolffers
Lecturer at the Free University of Amsterdam

Table of contents
Executive summary 5
List of abbreviations 8
1 Introduction 10
1.1 Background 10
1.2 Research question and objective 20
1.3 Theoretical framework 20
1.4 Outline 23
2 Methodology 24
2.1 Methods & research design 24
2.2 Procedures 25
2.3 Reliability & validity 27
3 Quick scan 28
4 Results 30
4.1 Step 1: identifying the policy 30
4.1.1 Sources & methods 30
4.1.2 Questions 31
4.1.3 Conclusions 40
4.2 Step 2: exploring the government’s commitments 41
4.2.1 Sources & methods 41
4.2.2 Questions 41
4.2.3 Conclusions 53
4.3 Step 3: describing the capacity for implementing the policy 54
4.3.1 Sources & methods 54
4.3.2 Questions 54
4.3.3 Conclusions 59
4.4 Lobby 60
4.4.1 Dutch parliamentary democracy 60
4.4.2 Lobby activities 61
4.4.3 Changes in the draft bill 62
4.5 Step 4: the impact on human rights 63
4.5.1 Sources & methods 63
4.5.2 Questions 63
4.5.3 Conclusions 73
4.6 Step 5: state obligations 74
4.6.1 Sources & methods 74
4.6.2 Questions 74
4.6.3 Conclusions 78

4.7 Step 6: recommendations and action plan 79
4.7.1 Sources & methods 79
4.7.2 Questions 79
4.7.3 Conclusions 89
5 Discussion 90
5.1 Final conclusions 90
5.2 Research quality 91
5.3 Future research 93
Acknowledgements 94
Annexes 95
Annex 1 Women’s Global Network of Reproductive Rights 95
Annex 2 Interviews 97
Annex 3 Other contacts 121
Annex 4 Lobby tool 126
Annex 5 Report meeting June 2 (2008) 128
Annex 6 Recommendations HeRWAI 130
Annex 7 Concepts 131
References 134

Executive summary
Research objective. The objective of this study is to examine the consequences of the draft bill, the
modification Health Care Insurance Law (ZvW) (31 249), for the access to obstetrician care for
uninsured and undocumented pregnant migrants in Amsterdam, in order to provide rights based
recommendations and an advocacy action plan for the Women’s Global Network for Reproductive
Rights (WGNRR).
Introduction. Maternal mortality is closely linked to human rights (e.g. right to health, and non-
discrimination) and has despite its high incidence not received the attention it deserves. Improve
maternal health states MDG 5, thereby trying to raise awareness for this problem. One of MDG5
targets aims to reduce the worldwide maternal mortality rate (MMR) by 75% before the year 2015.
However, ach year still over 500.000 women die of pregnancy-related causes; so the target will
probably not be obtained, regardless of the fact that 80% of the maternal mortalities are preventable by
accessible and safe health care, which is mostly problematic in developing countries.
However, also within a developed country like the Netherlands the accessibility of health care can
be a problem for certain groups in society, thereby affecting the MMR within this group: the
undocumented migrant women. Most undocumented women seek obstetrician care too late in their
pregnancies, which heightens their chance on complications during and after birth. The most important
reason for their delayed health seeking behaviours is that they are scared for not being able to pay and
therefore to receive care; which has its origins in the Dutch legal system.
This Dutch law disabled, by the introduction of the Benefit Entitlement Act (1998), undocumented
people right to collective facilities like health care insurance. Fortunately the Alien Law (2000) stated
two years later that undocumented citizens were able to receive ‘medically necessary care’, although in
practice this did not secure their access to health care (most problematic: preventative care, and
maternity care). In practice, health care providers experience, despite the fact that they are able to
receive compensation, financial barriers to treat undocumented patients (who are mostly not able to pay
for their own care).
The current compensation system is found for other reasons not effective: too disperse and not all
encompassing. Therefore the Ministry of Public Health, Welfare and Sport (VWS) designed a draft bill
(the modification ZvW) concerning a new compensation system: 80% compensation for directly
accessible health care providers; and compensation based on contracts for selected not directly
accessible providers. It is good that the new system will be more uniform (one fund) and all
encompassing (all forms of care), on the other hand it is expected that the partly compensation will
5

impact midwives ability to treat undocumented patients the most (care around birth is a fairly high and
vast sum), thereby negatively affecting the access to obstetrician care for these patients: patients can be
refused treatment or slide off to other health care providers.
Method. The Health Rights for Women Assessment Instrument (HeRWAI) was the leading method for
this research. The HeRWAI consists of six steps, accompanied by several key- and sub-questions,
leading to human rights based recommendations and an action plan. To obtain the information for the
analysis, the following methods were: desk study, individual interviews and group discussions.
Results. From step 1 (identifying the policy) of the HeRWAI can be concluded that the implementation
of the draft bill would form an even larger (financial) barrier for undocumented pregnant women to
seek care as well as for midwives to keep treating these women. The implementation of the draft bill
therefore violates the undocumented women’s fundamental rights.
To conclude from step 2 (exploring government’s commitments) is that the Dutch government
signed many international treaties and consensus documents: thereby supporting women’s reproductive
rights. Despite this, these rights do not have a prominent position in the Dutch national law and health
strategy.
From step 3 (describing the capacity for implementing the policy) can be concluded that the
financial and human resources, reserved for the implementation of the policy, seem sufficient. Possible
limit9ing factors related to the implementation of the policy are: the recently reformed health care
finance system; and conflicting interests (e.g. immigration and cost control).
During the analysis there was voted upon the policy within the House of Commons, which
demanded a timely lobby. A letter, supported by five organisations, with preliminary results and
recommendations was send to the Minister of VWS as well as its commissions. This lobby was
successful since amendment 30 was accepted: 100% instead of 80% compensation for obstetrician care
providers.
To conclude from step 4 (the impact on human rights) is that timely and appropriate health care
together with the underlying determinants of health (nutrition, education, and housing) are of utmost
importance during and after pregnancy, while the policy under research does not take these factors into
account. If the policy will be implemented it will negatively affect the availability, accessibility and
quality of obstetrician for undocumented women.
In step 5 the state’s obligations were analysed, thereby comparing the government’s commitments
with the effects of the policy on women’s health rights. From this analysis can be concluded that the
Dutch government can be held accountable for all the effects and therefore fails to meet its obligations.
6

Within step 6 of the HeRWAI recommendations and an action plan were formed. The
recommendations were based upon the individual interviews and group discussions. Examples of two
recommendations are: all midwives in Amsterdam need to be trained and supported in working with
undocumented patients; the implementation of the policy should be monitored within a rights-based
approach, and involving civil society. The plans for action are: spread the findings of this research
among important stakeholders; and in the future to appoint an intern at WGNRR in order to examine if
the recommendations are met, and if the right to health is improved for undocumented women.
Conclusion. By this thorough analysis more is known about the difficult situation undocumented
women’s are in, and by lobbying for their reproductive rights at least deterioration of their access to
obstetrician care is prevented. However, much more needs to be done in order for the rights position of
undocumented women to improve; since until this moment these women form one of the most
vulnerable and stigmatised women in Dutch society. This change can only be achieved if the Dutch
government acknowledges the fact that these women also have human rights, and more importantly
that it is their obligation (notice the signed treaties and consensus documents) to protect and fulfil these
rights.
7

List of abbreviations
AIDS Acquired Immune Deficiency Syndrome
ASKV Amsterdam Solidarity Committee Refugees
AWBZ General Law Special Sickness costs
CAT The Convention Against Torture and Other Cruel Inhuman or Degrading Treatment or
Punishment
CBS Central Bureau for Statistics
CCPR International Covenant on Civil and Political Rights
CCPR-OP1 Optional Protocol to the CCPR
CCPR-OP2-DP Second Optional Protocol to the CCPR
CEDAW Convention on the Elimination of All Forms of Discrimination against Women
CEDAW-OP Optional Protocol CEDAW
CRC International Convention on the Rights of the Child
CRC-OP-SC Optional Protocol to the CRC on the Sale of Children, child prostitution and child
pornography
CVZ Colleges For Health care insurances
DBC Diagnosis Treatment Combination
GGD Municipalities’ Health Service
GP General Practitioner
ECHR Convention for the Protection of Human Rights and Fundamental Freedoms
ESC European Social Charter
HeRWAI Health Rights of Women Assessment Instrument
HIV Human Immunodeficiency Virus
ICERD International Convention on the Elimination of All Forms of Racial Discrimination
ICESCR International Covenant on Economic, Social and Cultural Rights
ICPD International Conference on Population & Development
IFHHRO International Federation of Health and Human Rights Organizations
IFMSA International Federation of Medical Students’ Associations
IGZ Health Care Inspectorate
ILO International Labour Organization
IND Immigration and Naturalisation Force
8

JWS Johannes Wier Foundation
KIT Royal Tropical Institute
KNOV Royal Dutch Organization of Midwives
KNMG Royal Dutch Community to promote the Medical Art
LVRM Dutch League for Human Rights
MDG Millennium Development Goal
NGO Non-Governmental Organization
NVZ Association of Hospitals
NZa Dutch Health Care Authority
RIVM National Institute for Public Health and the Environment
RSHR Reproductive and Sexual Health Rights
STD Sexually Transmitted Disease
SVZV Support group Women Without Residence permit
VWS Public Health, Welfare and Sport
UDHR Universal Declaration of Human Rights
UN United Nations
WAZ Law Determination Pregnancy
WAZO Law Job and Care
WCPV Law on the Collective Prevention Public Health
WKCZ Law Complaint right Clients Care sector
WGNRR Women’s Global Network for Reproductive Rights
WGBO Law on the Medical Treatment Agreement
WHO World Health Organization
ZvW Health Care Insurance Law
9

1 Introduction
In this introduction background (1.1) information of the problem will be given first, followed by the
research question and objective (1.2). In paragraph 1.3 the theoretical framework of the research will be
shown, followed by the outline (1.4) of the report.
1.1 Background
According to new figures, presented by a joint United Nations (UN) agency working group, the
worldwide maternal mortality1 is decreasing (Women Deliver, 2007). However this decreasing trend is
not sufficient for achieving the Millennium Development Goal (MDG) 5 that wants to reduce the
worldwide maternal mortality ratio2 (MMR) with 75% by 2015 (Women Deliver, 2007). In 56 of the 68
priority countries, which are countries with the highest burdens of either maternal or child mortality
(seen in figure 1), the maternal mortality is still high to even very high at the moment (Countdown
Coverage Writing Group, 2008).
Figure 1. MDG 4 & 5 (child mortality & maternal health) countdown priority countries.
Source: Countdown Coverage Writing Group (2008).
1
the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy,
from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes (WHO, 2006).
2
the number of maternal deaths per 100.000 live births, during a certain period of time (WHO, 2006).
10

In total there are eights MDGs which were born out of the UN Millennium Declaration in 2000
(more information see chapter 4 s2/q3). The underlying reason for developing these time-bound goals
and target are to reduce extreme poverty (Millennium Project, 2006). A problem with the MDGs is that
they are not legally binding for governments; therefore they rely on will and commitment instead of
duty and obligation. International human rights treaties however do obligate governments, who signed
the treaties, to act according to the articles stated in these treaties; thereby making them accountable to
achieving the rights of all its citizens in a non-discriminative manner.
Maternal mortality: the facts
Facts about maternal mortality are stated on global and national level, since the Netherlands is the area
of research, on this country will be focused on as national level.
Globally
Global estimations show that more than 500.000 (= one per minute!) women die each year of
pregnancy-related causes, of which 99% in developing countries (Latin American and Caribbean
Women’s Health Network, 2006; WHO, 2005). Sub-Saharan Africa (270.000) and South Asia
(180.000) together formed 86% of the total global maternal mortality in 2005 (WHO, 2005). This
worldwide unequal distribution of MMRs per 100.000 live births3 is seen in figure 2 and ranges from
low, in most northern parts of the world, to very high in the southern parts.
Figure 2. Maternal mortality ratios (MMR) per 100,000 live births (2005). Source: Unicef (2005)
3
the complete expulsion or contraction from its mother of a product of conception, irrespective of the duration of the pregnancy, which, after such
separation, breathes or shows any other evidence of life, such as beating of the heart, pulsation of the umbilical cord, or definite movement of
voluntary muscles, whether or not the umbilical cord has been cut or the placenta is attached; each product of such birth is considered live born
(WHO, 2006).
11

The Netherlands
The Population Action (2007) called the Dutch MMR ‘very low’ in the year 2005. This organisation
even stated that the Netherlands is one of the safest countries for women’s sexual and reproductive
health. This positive image of the Netherlands is seen in table 1, which displays the MMRs worldwide
and in the Netherlands. Hereby keeping in mind that MMRs are sensitive to underreporting; therefore
the rates can be seen as rough estimates (Waelput et al., 2007).
Table 1. The maternal mortality ratios (MMR) and numbers of maternal deaths per year worldwide and in the Netherlands.
Sources: WHO (2005) & Waelput et al. (2007b)
Population MMR* Number of maternal deaths
per year
Worldwide 400 536.000
• Developing world 450 533.000
o Sub-Saharan Africa 900 270.000
o South Asia 490 188.000
• Developed world
9 960
o Netherlands
6 11
* Per 100.000 live births
Maternal mortality & morbidity: the causes
The direct causes of maternal deaths (seen in figure 3) are haemorrhage (severe bleeding), infection and
sepsis, unsafe abortion, hypertensive disorders, and obstructed labour (Matthews, 2007; United
Nations, 2007; United Nations Population Fund (UNFPA), 2008). These direct causes encompass 80%
(500.000) of all the maternal mortalities worldwide and can all be prevented or treated with accessible
and safe health care. The most important indirect causes of maternal mortality are anaemia, malaria and
heart disease (UNFPA, 2008).
Figure 3. Percentages of the causes of worldwide maternal mortality. Source: UNFPA (2008)
12

Besides mortality, there is even more pregnancy-related morbidity. From these morbidities suffer
about 9.5 million women all over the world and an estimated 10-20 million women develop mental or
physical disabilities every year (Wiebinga, 2007). Unsafe abortion is one of the most important causes
of pregnancy-related morbidities: about 5 million women suffer from temporary of permanent
disability as a result of an unsafe abortion (WHO, 2006b). Women mostly affected by pregnancy-
related morbidity are again women living in developing countries (WHO, 2006b).
It becomes clear that women in developing countries suffer the most from pregnancy-related
mortality and morbidity; which is not acceptable according to the Declaration of Alma Ata (see
statement below). This fact can be explained by poverty-related factors: low educational level of
pregnant women and birth attendants; low quality of health care facilities; poor access to health care
services and contraceptives; high fertility levels (Betran et al, 2005; Falkingham, 2006; Latin American
and Caribbean Women’s Health Network, 2006; United Nations, 2007).
– The existing gross inequality in the health status of the people particularly between developed and developing countries
as well as within countries is politically, socially and economically unacceptable and is, therefore, of common concern to
all countries – Declaration of Alma Ata, 1978
Access and quality of care
Especially the quality of and access to health care services is of importance. Access in relation to
maternal mortality concerns different forms of access: to skilled attendance, emergency obstetric care,
contraception and safe abortion (Wiebinga, 2007). As said before, 80% of all maternal deaths can be
prevented by interventions improving the access and quality of obstetrician care4 (Matthews, 2005;
United Nations, 2007; Wiegers et al, 2007).
– The States Parties to the present Covenant recognize the right of everyone to the enjoyment of the highest attainable
standard of physical and mental health – ICESCR, 1969
However access to health care is not enough in order to be healthy, as defined by the right to health
(see above statement): also access to safe water, food, sanitation and shelter, as well as freedom from
discrimination determine the health status of an individual (International Federation of Health and
Human Rights Organisations (IFHHRO), 2007).
The Netherlands
4
the whole continuum of care around the birth of a child: before pregnancy (family planning) during pregnancy (prenatal), the delivery (natal), after
delivery (postnatal) (Countdown Coverage Writing Group, 2008).
13

The Dutch government ensures appropriate services in connection with pregnancy, which is a very
important determinant for the sexual and reproductive health of its female citizens as stated by the
Convention on the Elimination of All Forms of Discrimination against Women (CEDAW) (see
statement under here).
– States Parties shall ensure to women appropriate services in connection with pregnancy, confinement and post-natal
period, granting free services where necessary, as well as adequate nutrition during pregnancy and lactation – CEDAW,
1994
Obstetrician care provided in the Netherlands is ensured for two reasons:
First, the accessibility and acceptability of obstetrician care is good: about 86% of the Dutch women
receive care from a midwife from the beginning of their pregnancy (Wiegers & Wieren, 2007). Prenatal
is care is important for preventing and identifying potential risks, and for planning a safe delivery
(United Nations, 2007). Congenital disorders5 like toxoplasmosis, mother to child HIV/AIDS
transmission, syphilis, and Spina bifida are examples of diseases, which can be prevented during the
prenatal period. Other congenital disorders cannot be prevented, but parents can be educated about the
consequences. If these consequences will form problems for the parents they are able to make an
informed decision to either go on or end the pregnancy: which is possible in the Netherlands since the
Law Determination Pregnancy was introduced in 1981(Schrijvers, 2007; Overheid.nl, 2008c).
Second, the quality of the Dutch obstetrician care is good (Ministry of VWS, 2007; Population
Action, 2007), which is a very important determinant of the population’s maternal health6 (Matthews,
2005)
The Netherlands: ethnic minorities
However, for the more vulnerable groups of women living in the Netherlands, improvements can be
made concerning their sexual and reproductive health. In 2003 a study showed a rising trend in the
incidence of sexually transmitted diseases (STDs) and abortions among immigrants (Hardon, 2003),
which heightens the risk of maternal mortality. The Realm Institute for Public Health and Environment
(RIVM) also showed this higher risk of maternal death among ethnic minorities: in one year 36
Surinam or Antillean women died per 100.000 live births because pregnancy-related causes, and 32 per
100.000 of other non-Western women (Waelput et al, 2007b).
5
a defect which is present at birth (Medical Dictionary, 2008b).
6
the health of women during pregnancy, childbirth and the postpartum period (WHO, 2008).
14

An important reason for these elevated risks among non-Western women is that they seek prenatal
care at a later stage than Western women do (Waelput & Schrijvers, 2007c), but also lower educational
levels play an important part here according to gynaecologist Jos van Roosmalen (Van Baarsel, 2008).
Table 2. The maternal mortality ratios (MMR) and numbers of maternal deaths per year in the Netherlands and its sub-groups.
Sources: WHO (2005) & Waelput et al. (2007b)
Population MMR* Number of maternal deaths
per year
Netherlands 6 11
• Ethnic minorities 32-36 no data available
o Undocumented > 36** no data available
* Per 100.000 live births
** Based on the fact that undocumented women have similar complications to documented ethnic minorities,
but have a lower access to health care, which heightens their MMR (PICUM, 2007)
The Netherlands: undocumented migrants
Undocumented7, or commonly known ‘illegal’ migrant women (from now on called ‘undocumented’,
due to the illegal connotation with criminality) belong predominantly to ethnic minorities, but they
experience even more often and more serious problems during pregnancy (Klazinga et al, 2007). The
main reason for these elevated problems is again that these women seek care (too) late; therefore
preventable diseases and/or complications cannot be prevented anymore and is their MMR expected to
be even higher then those of other groups (see table 2).
Reasons why undocumented pregnant women wait so long to seek care are: mostly young age of
undocumented people, afraid for authorities (IND), afraid to loose job and income, unfamiliarity with
the Dutch health care system, not being able to pay for health care (and therefore afraid not receive
any), and bad experiences with health care providers (Klazinga et al, 2007; Foundation GPs Services
posts Amsterdam, personal statement, March 10, 2008; H. Playfair, personal statement, March 18,
2008; Anonymous, personal statement, April 10, 2008; M. Kreyenbroek, personal statement, April 18,
2008).
7
a person whom conforms to one of the following phenomena:
a) A third-country national who enters the territory of a Member State illegally by land, sea or air, including airport transit zones. This is mostly
done by using false or forged documents, or with help of organized criminal networks of smuggles and traffickers;
b) Enters the Member State legally (with a valid visa or under visa-free regime), but stay longer or change the purpose of stay without the
approval of authorities;
c) Former asylum seekers who do not leave after a final negative decision (Commission of the European Communities, 2006).
15

According to different figures the total population of undocumented immigrants is around 125.000-
250.000. The four large cities in the Netherlands (Amsterdam, Rotterdam, The Hague and Utrecht)
encompass 36.7% of the total undocumented population (Engbersen, Leerkes, Van San, Cruijff & Van
der Heijden, 2004). The most important reasons for (undocumented) migrants to settle in large cities
are because of more network possibilities with people of the same background, and more job
opportunities (J. Van Amen, personal statement, March 5, 2008).
From these four large cities Amsterdam is the one who probably has the most undocumented
women, this since the Coupling Foundation received most requests for compensation from health care
providers in Amsterdam (J. Van Amen, personal statement, March 5, 2008). More about this
foundation and compensation system becomes clear further along in this report.
The government is the first responsible to secure the right to health for its citizens, this includes the
right to health for its undocumented citizens as seen by the resolution under here. However other actors
like (inter-) national organisations, health professionals and family members also have a large impact
on this right to health (IFHHRO, 2007).
– The UN Commission on Human Rights requests to all member states to effectively promote and protect the human
rights and fundamental freedoms of all migrants, especially those of women and children, regardless of their
immigration status – Resolution on Human Rights of Migrants, 2005
Legal system as determinant for access to health care for undocumented migrants
The Benefit Entitlement Act of 1998 (in Dutch: Koppelingswet) (Stichting AB, 1998) disabled
undocumented people living in the Netherlands the right to collective facilities like social security,
rental and study allowance, and health care insurance. This was done by blocking the functioning of the
Health Care Insurance Law (in Dutch: Zorgverzekeringswet (ZvW)) and the General Law Special
Sickness costs8 (in Dutch: Algemene Wet Bijzondere Ziektekosten (AWBZ)) for undocumented
migrants. The underlying reason for this action was to discourage illegal migration.
Fortunately the Alien Law 2000 (in Dutch: Vreemdelingenwet) (Stichting AB, 2008) changed some
of the disabled rights in the Benefit Entitlement Act and made it possible for certain groups of
undocumented people to receive education, medically necessary care, prevention of the public health,
or legal assistance. When making these laws the Dutch government assumed that the access to
8
the AWBZ is a national insurance for special health care risks which are not individually insurable. The health care which belongs to this insurance
are: personal maintenance, nursing, different forms of guidance, residence and treatment (Ministry of VWS, 2008).
16

‘medically necessary care’ for undocumented people was secured, this conversely appeared not to be in
practice (Klazinga et al, 2007; Klink, 2008). More about medically necessary care is found in the
results under s1/q7.
In practice health care providers experienced a financial barrier to treat undocumented people, who
are mostly not able to pay for their own care. Especially hospitals and AWBZ- institutions (mental
health care and nursing homes) seem to experience this barrier, possibly because care provided in these
institutions is more expensive than directly accessible (first-line9) care. As a result of this deterred
access to not directly accessible care: General practitioners (GPs), and other first-line care providers
like midwives, have problems referring undocumented patients to these hospitals and institutions
(Klazinga et al, 2007). Medically necessary care is therefore in most cases not obtained.
This difference in care is also seen in the financial barrier undocumented people experience for
themselves: health care providers are obligated by law to ask the patient for payment; however this
keeps the patient from seeking medical care. The reason for this is, that undocumented people mostly
have not much to spend and are therefore afraid not receiving any care, besides this they are also scared
of being registered (Klazinga et al, 2007; H.Playfair, personal statement, March 18, 2008; Anonymous,
personal statement, April 10, 2008; M. Kreyenbroek, personal statement, April 18, 2008).
Thus the Dutch legal system limits the access to health care for undocumented citizens, this while
the Dutch government ratified many international documents like the International Covenant on
Economic, Social and Cultural Rights (ICESCR) which states that:
– States are under the obligation to respect the right to health by, inter alia, refraining from denying or limiting equal
access for all persons, including prisoners or detainees minorities, asylum seekers and illegal immigrants, to
preventative, curative and palliative health services – ICESCR, 1969
The current compensation system
As just mentioned health care providers experience a financial barrier for treating undocumented
patients, yet there is a compensation system available in order to prevent financial reasons interfering
with medical treatment. In fact two different funds are available:
9
care directly accessible for people in need of care and encompasses the care provided by, for example, the following people: general practitioner,
dentist, physiotherapist, pharmacist, psychologist, and midwife. As the first contact person for patients, first-line care providers are very important
link in the health care system: these providers are the ones to refer patients to the more expensive and specialised second-line care (see second-line
care for more information) (NVSHV, 2006).
17

1) For first-line providers this can be done via the regional Municipalities’ Health Service10 (in Dutch:
Gemeentelijke Gezondheids Dienst (GGD)) platforms and the Coupling Foundation11, who administers
the Coupling Fund owned by the government (Stichting Koppeling, 2002).
2) The second-line12 providers, like hospital personnel, get compensation out of the dubious debtors (in
Dutch: dubieuze debiteuren) trust13, from which the height is determined by the hospital management
and the health care insurance companies hospitals are contracted by (Stichting Koppeling, 2002). For
AWBZ-care, however no trust is available at the moment for undocumented patients (Klink, 2008b).
Obstetrician care encloses all three lines of care. In first-line obstetrician care will be provided by
midwives (94%) or general practitioners who are specialized in obstetrics (6%). These first-line
providers are mostly there for ‘normal’ pregnancies and deliveries (Wiegers et al, 2007; Wiegers &
Wieren, 2007). Based upon the risk selection of the first-line providers, the women who are at higher
risk of complications will be referred to the second- or third-line14 care. The providers of these lines of
care are mostly specialists in hospitals like gynaecologists and paediatricians (NIVEL, 2008; Wiegers
et al, 2007). The pre- and post-natal care is mostly embedded in the first-line care and the actual
delivery takes for 60% place under supervision of a gynaecologist, thus the second-line (Wiegers &
Wieren, 2007).
The future compensation system
A new draft bill, concerning the compensations of income losses for health care providers who treat
undocumented people, has been designed in the year 2007 and is called: modification Health Care
Insurance Law (31 249). The main reason for developing this draft bill was that the current
compensation system was too divided (Coupling fund, dubious debtors) and not all encompassing
(AWBZ-care). Within the new bill the two trusts will therefore be merged together in order to form
more uniformity (Klink, 2008; Leemhuis-Stout, 2007; Medisch Contact, 2007) as well encompasses
AWBZ-care (Klink, 2008).
10
the GGDs execute instructions of their municipalities. The GGD is responsible for the public health of its citizens (GGD, 2008).
11
a foundation founded by private initiative to give financial support to health care providers. The budget (Coupling Fund) is provided by the
Dutch government. The private initiative, the board of the foundation, was formed by people of the field, like (former) employees of the health
insurance fund and the GGD (J. Van Amen, personal statement, March 5, 2008).
12
care not directly accessible for people in need of care: referral by a first-line health care provider is needed in order to access this sort of care.
Second-line care consists of hospital and mental health care (Tweede Kamer der Staten-Generaal, 2008b).
13
a variable budget for hospitals in the Netherlands from which income losses (like undocumented patients unable to pay for their own care) can be
compensated for. The height of the trust is arranged in the contracts hospitals have with their insurance companies (J. Van Amen, personal statement,
March 5, 2008).
14
care not directly accessible for people in need of care: referral by a first-line health care provider is needed in order to access this sort of care.
Third-line care consists of top clinical facilities in academic hospitals (Tweede Kamer der Staten-Generaal, 2008b).
18

In the draft bill a distinction is made between two kinds of care:
1) Directly accessible care (similar to first-line care), which will be 80% compensated for;
2) Not directly accessible care (similar to second- and third-line care), for which the percentage of
compensation is stated in contracts made between the Colleges For Health care insurances15 (CVZ) and
selected health care providers. The CVZ will take over the role of the Coupling Foundation and will be
a governing body, which will manage the budget made available by government (Klink, 2008).
Different organizations, concerning the access to health care services for undocumented people,
already expressed their objections of the draft bill to the Ministry of VWS. According to the
Association of Hospitals (NVZ) the draft bill is a step into the right direction. Also the Johannes Wier
Foundation (JWS) (an organization who is active in the area of human rights and the health care
system) could appreciate the bill, because of the merging of the three-lines of care and their funds for
treating undocumented people into one system.
However some possible detrimental consequences are to be considered. First, the only partly
compensation of directly accessible care could form a barrier for health care providers to treat
undocumented women (Otter, 2008). Income loss, caused by the party compensation, could deprive the
motivation of health care providers for treating undocumented women, which heightens the chance that
they refuse treating these women or slide them off to other providers of care. This ‘sliding off’,
although prohibited, is seen to be the case for undocumented patients in the past (Breed Medisch
Overleg, 2007; Klink, 2008).
Second, the not directly accessible care is only compensated for by selected health care providers.
Which is merely 1 hospital and 3-4 pharmacists per region (unless the number of undocumented people
is larger than 5%), and 15 AWBZ-institutions and 10 ambulance services in the entire country (Klink,
2008). This selection of providers could certainly form a barrier to the access of health care for
undocumented women by possible longer travel distances and higher travel costs.
It is predicted that midwives will experience the highest financial barriers caused by the new
financing system: expenses involving obstetrician care are fairly high, and moreover a vast amount (J.
Van Amen, personal statement, March 5, 2008; Leemhuis-Stout, 2007; Medisch Contact, 2007). This
high financial barrier endangers the future access to obstetrician care for pregnant undocumented
women.
15
a professional independent managing body who watches over the Dutch health care system. The citizen is central in CVZs work: it secures and
develops the conditions of the health care system, in order for the citizens to realize their right to health care (CVZ, 2008).
19

1.2 Research question and objective
The central question is in this study is: what are the consequences of the draft bill, the modification of
the Health Care Insurance Law (31 249), on the access to obstetrician care for uninsured and
undocumented pregnant migrants in Amsterdam?
The objective of this study is to examine the consequences of the draft bill, the modification of the
Health Care Insurance Law (31 249), on the access to obstetrician care for uninsured and
undocumented pregnant migrants in Amsterdam, in order to provide rights based recommendations and
an advocacy action plan for the Women’s Global Network for Reproductive Rights16 (WGNRR).
The WGNRR is a non-governmental organisation (NGO) which aims to inform, link, engage and
strengthen organisations and individuals worldwide in order to effectively promote and improve
reproductive and sexual health and rights for all women and girls (this mission and more information
about the WGNRR are found in annex 1). One of the objectives of WGNRR to attain this goal is
capacity development for its member’s organisations. Members showed their concerns about the
feasibility to reach the MDGs; one of its problems, as defined in the beginning of the introduction, is
that MDGs are not seen as goals government’s can be held accountable for. Another problem is that
policy makers at national level are not aware of what actually happens in reality. As a solution to these
problems the WGNRR decided to develop the MDG- Health Rights of Women Assessment Instrument
(HeRWAI) toolkit; a tool which links MDGs to human rights, thereby is making it possible to lobby at
national level for improvements of these rights and eventually attaining the MDGs.
However, since the toolkit was not finished before the start of the research, current analysis will
only be used to get familiar with the HeRWAI, which is an existing instrument part of the toolkit (see
chapter 2 for more information on the HeRWAI).
1.3 Theoretical framework
A theoretical framework will be described in order to facilitate the analysis. The framework is
encompassed by two models: 1) why pregnant women sometimes seek care too late is explained by ‘the
three delays model’; 2) how the agenda setting process of the draft bill works is explained by ‘the three
streams model’ of Kingdon.
The three delays model
The three delays model explains three phases of delay in receiving proper obstetrician care. Proper
obstetrician care is of importance to maternal health: therefore this model is commonly used in
16
More information about the WGNRR is found on the following website: www.wgnrr.org
20

maternal mortality research (Barnes-Josiah, Myntti, & Augustin, 1998; Barkat, Rahman, Lal Bose, &
Akhter, 1998; Wiebinga, 2007) and is seen in figure 4.
Figure 4. ‘The three delays model’. Source: UNFPA (2008)
Phase I includes the decision-making process to seek care. Factors which can influence this process
are the woman herself, her husband and/or relatives, the availability of skilled birth attendants, the birth
attendants’ ability to recognise high-risk pregnancies and complications and to give appropriate advice,
the status of the women, illness characteristics (e.g. severity and duration), distance from the health
facility (accessibility), financial and opportunity costs (affordability), previous experiences and
perceived quality of care (Stekelenburg, Van Dillen, Schutte, Walraven,& Van Roosmalen, 2004). All
these factors belong to the three concepts, displayed left in the model, which affect the utilization and
outcome: socio-economic and cultural factors, accessibility of facilities, and the quality of care.
Phase II is the delay in the identification of the right health facility and to reach this facility. This
delay is influenced by the accessibility of facilities: physical accessibility, travel time from home to
facility, the availability and cost of transportation, the condition of roads (Stekelenburg et al, 2004).
Phase III encompasses the delay in the reception of the adequate and appropriate treatment. The
quality of care is of importance in this phase and is determined by the availability of supplies (blood
transfusion, intravenous fluids and drugs), equipment and trained personnel, and the competence of
available personnel (Stekelenburg et al, 2004).
21

The accessibility of the obstetrician facility is the most important factor in this research and affects
the decision of the undocumented pregnant woman to seek care (phase I) and her ability to identify and
reach the obstetrician facility (phase II).
The three streams model
The model of Kingdon (1984) explains how certain issues reach the government’s policy agenda.
Kingdon says that policies are only be taken seriously by the government when a major ‘window of
opportunity’ opens up in the three streams at the same moment (Walt, 2006), this is the moment when
the three waves, as displayed in figure 5, would overlap each other.
The problems stream explains why some problems occupy the attention of the Dutch government.
According to Kingdon this can be explained by the ways politicians learn about problems. He mentions
three roads of this learning process: indicators, focusing events and feedback. Indicators are routine
information like health statistics of the undocumented women. Focusing events may be a crisis in
which the maternal mortality suddenly rises within the study group. Feedback can be given by users of
already implemented programmes like first-line midwives using the current compensation system
through the Coupling Foundation (Walt, 2006).
Problems stream: from many problems some get under the attention of politicians
Politics stream: agenda setters (hidden and visible) put problems on the agenda
Policy stream: selection from all problems and politics the one to become public policy
Figure 5. ‘The three streams model' of Kingdon (1984)
The visible and hidden participants in the agenda setting process form the politics stream. The
visible participants are organized interests which may be located from as well the inside as from the
outside of the Dutch government. Examples here are ministers within the government, the media and
interest groups like Non-Governmental Organizations (NGOs). The hidden participants are the
specialists like academics, researchers and consultants. The difference between the two sorts of
participants is that hidden participants focus less on the agenda setting and more on solving the
problem as visible participants have a particular point of view and aim for getting attention to it (Walt,
2006). The WGNRR can be seen as a visible participant, since it is an NGO with a specific point of
22

view (see also annex 1): a world where women can enjoy their sexual and reproductive rights
(WGNRR, 2008).
The policy stream selects from problems and politics the proposals that will become public policy.
In this case there already is a proposal: the modification of the Health Insurance Law. It depends on
several criteria if the Dutch government will select the current proposal: technical feasibility,
congruence with existing values, anticipation of future constraints, public acceptability, and politician’s
receptivity (Walt, 2006).
1.4 Outline
The outline of this report will be as following: in chapter 2 the methodology is described by its
methods and research design, procedures, and reliability and validity; in chapter 3 a quick scan is
outlined which explains why the draft bill is chosen as the policy for research; in chapter 4 the results
of the analysis are reported; and finally in chapter 5 the results are discussed, the benefits and
limitations of the research mentioned, and recommendations given for future research.
Five annexes are to be found in this report: information about the WGNRR (annex 1); the interviews
held during the research (annex 2); short conversations with stakeholders as well as emails (annex 3);
the tool/ letter used for lobbying (annex 4); report meeting June 2 (2008) in which group discussions
took place (annex 5); recommendations for future use of the HeRWAI (annex 6); and last the most
important concepts used in this report (annex 7). At the end of the paper the references used are listed.
23

2 Methodology
In this chapter the methods and research design, the procedures, and the reliability and validity will be
described.
2.1 Methods & research design
The main method which will be used in this research is the Health Rights of Women Assessment
Instrument17 (HeRWAI), developed by the Humanist Committee on Human Rights (HOM) now called
Aim for human rights18 in cooperation with organisations from various parts of the world. The
HeRWAI is a strategic tool to provide NGOs valid argumentations based on human rights and national
policies (HOM, 2006). These argumentations can further be used for lobbying activities.While using
the HeRWAI other methods are needed in order to obtain the right information, therefore the following
methods will be used as well:
• Desk study: a desk study will be done order to obtain available (scientific) information. Sources to
be used here are literature, articles, documents, websites, and the media (e-mail, news-papers).
• Interviews: several interviews will be held among important stakeholders in order to obtain primary
information from different sides of the problem. The stakeholders here aimed for are: one
representative from the Coupling Foundation, CVZ, and the Ministry of VWS; at least two midwives
from two different hospitals in Amsterdam; and at least four undocumented women. The characteristics
of the interviews will be: individual, face-to-face, open-style, and limited degree of pre-structuring. By
a ‘limited degree of pre-structuring’ is meant that not all individuals will be asked the same questions,
which is needed when very different stakeholders will be interviewed. And by an ‘open-style’ is meant
that the most important questions will be written down beforehand, however during the interview new
or additional questions will be asked depending on the answers of the person interviewed (Verschuren
& Doorewaard, 2005).
• Group discussions: group discussions will be held among important stakeholders (interviewed
stakeholders, delegates from different human rights organisations) in order to obtain their input
concerning the recommendations and action plan, which will be made in step 6.
As seen by the different methods that will be used this research has a qualitative design, which is more
explorative (Verschuren & Doorewaard, 2005). The reason for this qualitative design is
17
The HeRWAI is downloadable from the following site: http://www.humanrightsimpact.org/resource-
database/toolsets/resources/view/39/user_hria_toolsets/
18
More about Aim for human rights is found on the following site: www.aimforhumanrights.nl
24

because not much research has been conducted yet on this specific subject, besides it is expected to be
very difficult to find enough undocumented women in order to conduct quantitative research (with
questionnaires); therefore qualitative research is best in this case.
2.2 Procedures
The procedures of the four methods that will be used will be described here per method.
HeRWAI
The HeRWAI consists of six steps and will all be followed:
1) Identifying the policy
2) Exploring government’s commitments
3) Describing the capacity for implementing the policy
4) The impact on human rights
5) State obligations
6) Recommendations and action plan.
The more specific methods and sources used during the HeRWAI analysis will be
described at the beginning of each of these six steps.
The steps are all accompanied by key and sub-questions, an explanation of the questions, and places
to find suitable information (HOM, 2006). All questions will be answered, since then the all dimensions
of the problem should be analysed.
Desk study
Several procedures will be used in order to obtain available (scientific) information:
• Websites and documents mentioned in the HeRWAI.
• Search methods like: pub-med, and google.
• Information available at the WGNRR office.
• Documents and books used during the theoretical part of the Master International Public Health.
• Email contact or short conversations with persons who know more about the problem like workers at
human rights and health related organisations. These contacts will be described at the beginning of each
step of the HeRWAI separately (under ‘other contacts’).
25

Interviews
Representatives from the Coupling Foundation, CVZ, and the government as well as midwives from
hospitals (second-line) and midwife-practices (first-line) will be contacted via email and/or phone
(found on web-sites). For midwives inclusion criteria for selection are that she should: 1) work in
Amsterdam; and 2) have sufficient experience in treating undocumented women. The objective of the
study will be explained and the importance of their cooperation in order to motivate all these persons
for interviewing.
As just mentioned it is expected to find more difficulties to find undocumented women for
interviewing, therefore first organisations will be contacted who come in contact with these women like
Amsterdam Solidarity Committee Refugees (ASKV), Pharos, and Doctors of the World. Second, a
diner will be attended in women’s café “de Peper”, which is organised each month in order for
documented and undocumented women to meet each other. Third, the snowball method (Verschuren &
Doorewaard, 2005) will be used: interviewed midwives will be asked if they could provide contact
details of undocumented women. The inclusion criteria for undocumented women are that she should:
1) have been undocumented when in contact with obstetrician care; and 2) live in Amsterdam; and 3) be
pregnant at the moment or have delivered her child while living in Amsterdam.
During the interviews the following procedures will be executed:
• Respondents will be informed about the confidentiality of the interview as well as being given the
possibility to stay anonymous.
• The researcher concerning the answers of respondents will take notes.
• The conducted interviews will be summarised afterwards, based on the notes taken. Preferable as
quickly as possible afterwards in order to prevent recall bias of the interviewer.
• The summaries of the interviews will be send back to all respondents in order for them to check the
facts and if necessary to change and/or add lines.
Group discussions
When the HeRWAI analysis has come to step 6 group discussions will be held among important
stakeholders. These stakeholders will be selected on basis of there expertise with undocumented
women. Which stakeholders this are will become clear during the analysis, desk study and interviews.
At least the interviewed stakeholders and delegates from human rights related organisations will be
invited.
A presentation will be given about this research in order to inform stakeholders as well as to
motivate them to come to the meeting. Group discussions will be the second part of the meeting:
26

stakeholders can help making good recommendations to the government and an action plan for
obtaining these recommendations.
2.3 Reliability and validity
The HeRWAI has been used in several studies. One of these studies has been conducted in the
Netherlands and was called: ‘The annulment of the prostitution zones in large cities and the right to
health of women’ (Bruins & Leeuwenburg- van Erkel, 2005). Other studies were conducted in
Bangladesh, Pakistan, Kenya, Uganda, Tanzania, Malawi, and Kyrgystan (Aim for Human Rights
Conference, 2008). It is difficult to determine the reliability of the HeRWAI, since the length and
complexity of the instrument make an analysis impossible to replicate. Besides this it is also not the aim
of this qualitative instrument to measure the same problems. Despite this, since the instrument has been
used multiple times in various countries, it can be expected that the reliability of the HeRWAI will be
sufficient.
The HeRWAI measures what the specific problem is (in this case: the access to obstetrician care for
undocumented pregnant women) and which policy affects this problem the most. Moreover, when
going through al the questions, a thorough analysis of all aspects of the problem and the policy will be
addressed. By this thorough analysis the HeRWAI measures what it is supposed to measure and is it
expected that its validity will be sufficient.
As mentioned is paragraph 2.1 the interviews will be individual, face-to-face, open-style, and with a
limited degree of pre-structuring. Here the benefits of these characteristics of an interview will be
described. The benefits of the combination of a limited pre-structuring and an open-style are that the
interviewed individuals will be able talk more openly about their knowledge concerning the problem
and policy under research, which will resulted in the gathering of more in-depth information. The
benefits of individual face-to-face interviews will be that; by individual interviewing it will be possible
to focus on just one person, which will make the person talk more openly about the subject (e.g. no
group conforming behaviours); face-to face interviewing will make it possible to read body language
and get direct feedback, which will result in higher quality questions and reactions from the interviewer.
Overall by using different methods (HeRWAI, desk study, interviews, group discussions) there will
be ‘triangulation of methods’ which will heighten the quality of the research (Verschuren &
Doorewaard, 2005).
27

3 Quick scan
The purpose of the quick scan is firstly to link the problem to the best suitable policy, but since the
policy under research is already mentioned in the introduction this chapter can be used in order to see
why this particular policy is chosen. Besides this, the quick scan is used in order to find out if the
chosen policy is applicable to a HeRWAI analysis (HOM, 2006). The quick scan was partly done
during a HeRWAI training at the WGNRR office, in which six staff members participated.
Question 1: What is your first concern?
The first concern is the access to obstetrician care services for uninsured and undocumented women
living in Amsterdam.
Question 2: Which government policies have a significant influence on the problem?
The following governments’ policies and laws are influential on the concern mentioned above:
• Alien policy
• Alien Law
• Benefit Entitlement Act
• Draft bill about the modification of the Health Care Insurance Law (ZvW) (31 249)
• Health policy
• Introduction- and Adjustments Law ZvW
• Immigration policy
• Compulsory Identification Law
Question 3: Which of these policies has the best potential to be changed, with as result a better impact
on the problem? This policy will be the focus of your analysis.
The draft bill about the modification of the Health Care Insurance Law (31 249) has the best potential to
be changed, since it is still a proposal and therefore not implemented yet.
Question 4: Is a HeRWAI analysis relevant for this policy?
A HeRWAI analysis is relevant, because the analysis can be used in order to predict the consequences
of the implementation of the policy on the access to health care for this particular group of women:
undocumented women.
28

Question 5: Will your organization be able to access more detailed information to analyse the policy
within a reasonable time span?
Yes.
Question 6: Can your organization liase with other organizations to strengthen your analysis and
lobbying activities?
A network of many different women’s rights organizations forms the WGNRR, thus liaison with other
organisations is expected not to form a problem.
Question 7: Is making an analysis the best way to contribute to lobbying for improvements to the
policy?
As mentioned in question 4, an analysis of the problem and policy is needed in order to define future
consequences of the draft bill. Only after this analysis it is possible to lobby for improvements, since
then well-founded arguments can be made.
Question 8: Please formulate clearly the policy on which the HeRWAI analysis will be focused.
Draft bill about the modification of the Health Care Insurance Law (31 249).
Question 9: In which stage is the policy?
Policy formulation
29

4 Results
The results of the HeRWAI analysis will be shown according to the six steps: identifying the policy
(4.1); exploring government’s commitments (4.2); describing the capacity for implementing the policy
(4.3); the impact on human rights (4.5); state obligations (4.6); recommendations and action plan (4.7).
Within each step first the sources and methods used for answering the questions will be mentioned;
followed by the answers to all the questions; and the conclusions based on these answers.
In paragraph 4.4 a lobby will be described which was held during the analysis (after step 3). The
reason for this preliminary lobby is that their was voted up on the policy in parliament, and since the
preliminary results showed already negative consequences for the access to obstetrician care timely
action was needed.
The key-questions are shown within a box and answered by the followed questions. Each question is
marked according to the number of the step and question, for example question 1 in step 1 is marked by
s1/q1. This is done in order to easily recall to specific questions. Some questions were inapplicable;
however they were still mentioned for the completeness of the analysis.
4.1 Step 1: identifying the policy
In this first step the problem and policy were researched more thoroughly, as well as the more specific
groups and rights affected by this policy.
4.1.1 Sources and methods
The methods used in order to answer step 1 were a desk study, interviews and other contacts (short
personal conversations or emails). The most important sources used by applying these methods were:
Desk study
- Documents from the House of Commons and the Minister of VWS
- Document of the Commission Medical Care
- Reader “Health, Globalisation and Human Rights” from the Faculty of Earth and Life Sciences of
the Free University in Amsterdam
Interviews
- J. Van Amen from the Coupling Foundation
30

- S. Oudenhuijzen from the CVZ
- H. Playfair, midwife at the Bijlmermeerpractice
- Anonymous, midwife in an Amsterdam hospital
- M. Kreyenbroek, social worker at the AMC (hospital in Amsterdam)
- Undocumented women
Other contacts
- Short talks with: GP friend, Bureau Intake AMC, and a German woman at the women’s café “De
Peper”
- Emails from: Foundation GPs Services posts Amsterdam, and the NZa
4.1.2 Questions
Which (problem and related) policy will be analysed?
S1/q1 Describe the problem
The problem is the access to obstetrician care for uninsured and undocumented pregnant migrants living
in Amsterdam. For more information about the problem, see introduction.
S1/q2 Which ‘main’ policy will be the focus in the HeRWAI analysis? Why has this policy been
selected?
Since a new draft bill (the modification of the Health Care Insurance Law (31 249)) is being discussed
in Dutch parliament at the moment, now is the time to do research about the possible impact of this bill
on the maternal health of undocumented pregnant women.
S1/q3 Who is the main actor implementing the policy?
The main actors for implementing the policy are:
1. Health care providers: general practitioners, doctors, nurses, medical specialists, midwives,
maternity care19 providers, hospital management, workers at AWBZ- institutions, ambulance workers,
and pharmacists.
19
care for mother and child from child birth until the first days after. Maternity care includes: assistance during birth; nursery of mother and child;
early detection of complications; education of mother in caring for the child; if needed household tasks (Encyclo.nl, 2008).
31

2. Government: Ministry of Public Health, Welfare and Sport (VWS).
3. Health professional associations: Royal Dutch Organization of Midwives (KNOV), Royal Dutch
Community to promote the Medical Art (KNMG), Association of Hospitals (NVZ).
4. Funding agencies: Colleges For Health care insurances (CVZ), and maybe regional platforms.
S1/q4 What does the government aim to achieve with this policy?
The main reason for developing the draft bill, as already mentioned in the introduction, was that the
current compensation system was too divided (within Coupling fund, and dubious debtors) and not all
encompassing (AWBZ-care), and therefore not adequate. In the new situation there will only be one
fund, financed by the government (Klink, 2008; Leemhuis-Stout, 2007; Medisch Contact, 2007;
Tweede Kamer der Staten Generaal, 2007).
Another reason for developing a new system was related to the fact that the current implementer of
the compensation system (the Coupling Foundation) was in retroactive effect called by the court a
governmental body. The voluntary board of the foundation wished not to continue under these
conditions, therefore the future existence of the foundation was questioned. Meanwhile, the Coupling
Foundation merged with the CVZ in order to go on with its job until a solution has been brought up. As
a response to this reformation of the foundation, the government came up with a plan about who will be
taking over the foundation’s job: the modified ZvW (J. Van Amen, personal statement, March 5, 2008).
The draft bill assigned CVZ to take over the job of the Coupling Foundation, since it already worked
together with the foundation and had experience with the Dutch health care system.
The goal of the draft bill itself is to prevent considerable income damage of health care providers
who provided ‘medically necessary’ care (see s1/q7 for more information) for undocumented patients
which were not able to pay for their own care (Tweede Kamer der Staten Generaal, 2007). According to
the minister, by providing partial (80%) compensation for medically necessary care the responsibility
stays with undocumented migrants and the health care providers themselves. Full compensation (100%)
would take the urge away for care providers to ask the undocumented patients to pay for their own care
(Tweede Kamer der Staten Generaal, 2007).
S1/q5 What is the actual effect of the policy on women’s health?
The actual effect on women’s health is already mentioned in the introduction, and is also found in
s1/q10 and step 4.
32

S1/q6 Are there special programs to implement the policy? Who is responsible for these programs?
At the moment, March 2008, the Dutch government for implementation of the policy mentions no
special programs.
It is to be recommended though to train health care providers in working with the new finance
system. First-line providers should know where and how to get their compensation and to which
second-line providers (hospitals, pharmacist, AWBZ-institutions and ambulance services) within the
Netherlands to refer to, since only a small selection of second-line providers will be contracted by the
CVZ. A fast referral system is needed in order to give care within an acceptable amount of time.
Second-line providers who are contracted to treat undocumented people should also be trained about
where and how to compensate for the care they provide.
The Commission Medical Care (commonly called ‘Commission Klazinga’) already stated this need
for educating health care providers about the rights, duties, arrangements and procedures involved in the
implementation of the bill (Klink, 2008). Minister Klink (2008) promised to implement an education
program along with the implementation of the policy, but no concrete plans have yet been made.
S1/q7 Are there protocols and regulations to guide the implementation of the policy? Do they include a
description of the exceptions?
No specific protocols are available to guide the implementation; however some guidelines can be
extracted from debates in the House of Commons and conducted interviews (see annex 2).
Medically necessary care
What medically necessary care exactly is was never defined by the implementation of the Benefit
Entitlement Act in 1998. The assumption was at that time that health care providers of undocumented
patients would know for themselves what was necessary and what not. In practice this fact, that no
guidelines are available about medically necessary care, seemed to have caused a problem in the access
to health care for undocumented people (Klazinga et al., 2007).
The Commission Klazinga was appointed to make those guidelines and redefined medically
necessary care as ‘responsible and appropriate medical care’. This kind of care is effective and targeted:
patient-oriented and fine-tuned to the patient’s actual needs. Doctors provide responsible and
appropriate care by applying the same guidelines, protocols, standards and codes of conduct, as defined
by the medical and scientific professions, which they use in regular health care (Klazinga et al., 2007).
The report of the commission was used as guideline in the formation of the draft bill, and during the
debates in the House of Commons (Klink, 2008).
33

Directly accessible care
Health care providers must fill in a form, similar to the forms now used by the Coupling Foundation, in
order to request for compensation for an undocumented patient (Ministry of VWS, 2007b). Data of a
patient needed for the Coupling Foundation are: initials, age, gender, and nationality. According to J.
Van Amen of the foundation (personal statement, March 5, 2008), these data, together with a stamp of
the health care provider and height of the bill, would be sufficient in order to receive compensation.
The only difference in the future system, via the CVZ, is at first that no initials will be asked
anymore in order to avoid the possibility to trace the undocumented care seekers. Second, the health
care providers will be checked upon the fact if they really tried making the patient pay the bill at first
(S. Oudenhuijzen, personal statement, April 22, 2008). However how the latter will be applied in
practice is unknown yet.
Not directly accessible care
The CVZ will also arrange the contracts with selected second-line (not directly accessible health care
providers) providers and the content of these contracts. For selected providers it will also be made
possible to arrange first-line (directly accessible) care within their contracts (Ministry of VWS, 2007b).
No criteria to select the ‘best’ health care providers were mentioned in the law; therefore the CVZ
had to make its own. This was rather difficult, since it is not possible to select upon care offer while no
data is available on what sorts of care undocumented people need the most. It is also impossible to
select upon care rates, since rates do not define what is best for the undocumented population. Despite
these difficulties S. Oudenhuijzen from the CVZ (personal statement, April 22, 2008) could state five
criteria CVZ staff is going to use when selecting the ‘best’ health care providers:
1. Are there large concentrations of undocumented migrants living nearby the health care provider?
2. Does the health care provider have experience with treating undocumented patients, and does he
reports on this?
3. Does the health care provider have protocols available for treating undocumented patients?
4. Does the health care provider have the reputation to make effort in first trying to arrange payments
with the patients themselves (like partial payment arrangements)?
5. Does the health care provider make a clear distinction between directly and not directly accessible
care?
When all these questions are answered by ‘yes’ than the health care provider will be a good candidate
for selection. In order to answer these five questions for all health care providers (hospitals, pharmacies,
and AWBZ-institutions) al lot of research needs to be done by the CVZ.
34

Ambulance services are not possible to contract in the opinion of the CVZ since they work within a
specific area. It will therefore form a problem if the undocumented patient lives outside this area. As
solution to this problem ambulance services will probably be offered an open contract. This contract can
then be signed by all ambulance services in the Netherlands who wish to receive compensation for
transporting undocumented patients (S. Oudenhuijzen, personal statement, April 22, 2008).
Which groups are affected by the policy?
S1/q8 Which groups does the government (or other main actor) intend to reach with the policy?
The government aims to reach all health care providers which suffer income loss from treating
uninsured and undocumented patients who are not able to pay for their own care (Ministry of VWS,
2007b).
S1/q9 Which groups does the policy actually affect (positively or negatively)?
The policy will probably have different effects on various groups of health care providers and
undocumented women.
The first-line providers will face an income loss of 20%, the higher the treatment fee the more the
provider will suffer from the policy. Care during pregnancy is a vast and fairly high sum, meaning that
midwives will suffer more income loss than other first-line providers like GPs who have more variable
and lower bills (GP friend, personal statement, February 27, 2008; S. Oudenhuijzen, personal statement,
April 22, 2008).
Within the group of midwives again differences can be found. Some midwife-practices are located
within an area where many undocumented people live and therefore treat many undocumented pregnant
patients. An example is a practice in the Bijlmer in Amsterdam of which 30% of its pregnant patients
are undocumented. (H. Playfair, personal statement, March 18, 2008; J. Van Amen, personal statement,
March 5, 2008; S. Oudenhuijzen, personal statement, April 22, 2008; Klazinga et al, 2007). The new
compensation system will have a large impact on practices like these as seen by the statement below.
– “I know that I have a care duty and am therefore not allowed to slide women off to other health care providers, but I
will of course not work for free. My boundaries will be crossed if the draft bill will be implemented in its current content
(80% compensation)” – H. Playfair, midwife in Bijlmermeerpractice in Amsterdam (personal statement, March 18, 2008)
35

Within second-line providers the effect of the policy will also vary. Contracted not directly
accessible providers, as mentioned in s1/q7, can also be contracted for directly accessible care (e.g. first
aid care in a hospital). These contracted providers have consequently the prospect of receiving more
compensation (probably the full 100%) for directly accessible care than the non-contracted (80%) (S.
Oudenhuijzen, personal statement, April 22, 2008).
Subgroups of undocumented women are important to identify here, since they could face different
problems.
1. Rural - urban: only a few contracted health care providers (1-2 hospitals in Amsterdam) will be
available for undocumented pregnant women. Women living in urban areas, nearby the hospitals, will
not need to travel as long as women living in rural areas. Thus women in rural areas are therefore
disadvantaged: longer travel time and higher travel expenses.
2. Money: there are women who are able to (partly) pay for their care since they have an (illegal) job or
another person (spouse, relative etc.) who is willing to pay for the care, but there are also women who
are not able to pay even partly for their treatment. The latter will probably be more afraid to seek care
and besides this will presumably have more difficulties in finding proper housing or buying healthy
foods (both very important determinants of health).
3. Knowledge of Dutch health care system: some undocumented patients have more knowledge about
the Dutch health care system like rejected asylum seekers and/ or undocumented migrants with a large
social network (Klazinga et al, 2007). This all has to do with the length of stay in the Netherlands: the
longer the more they know and are able to manage in Dutch society.
4. Women with HIV/AIDS: these women are also more vulnerable, because they need to use health care
services more often than women who are not affected by this serious infectious disease. They need to
travel more often to contracted health care services in order to get their medicines and physical exams.
Pregnant women with HIV/AIDS always need to deliver under supervision of a gynaecologist in the
hospital, which is mostly further away than the first-line obstetrician. Moreover, HIV-positive or not,
most undocumented pregnant women need to deliver in hospital, because of their elevated risk on
complications during delivery (Anonymous, personal statement, April 10, 2008).
S1/q10 What are the perceptions of the affected groups regarding the problem and related policy?
The most important perceptions of and about the affected groups (midwives, and undocumented
women) are enlisted below. These perceptions were collected from interviews (annex 2) and other
contacts (annex 3).
36

Problem
• Undocumented pregnant women seek care at a much later stage in pregnancy, which heightens the
risk on complications for both mother and child. The reasons for this delayed care seeking are already
mentioned in the introduction under “The Netherlands: illegal migrants”, but the most important one is
the financial barrier (Klazinga et al, 2007; Foundation GPs Services posts Amsterdam, personal
statement, March 10, 2008; H. Playfair, personal statement, March 18, 2008; Anonymous, personal
statement, April 10, 2008; M. Kreyenbroek, personal statement, April 18, 2008).
• Undocumented pregnant migrants are more at risk for various diseases like HIV/AIDS and therefore:
heightens their risk on complications during pregnancy; and makes them need to visit the hospital
regularly for CD4 count20 monitoring and medication (H. Playfair, personal statement, March 18, 2008;
Anonymous, personal statement, April 10, 2008; Undocumented woman 1, personal statement, May 20,
2008; Undocumented woman 2, personal statement, May 27, 2008).
• HIV-infected undocumented women are allowed to stay in the Netherlands until her CD4 count is
stable and it is safe to return to her country of origin. However the safety of returning to the country of
origin is measured by the availability of HIV-medications and neither its accessibility nor affordability
(M. Kreyenbroek, personal statement, April 18, 2008; Undocumented woman 2, personal statement,
May 27, 2008).
• It takes a lot more time and effort for midwives to treat undocumented pregnant women than other
women: more pathology is prevalent among these women, therefore a higher number of consultations
are needed; they seek care more often at a later stage, with the consequence of being too late to prevent
certain diseases; they mostly are not able to pay for their own care, which means that midwives are left
with an administrative load in order to get compensation via the Coupling Foundation (in the future the
CVZ). Besides this, midwives have difficulties in communicating with undocumented women: they
speak hardly English and some are even illiterate, for which education leaflets is no use (H. Playfair,
personal statement, March 18, 2008; Anonymous, personal statement, April 10, 2008).
• Occasionally uninsured and undocumented patients are asked to pay upfront before receiving the
needed treatment; this is mainly the case within hospitals. Hospitals are therefore known to be more
difficult to access for undocumented patients than first-line practices. Also between hospitals
differences in accessibility are to be found, causing undocumented patients to be concentrated within a
small number of hospitals in Amsterdam (German woman at women’s café “De Peper”, personal
20
a measure of the number of helper T cells per cubic millimetre of blood, used to analyse the prognosis of patients infected with HIV (Medical
Dictionary, 2008).
37

statement, February 2, 2008; Foundation GPs Services posts Amsterdam, personal statement, March 10,
2008; H. Playfair, personal statement, March 18, 2008; Bureau Intake AMC, personal statement, April
18, 2008; NZa, personal statement, May 15, 2008; Undocumented woman 1, personal statement, May
20, 2008).
• All new patients, and therefore also undocumented patients, are in hospitals referred to Bureau
Intake in order to get registered. This registration is usually done before treatment is provided (unless in
case of emergency or HIV-infection). At the Bureau the payment arrangements are made for
undocumented patients who cannot get insurance (Anonymous, personal statement, April 10, 2008; M.
Kreyenbroek, personal statement, April 18, 2008). Many undocumented pregnant patients however
never show up at the Bureau, because they are afraid of being registered. Some of these patients are
even so scared that they never return to the hospital, and what happens to them nobody knows
(Anonymous, personal statement, April 10, 2008). The latter also seems the case for directly accessible
midwife-practices: that undocumented women disappear after several consultations (H. Playfair,
personal statement, March 18, 2008).
• Midwives, especially the ones working in hospitals (where care is more expensive), are constantly
aware of the costs and therefore necessity of the treatment and medicines they provide for
undocumented women. Besides this maternity care is an example of care which is mostly not provided
because of its high costs (Foundation GPs Services posts Amsterdam, personal statement, March 10,
2008; Anonymous, personal, statement, April 10, 2008; Undocumented woman 1, personal statement,
May 20, 2008).
Policy
• From all the health care providers, obstetrician care providers are the group which will be affected
the most from the new compensation arrangement: the reasons for this were already mentioned in the
introduction (GP friend, personal statement, February 27, 2008; J. Van Amen, personal statement,
March 5, 2008; S. Oudenhuijzen, personal statement, April 22, 2008).
• The fact that directly accessible midwife-practices will be suffering a fair income loss for treating
undocumented patients heightens the chance that these midwives will slide patients off to not directly
accessible providers that do receive fully compensation (H. Playfair, personal statement, March 18,
2008; S. Oudenhuijzen, personal statement, April 22, 2008).
• Compensation is based upon the uncollectable bill and not the whole account. For example if an
undocumented patients pays 20% of the bill merely 80% from the uncollectable is compensated for via
38

the CVZ, which causes the health care provider to never receive money for the whole account (S.
Oudenhuijzen, personal statement, April 22, 2008).
• In the new compensation system the health care providers will be checked upon about the fact if they
have taken effort to make the undocumented patient pay first for the treatment, which in the old system
was based upon trust (J. Van Amen, personal statement, March 5, 2008; S. Oudenhuijzen, personal
statement, April 22, 2008). This change will probably negatively affect the relationship between the
health care professional and the patient.
• The criteria ‘duration of stay’ is seen by midwives as inapplicable since it is not possible to base the
provision of obstetrician care on the length of stay: pregnancy takes a set period of time and is all
medically necessary (H. Playfair, personal statement, April 10, 2008; Anonymous, personal statement,
April 10, 2008).
• The process of compensation for first-line midwives, thus via the local GGD and the Coupling
Foundation, take a lot of time and effort: takes one weekend per month to fill in all the forms, which
need to be send in two months after the provided treatment. Then it takes another three months before
the reimbursement is received (H. Playfair, personal statement, March 18, 2008). Since the policy states
that not much is going to change within this process, nothing is done about the administrative load
midwives need to deal with.
• Overall, no money was available to research the possible negative consequences of the introduction
of the new compensation system; therefore future obstacles could prevail (S. Oudenhuijzen, personal
statement, April 22, 2008).
Which rights are affected by the policy?
S1/q11 Which human rights may be affected?
Human rights are not binding, but are seen as a common standard of achievement for all persons of all
nations. Human rights were first stated in the Universal Declaration of Human Rights (UDHR), and the
rights from this declaration important in this case are:
• Right to equality (Article 1)
• Right to non-discrimination (Article 2)
• Right to life, liberty and security (Article 3)
• Right to equality before the law (Article 7)
• Right to a standard of living adequate for the health and well-being of herself and her family,
including food, clothing, housing and medical care and necessary social- services, and the right to
39

security in the event of unemployment, sickness, disability, widowhood, old age or other lack of
livelihood in circumstances beyond her control (Article 25) (Free University, 2008).
4.1.3 Conclusions
The government’s aimed with the implementation of the modification ZvW to make the compensation
system for health care providers more uniform and all encompassing. In order to do so, they introduced
one fund for the all forms of care. This fund should prevent health care providers, who provide care to
undocumented people whom are not able to pay for their own care, having considerable income losses.
Despite of these good intentions it is expected that the implementation of the draft bill in its current
content will form an even larger barrier for undocumented pregnant women to seek care and for
midwives to keep treating these women. Besides this, some groups of midwives and undocumented
women will be more disadvantaged than the other and the policy does not take this into account.
Some guidelines in relation to the implementation of were mentioned concerning: the definition of
medically necessary care; how directly accessible care providers are able to ask for compensation; and
the selection of the ‘best’ not directly health care providers. However no specific programs and
protocols have been stated yet to guide the implementation and this can be problematic. Problematic can
be: the checking upon health care providers if they asked the patient for payment first; the distinction
between directly and not directly accessible care; the administrative load of health care providers for
receiving compensation.
According to the perceptions of and about the affected groups, undocumented women and midwives
can be concluded that undocumented pregnant women face many problems (e.g. more complications,
higher prevalence of infectious diseases) during their pregnancy. And that these problems can be
explained by their delayed care seeking behaviours which again is caused by financial barriers: anxiety
for not receiving health care if the patient is neither insured nor has any money. As for midwives they
struggle with the fact that undocumented patients take more time and effort to treat. If they will receive
less money in the future for these patients this make if difficult to keep treating them, which again
affects the access to health care.
If the modification ZvW will be implemented it will violate the undocumented pregnant women’s
right to equality (before the law), non-discrimination, health, life, liberty and security.
40

4.2 Step 2: exploring the government’s commitments
In step 2 of the HeRWAI analysis the Dutch government’s commitments were researched. This was
done by exploring the national and international agreements the government has made as well as the
procedures in which civil society can participate in decision-making.
4.2.1 Sources & methods
The method used in order to answer step 2 is a desk study. The most important sources used by
applying this method are:
- Conventions, declarations and consensus documents
- Documents from the Dutch government and its ministries
- Reader “Health, Globalisation and Human Rights” from the Faculty of Earth and Life Sciences of
the Free University in Amsterdam
- Online law books
- Sites from large human rights related organizations like PICUM, UN, European Council, Peoples
Health Movement, and Social Watch.
4.2.2 Questions
Which treaties and consensus documents are relevant?
S2/q1 Which international treaties has your country ratified? Were any reservations or limitations
made?
Treaties are binding documents and the following international treaties and their optional protocols are
signed (year of signing mentioned behind the treaties) by the Dutch government:
1. The Convention on the Elimination of All Forms of Discrimination against Women (CEDAW) and
the Optional Protocol (CEDAW-OP), respectively in 1994 and 1999.
2. The International Convention on the Elimination of All Forms of Racial Discrimination (ICERD),
1966.
3. The International Covenant on Economic, Social and Cultural Rights (ICESCR), 1969.
4. The International Convention on the Rights of the Child (CRC) and the Optional Protocol to the
CRC on the Sale of Children, child prostitution and child pornography (CRC-OP-SC), 1990 and 2000.
5. The International Covenant on Civil and Political Rights (CCPR), the Optional Protocol to the CCPR
(CCPR-OP1), in 1969, and the Second Optional Protocol to the CCPR (CCPR-OP2-DP), 1990.
41

6. The Convention Against Torture and Other Cruel Inhuman or Degrading Treatment or Punishment
(CAT), 1985.
7. The Convention related to the status of Refugees and the Protocol, respectively in 1956 and 1968
(United Nations Human Rights, 2008).
The most important articles mentioned in these conventions for this specific case are:
• The States Parties to the present Covenant recognize the right of everyone to the enjoyment of the
highest attainable standard of physical and mental health (ICESCR Article 12.1).
• The steps to be taken by the States Parties to the present Covenant to achieve the full realization of
this right shall include those necessary for:
a) The provision for the reduction of the stillbirth-rate and of infant mortality and for the healthy
development of the child;
b) The improvement of all aspects of environmental and industrial hygiene;
c) The prevention, treatment and control of epidemic, endemic, occupational and other diseases;
d) The creation of conditions which would assure to all medical service and medical attention in the
event of sickness (ICESCR Article 12).
• States are under the obligation to respect the right to health by, inter alia, refraining from denying or
limiting equal access for all persons, including prisoners or detainees minorities, asylum seekers and
illegal immigrants, to preventative, curative and palliative health services (ICESCR General Comment
14).
• Although some of these rights, such as the right to participate in elections, to vote and to stand for
election, may be confined to citizens, human rights are, in principle, to be enjoyed by all persons. States
parties are under an obligation to guarantee equality between citizens and non-citizens in the enjoyment
of these rights to the extent recognized under international law (ICERD General Comment 30).
• All of the rights outlined in the ICCPR must be guaranteed without discrimination between citizens
and aliens (ICCPR General Comment 15).
• No discrimination against women of any kind (CEDAW Article 1).
• States parties shall take all appropriate measures to eliminate discrimination against women in the
field of health care in order to ensure, on a basis of equality of men and women, access to health care
services, including those related to family planning (CEDAW Article 12.1).
• Notwithstanding the provisions of paragraph I of this article, States Parties shall ensure to women
appropriate services in connection with pregnancy, confinement and the post-natal period, granting free
42

services where necessary, as well as adequate nutrition during pregnancy and lactation (CEDAW
Article 12.2)
• To diminish infant an child mortality; to ensure appropriate prenatal and postnatal health care for
mothers; to develop preventive health care, guidance for parents and family planning education and
services (CRC Article 24.2a, d, f) (Human Rights Library, 2008; Platform for International Cooperation
on Undocumented Migrants (PICUM), 2007).
S2/q2 Which relevant regional treaties has your country ratified?
The following regional treaties and their optional protocols are signed by the Dutch:
1. Convention for the Protection of Human Rights and Fundamental Freedoms (ECHR), 1954
2. European Social Charter (ESC), 1961
3. International Labour Organization (ILO) Convention on Migrant Workers, 1975
The most important articles mentioned in theses convention are in this specific case:
• Everyone’s right to life shall be protected by law (ECHR Article 2).
• The enjoyment of the rights and freedoms set forth in this Convention shall be secured without
discrimination on any ground such as sex, race, colour, language, religion, political or other opinion,
national or social origin, association with a national minority, property, birth or other status (ECHR
Article 14) (Human Rights Library, 2008).
• With a view to ensuring the effective exercise of the right to protection of health, the Contracting
Parties undertake, either directly or in co-operation with public or private organizations, to take
appropriate measures designed inter alia:
1. To remove as far as possible the causes of ill-health;
2. To provide advisory and educational facilities for the promotion of health and the encouragement of
individual responsibility in matters of health;
3. To prevent as far as possible epidemic, endemic and other diseases (ESC Article 11).
• With a view to ensuring the effective exercise of the right to social and medical assistance, the
Contracting Parties undertake:
1. To ensure that any person who is without adequate resources and who is unable to secure such
resources either by his own efforts or from other sources, in particular by benefits under a social
security scheme, be granted adequate assistance, and, in case of sickness, the care necessitated by his
condition;
2. To ensure that persons receiving such assistance shall not, for that reason, suffer from a diminution of
43

their political or social rights;
3. To provide that everyone may receive by appropriate public or private services such advice and
personal help as may be required to prevent, to remove, or to alleviate personal or family want (ESC
Article 13).
• Undocumented workers shall enjoy equality of treatment for himself and his family in respect of
rights arising out of past employment as regards remuneration, social security and other benefits (ILO
Convention Article 9.1) (Council of Europe, 2005; Human Rights Library, 2008; Human Rights
Library, 2008b; PICUM, 2007).
S2/q3 Which consensus documents does your government support?
Consensus documents are not binding, but if supported they form a moral obligation. The most
important consensus documents, supported by the Dutch government, will firstly be enumerated and
secondly elaborated on more thoroughly. The consensus documents supported by the Dutch government
are:
1. Declaration on the Human Rights of Individuals Who Are Not Nationals of the Country in Which
They Live, 1985
2. Declaration of Alma Ata, 1987
3. Vienna Declaration and Programme of Action, 1993
4. Programme for action on the United Nations International Conference on Population & Development
(ICPD), 1994
5. Beijing Declaration and Platform for Action, 1995
6. The UN Millennium Declaration, 2000
7. Resolution Concerning a Fair Deal for Migrant Workers in a Global Economy, 2004
8. Resolution on the Protection of Migrants, 2004
9. Resolution on the Human Rights of Migrants, 2005
Declaration on the Human Rights of Individuals Who Are Not Nationals of the Country Which They
Live
The General Assembly of the UN adopted this resolution in 1985, which encompasses ten articles about
the protection of human rights, without discrimination on residence status. The human rights here
referred to are: right to equality before the courts, freedom of thought, opinion, conscience and religion
(PICUM, 2007).
44

Declaration of Alma Ata
The International Conference on Primary Health Care, held in Alma Ata in September 1978, expressed
the need to a fast action by all governments, health and development workers, and the world community
to protect and promote the health of all people in the world (People’s Health Movement, 2005).
The first two statements of the Declaration are most interesting to state here: the Conference strongly
reaffirms that health, which is a state of complete physical, mental and social well-being, and not
merely the absence of disease or infirmity, is a fundamental human right and that the attainment of the
highest possible level of health is a most important world-wide social goal whose realization requires
the action of many other social and economic sectors in addition to the health sector; the existing gross
inequality in the health status of the people particularly between developed and developing countries as
well as within countries is politically, socially and economically unacceptable and is, therefore, of
common concern to all countries (People’s Health Movement, 2005).
Vienna Declaration and Programme of Action
In 1993, during the World Conference on Human Rights, the Vienna Declaration and Programme of
Action were formed. The promotion and protection of human rights were found to be of utmost
importance; hereby reaffirming the rights mentioned in the UDHR (United Nations, 1993).
In the Programme of Action all sorts of rights are being translated into an action statement like the
rights for ethnic groups, women and children.
Program for Action ICPD
The Program for Action was formed by world leaders, high ranking officials, representatives of NGOs
and United Nation agencies during the ICPD in Cairo, Egypt 1994 (International Institute for
Sustainable Development, 1994).
Within this Program for Action many actions are stated which are important for the subject of this
report. Principle 2 is interesting to state here: Human beings are at the centre of concerns for sustainable
development. They are entitled to a healthy and productive life in harmony with nature. People are the
most important and valuable resource of any nation. Countries should ensure that all individuals are
given the opportunity to make the most of their potential. They have the right to an adequate standard of
living for themselves and their families, including adequate food, clothing, housing, water and
sanitation (International Institute for Sustainable Development, 1994).
45

Beijing Declaration and Platform for Action
The Beijing Declaration and Platform for Action was adopted during the fourth world conference on
women which was held in Beijing in September 1995. Governments participating in this conference
determined to advance the goals of equality, development, and peace for all women around the world,
in the interest of all humanity (Social Watch, 1995). Commitments made in previous declarations and
conventions were reaffirmed and put on the agenda again.
An important strategic objective in the case of access to obstetrician care for undocumented pregnant
women is C1: increase women's access throughout the life cycle to appropriate, affordable and quality
health care, information and related services. Also interesting to note here is action ‘i’ for the
government: strengthen and reorient health services, particularly primary health care, in order to ensure
universal access to quality health services for women and girls; reduce ill health and maternal morbidity
and achieve world wide the agreed-upon goal of reducing maternal mortality by at least 50 per cent of
the 1990 levels by the year 2000 and a further one half by the year 2015; ensure that the necessary
services are available at each level of the health system and make reproductive health care accessible,
through the primary health-care system, to all individuals of appropriate ages as soon as possible and no
later than the year 2015 (Social Watch, 1995).
UN Millennium Declaration
The UN Millennium Declaration was submitted by a large number of world leaders during the
Millennium Summit in September 2000. By signing this declaration many nations (e.g. the Netherlands)
formed together a global partnership in reducing extreme poverty. This was done by the settlement of
time-bound goals and targets for the year 2015: the MDGs (Millennium Project, 2006).
In total there are eight MDGs: 1) eradicate extreme hunger and poverty; 2) achieve universal primary
education; 3) promote gender equality and empower women; 4) reduce child mortality; 5) improve
maternal health; 6) combat HIV/AIDS, malaria, and other diseases; 7) ensure environmental
sustainability; 8) develop a global partnership for development (Millennium Project, 2006). The MDGs
all consist of one or more measurable targets, which describe more precisely what needs to be achieved
before 2015. The targets are accompanied by the description of several indicators in order to measure
progress towards the accomplishment of the MDGs.
MDG 4 and 5 are closely related (Wiebinga, 2007) and of importance to undocumented pregnant
women and their unborn children. MDG 4 is about the reduction of worldwide under-five child
mortality rate by two-third by the year 2015. The indicators mentioned by this target are: 1) under-five
46

mortality rate; 2) infant mortality rate; 3) proportion of one-year old children immunized against
measles (Millennium Project, 2006).
MDG 5 states to improve the maternal health by aiming for the reduction of the worldwide maternal
mortality by 75% by the year 2015 (Women Deliver, 2007). The indicators for this target are: 1)
maternal mortality ratio; and 2) proportion of births attended by skilled health personnel (Millennium
Project, 2006). In 2006 a third target was added: 3) universal access to reproductive health (Wiebinga,
2007).
Resolution Concerning a Fair Deal for Migrant Workers in a Global Economy
In 2004, during the 92nd Session of the General Conference of the International Labour Organization,
the Resolution Concerning a Fair Deal for Migrant Workers in a Global Economy was adopted.
This resolution says that it is important to ensure that the human rights of irregular migrant workers
are protected. It should be recalled that the ILO instruments apply to all workers, unless otherwise
stated. Consideration should be given to the situation of irregular migrant workers, ensuring that their
human rights and fundamental labour rights are effectively protected, and that they are not exploited or
treated arbitrarily (PICUM, 2007).
Resolution on the Protection of Migrants, 2004
By adopting this resolution all the member states of the UN General Assembly need to promote and
protect the human rights of all migrants, in conformity with the UDHR and the international instruments
to which they are party (PICUM, 2007).
Resolution on the Human Rights of Migrants, 2005
With the Resolution on the Human Rights of Migrants, the UN Commission on Human Rights requests
all member states to effectively promote and protect the human rights and fundamental freedoms of all
migrants, especially those of women and children, regardless of their immigration status, in conformity
with the UDHR and the international instruments to which they are party (PICUM, 2007).
S2/q4 Is the government bound to other bilateral or multilateral agreements which may influence the
policy? Which ones?
The Dutch government contributes to international multilateral organizations which are concerned with
health like the World Health Organisation (WHO), UNFPA (sexual and reproductive health), UNICEF
(children’s health) and the World Bank.
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The Netherlands also supports the health sector of twelve partner countries. This support is arranged
by bilateral funding of programmes related to two priorities stated in the Dutch development policy:
HIV/AIDS, and sexual and reproductive health and rights (Ministry of Foreign Affairs, 2008).
Reproductive health is seen as prerequisite for achieving the MDGs, therefore the Dutch government
stated a few objectives: more people deciding freely whether or not to have children and how many;
fewer women dying during pregnancy and childbirth; fewer new cases of HIV infections, especially
among adolescents; more people with access to prevention, care and treatment for HIV/AIDS; improved
reproductive rights (Ministry of Foreign Affairs, 2008b).
The Dutch Ministry of Foreign Affairs (2007) even formulated a human rights strategy for their
foreign policy. Within this human rights strategy the Dutch government wants to make human rights an
integral part of the relations with other countries. Equality is seen as an important subject and cultural
differences may not be used as a justification for not respecting certain rights. The strategy states that
the Netherlands will make an effort to move women’s rights higher up the political agenda of the
Council of Europe and the UN. The Netherlands will therefore also support human rights defenders and
promote freedom of expression. A new human rights fund is to financially support human rights
projects, for the year 2008 the fund consists of 20 million euros.
What does national legislation say about women’s right to health?
S2/q5 What does the constitution or other national laws say about the right to health?
The constitution of the European law states in Article 95 that everyone has the right to access to
preventative and medical health care, but under the conditions of the national law (Wetboek-online,
2008).
The constitution of the Dutch law states in Article 1: “everybody in the Netherlands should be
treated equally, and that discrimination is not permitted on any basis” (Overheid.nl, 2008).
Dutch laws that are important for reproductive health are:
1. The Law Determination Pregnancy (in Dutch: Wet Afbreking Zwangerschap, WAZ) allows women
to have an abortion under certain prerequisites like: abortion is only allowed within a certain period of
the pregnancy; informing the pregnant woman about the consequences and other options than abortion
is obliged; and only a trained doctor is allowed to end a pregnancy (Healthlaw, 2006).
2. The Law on the Collective Prevention Public Health (in Dutch: Wet op de Collectieve Preventie
Volksgezondheid, WCPV) states that the local municipalities are responsible for the protection and
48

promotion of the health of the community, also the prevention and the early detection of diseases fall
under the municipalities’ responsibility (Healthlaw, 2006b).
3. The Law Job and Care (in Dutch: Wet Arbeid en Zorg, WAZO) proclaims the right of pregnant
women to have 16 weeks off during maternity leave by providing money (based on their salary) during
this leave (UWV, 2008).
4. The Law Complaint right Clients Health sector (in Dutch: Wet Klachtrecht Clienten Zorgsector,
WKCZ) gives patients the ability to complain about the Dutch health care system and providers. The
Health Care Inspectorate (IGZ) has the responsibility to watch over the implementation of the law (IGZ,
2008).
S2/q6 Does the country have a law prohibiting the discrimination of women?
Article 1 of the Dutch constitution, as mentioned in the previous question, prohibits the discrimination
on any base, thus also on gender and residence status.
S2/q7 What does the constitution or other national laws say about other rights which are relevant to the
policy?
Besides the laws mentioned in s2/q5 also of importance here is Article 22 of the constitution, which
states three obligations of the Dutch government:
1. The government makes arrangements to promote public health;
2. Promotes sufficient housing opportunities;
3. Cares for the social and cultural development and for recreation (Overheid.nl, 2008).
The three obligations of the government can be regarded as rights of the Dutch citizens.
Another obligation which can be regarded as a right for Dutch patients is stated in the Law on the
Medical Treatment Agreement (WGBO): the physician should act as a good health care provider and
can only deviate from the guidelines in benefit of the patient (Klazinga et al, 2007).
S2/q8 Does the country have laws that criminalize medical procedures only needed by women and/or
that punish women who undergo those procedures?
No.
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S2/q9 Do local, customary or religious laws influence the health rights of women in relation to your
policy?
The Hippocrates’ Oath (seen in box 1) can be regarded as a customary law for all medical practitioners
in the world. The oath states the practitioners’ responsibilities and the things he/she should or should
not do. However, the oath is very old (stated 400 BC) and therefore not very practical in these times.
Besides this, medical practitioners from different countries practice the oath differently, or sometimes
even do not (De Commissie Herziening Artseneed, 2003).
Box 1. Hippocrates’ Oath dated 400 BC. Source: Howard University College of Medicine (2002).
I SWEAR by Apollo the physician, and Aesculapius, and Health, and All-heal, and all the gods and goddesses, that,
according to my ability and judgment, I will keep this Oath and this stipulation- to reckon him who taught me this Art
equally dear to me as my parents, to share my substance with him, and relieve his necessities if required; to look upon his
offspring in the same footing as my own brothers, and to teach them this art, if they shall wish to learn it, without fee or
stipulation; and that by precept, lecture, and every other mode of instruction, I will impart a knowledge of the Art to my own
sons, and those of my teachers, and to disciples bound by a stipulation and oath according to the law of medicine, but to
none others. I will follow that system of regimen which, according to my ability and judgment, I consider for the benefit of
my patients, and abstain from whatever is deleterious and mischievous. I will give no deadly medicine to any one if asked,
nor suggest any such counsel; and in like manner I will not give to a woman a pessary to produce abortion. With purity and
with holiness I will pass my life and practice my Art. I will not cut persons laboring under the stone, but will leave this to be
done by men who are practitioners of this work. Into whatever houses I enter, I will go into them for the benefit of the sick,
and will abstain from every voluntary act of mischief and corruption; and, further from the seduction of females or males, of
freemen and slaves. Whatever, in connection with my professional practice or not, in connection with it, I see or hear, in the
life of men, which ought not to be spoken of abroad, I will not divulge, as reckoning that all such should be kept secret.
While I continue to keep this Oath unviolated, may it be granted to me to enjoy life and the practice of the art, respected by
all men, in all times! But should I trespass and violate this Oath, may the reverse be my lot!
In order to solve the problem of the unpractical Hippocrates’ Oath the KNMG requested the
Commission Revision Physician’ Oath to reformulate the oath; making it more applicable to the current
Dutch society and its renewed considerations. This renewed oath is seen in box 2 on the next page.
Attention will be given about this Dutch physician’ oath during the graduation ceremony of medical
practitioners in the Netherlands, in order to reflect upon its norms and values (De Commissie
Herziening Artseneed, 2003). The medical practitioners here aimed for are: basic physicians, GPs, and
medical specialists (Klazinga et al, 2007).
Box 2. The Dutch physician’ oath. Source: De Commissie Herziening Artseneed (2003).
I swear/promise that I will exercise the medical art as well as possible to serve my fellow human beings. I will take care of
the sick, promote health and relieve suffering.
I put the interest of the patient first and respect his conceptions. I will do no damage to the patient. I listen to him and will
inform him well. I will keep secret what has been entrusted to me.
I will promote the therapeutic knowledge of myself and others. I recognize the borders of my possibilities. I will establish
myself open and verifiable, and I know my responsibility for the society. I will promote the availability and accessibility of
the health care. I make no abuse of my medical knowledge, also not when pressurized.
I will keep the profession of physician in honour.
That is what I promise.
or
So help me God almighty.
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For obstetrician care providers, different guidelines and protocols (concerning care before, during,
and after pregnancy) are available which can be regarded as customary laws. These guidelines and
protocols are mostly stated by the KNOV (2008).
Some religions are not in favour of contraception and/ or abortion, which could influence the sexual
and reproductive rights of these women. However, how much influence this is remains uncertain.
Does the government have a national health strategy and other relevant policies?
S2/q10 does the government have a national health strategy?
Every year the Dutch Ministry of VWS presents its policy agenda for the coming year. For the year
2008 the focus is on quality, safety, innovation, work in health care, and prevention and participation
(Ministry of VWS, 2007c). Interesting in this case are the following points of the policy agenda:
• Prevention is marked as a priority in order to prevent curative care. First-line care providers are
important in preventing the need for curative care by detecting risk factors at an early stage.
• The birth control pill is reintroduced in the basic insurance package.
• The requests for care are increasing because of the demographic changes (more elderly), which
means that the health care providers need to work more efficiently. In order to do so the government
wants to force back the administrative load and bureaucracy health care providers need to deal with.
• The government supports the reception service of women, which is the responsibility of
municipalities, by the provision of extra money. Also the reception and assistance of pregnant teenagers
is stated as important to support.
• The norms of the medical-ethical policy of the Dutch government are based upon the human rights
conventions it supports.
Since the municipality Amsterdam is responsible for a large part of the preventative care, which
involves family planning, it is imperative to look at its local health strategy of 2008-2011. One of the
local strategy’s priorities is sexual health, which encompasses safe sex, teenage pregnancies and
abortions, and sexual defensibility (GGD Amsterdam, 2007).
S2/q11 Has the government developed indicators and benchmarks to measure its progress?
Within neither the national nor the local health strategy there are benchmarks stated about the points
mentioned in the previous question. However there are several independent research institutions, like
the RIVM, who report regularly on public health issues. Data from these institutions can be used in
order to measure its progress.
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S2/q12 Which other national policies are relevant to the policy under analysis?
The national policies relevant for the modification of the Health Care Insurance Law are mentioned in
question 2 of the quick scan.
How is the participation of civil society organized?
S2/q13 What are the official ways by which individuals, NGOs and civil society groups can influence
policy-making and legislation (mechanisms for civil society participation)?
The Netherlands is directed by means of a parliamentary democracy, with the government as highest
authority. The government consists of: the head of state, the queen, and the parliament itself. The Dutch
citizens are able to vote during elections for the representatives of their choice in parliament (national
level), the provinces (regional level), and the municipalities (local level) (Overheid.nl, 2008b).
In referenda Dutch citizens are able to vote on specific topics (like the Euro currency), but this does
not occur very often.
Citizens can influence decisions of the parliament in the form of organizations (patients, volunteers,
NGOs, community etc.), research (Health Council, RIVM, universities etc.), demonstrations and strikes,
and in many more ways.
S2/q14 Where can people go to make a complaint (mechanisms for redress)?
Different mechanisms for redress are present in the Netherlands:
• The national and municipal ombudsman takes care of complaints inhabitants have about the Dutch
government. Every year about 10.000 complaints are made. The ombudsman can be seen as an effective
organization, despite of the fact that the law states which complaints the ombudsman is granted to do
research on (Ombudsman.nl, 2008).
• There are a lot of patient’s rights organizations in the Netherlands; almost for every disease an
organization can be found. Health care providers are obliged, as written in the WKCZ, to inform
patients to which organization to go to for a certain complaint (Kiesbeter.nl, 2008). Many hospitals or
health care practices themselves also have either an arrangement for complaints or even a complaint
commission. The effectiveness of all these organizations in redressing the issues of patients would be
too much to list here, but expected is that some are more effective than the other.
• The Health Care Inspectorate (IGZ) acts in public interest on problems in the health care sector
which citizens are unable to assess or influence by themselves. The IGZ is an independent organization,
but falls under the responsibility of the Ministry of VWS. The Inspectorate reports each year within
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several surveys on the Dutch health care, and evaluates the yearly developments in an annual report.
Some reports are made on request of the national, provincial or local governments (IGZ, 2008b). The
effectiveness of the IGZ is to be doubted since a conflict of interest is prevalent here: on one hand the
IGZ has the task to report on issues requested by the government, and on the other the IGZ handles
complaints of the community about this same government.
• Undocumented women are able to complain about their access to the Dutch health care via Pharos.
Pharos started in 2006 a complaint system for undocumented people, refugees, and asylum seekers
(Lampion, 2008). The effectiveness of this complaint system is unknown since it has recently been
introduced.
4.2.3 Conclusions
The Netherlands positively supports many international and regional treaties and consensus documents
concerning reproductive rights and non-discrimination of women. The Dutch government seems to be
willing to act upon the improvement of maternal health (MDG 5) on global level by: having worldwide
bilateral and multilateral agreements which promote (reproductive) health; and attaining human rights
based foreign policy.
On national level the Dutch government seems also willing to improve maternal health (see national
law, and local health strategy) on a non discriminative manner (see constitution): how can it then be that
the maternal health of undocumented women is not found important? Preventative care is important in
preventing curative care (e.g. complications during and after pregnancy) and found a priority in the
national health strategy: how come preventative (e.g. contraceptives, regular consultations, and echo’s)
and maternity care is made so difficult to access for undocumented (pregnant) women? Also stated as
priority in the health strategy is to reduce the administrative load for health care providers: why doe the
new policy not reduce the administrative load by changing the ways(e.g. via an electronic system) for
compensation for health care providers who treated undocumented patients?
The responsibilities and tasks of health care providers are stated in different laws like the WGB, but
also in customary laws for health care providers like the Hippocrates’ and Dutch physician oath.
Besides this, many protocols and guidelines for obstetrician care providers are prevalent. All these laws,
protocols and guidelines facilitate the work of obstetrician care providers, thereby positively influencing
the (reproductive) health of undocumented women.
The organization of the civil society seems to be widespread: many different paths exist in which
inhabitants can influence governmental decisions; and many organizations are prevalent which offer
some kind of complaint system about either the government or the health care system.
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4.3 Step 3: describing the capacity for implementing the policy
In this third step the capacity for implementing the policy (modification Health Care Insurance Law)
was analysed by defining its available financial and human resources as well as its possible limiting
factors.
4.3.1 Sources & methods
The methods used in order to answer step 3 were a desk study and interviews. The most important
sources used by applying these methods were:
Desk study
- Documents from the Minister and Ministry of VWS
- Sites like from HOM, Immigration and Naturalisation Service (IND), and the International
Monetary Fund (IMF)
Interviews
- J. Van Amen from the Coupling Foundation
- S. Oudenhuijzen from the CVZ
- H. Playfair, midwife at the Bijlmermeerpractice
- Anonymous, midwife in an Amsterdam hospital
- M. Kreyenbroek, social worker at the AMC (hospital in Amsterdam)
4.3.2 Questions
Which financial resources are available for the implementation of the policy?
S3/q1 What is the budget for the implementation of the policy?
Minister Klink (2007) says that more than 44 million euros will be budgeted each year in order to
realize the implementation of the policy. This amount will be subtracted from the yearly VWS-budget.
The budget will be variable each year, because if a contracted hospital has provided more care to
undocumented people than its contracted budget (and the hospital kept to its arrangements stated in the
contract), then the budget will be larger the following year (Klink, 2007). Yet this system does not
motivate the contracted providers to treat more undocumented people than stated in their contract, since
they otherwise will suffer an income loss.
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According to the WHO 60 dollars (= 36.95 euro) per person per year is needed for reasonable health
care (HOM, 2006). The Alien services estimated that the prevalence of undocumented migrants was
between the 75.000-185.000 from April 2005 to April 2006 (Immigration and Naturalisation Service
(IND), 2008). When dividing the budget of 44 million between the 185.000 undocumented migrants
237.84 euro per person remains, which is more than the estimation of 36.95 euros from the WHO.
Besides this, undocumented migrants seek care less often than documented citizens. S. Oudenhuijzen
(personal statement, April 22, 2008) from the CVZ estimated that around 7.000 undocumented persons
make use of health care each year, of which about 1% is paid from the undocumented patients’ own
expenses (Klink, 2007).
S3/q2 Is the budget for the implementation of the policy decreasing or increasing?
Since the policy is not yet implemented this question is not relevant.
S3/q3 Do allocations to specific areas of health indicate where the government sets its priorities?
The government prioritises curative above preventative care: this year (2008) only 0.2% of the total
health care expenses is arranged for preventative care (Ministry of VWS, 2007c).
For maternity and obstetrician care 446 million is budgeted for the year 2008 (Ministry of VWS,
2007c), which is 0.8% of the total health care expenses.
The budget arranged for undocumented patients is, in comparison with the total amount arranged for
health care expenses this year, only a very minor part (0.08%).
S3/q4 Are the public health and health-care facilities, goods, services and programmes functioning
properly?
As mentioned in the introduction: the Netherlands is one of the safest countries for women’s sexual and
reproductive health (Population Action, 2007), therefore the quality of the health care system is
presumed to be good. This was confirmed by the Ministry of VWS (2007), which also stated that some
improvements can be made in the area of monitoring the quality of care, patient involvement, and the
safety of care.
Which human resources are available for the implementation of the policy?
S3/q5 Which staff is involved in implementing the policy or related programs?
Staff from the CVZ, all health care providers, and maybe the regional platforms will be the main
implementers of the draft bill.
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The CVZ will be taking the requests for compensation of treating undocumented people in, checking
upon the validity of these requests, and providing the monetary compensation. The CVZ will also be
making up the contracts with the not directly accessible health care providers. The selection of these
providers will be made publicly and will be promoted by the CVZ in cooperation with the government
(Klink, 2007). Probably less than 10 employees of the CVZ will be working on the implementation of
the policy (S. Oudenhuijzen, personal statement, April 22, 2008).
The health care providers will be the ones who are in direct contact with the undocumented people,
since they provide the actual care. All Dutch health care providers swore, by the Dutch physician oath
(mentioned in s2/q9) to practice their medical art as good as possible in order to serve fellow human
beings, consequently including undocumented people. However, contracted providers, whom have
proven to have protocols and experience in treating undocumented people, should preferably only
administer not directly accessible care. In this way the new policy interferes with the care duty of non-
contracted health care providers in case of not directly accessible care for undocumented patients (J.
Van Amen, personal statement, March 5, 2008).
If the regional platforms, which consist of local GGD staff and other health care professionals, will
exist is unsure. These platforms have at the moment the tasks to evaluate and reimburse the direct
requests from health care providers. The money for reimbursement is provided by the Coupling
Foundation, which also checks upon the validity of the requests. The reason why the future existence of
the platforms is uncertain is that not much money will be left within the budget to spend on these
platforms. Unless the platforms want to work for less money, and under more strict conditions (new
system is bound to law) their existence remains secured (S. Oudenhuijzen, personal statement, April 22,
2008).
S3/q6 How is the staff distributed in terms of location, level, background?
The CVZ office and its staff are located in Amsterdam. The CVZ is a professional independent
managing body who watches over the Dutch health care system. The citizen is central in its work by
securing and developing conditions of the health care system in order for citizens to realize their right to
health care. One of the more specific tasks of the managing body is to make arrangements for patients
who cannot or will not insure themselves (CVZ, 2008).
If the local platforms still participate in the implementation, they will be located closely to the health
care providers. The compensation via the local platforms and the Coupling Foundation worked very
well since professionals form the local platforms. These professionals are very knowledgeable about the
problems prevailing in the specific area they work in (J. Van Amen, personal statement, March 8,
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2008). Therefore it is expected that, if these intermediary platforms stop existing, this will not benefit
the quality of the compensation system.
S3/q7 Which level of government is directly responsible for the implementation of the policy?
The CVZ will be the governmental organisation directly responsible for implementing the policy
(Klink, 2007) and the final responsibility lies at the Ministry of VWS.
Which factors limit or expand the implementation capacity?
S3/q8 Which cultural, religious, social, environmental and other factors influence the implementation of
the policy?
This question is closely related to the ‘decision to seek care’, which is phase I of the ‘three delays
model’ mentioned in paragraph 1.3.
Migrants have a different cultural and social background; however during the interviews this
background seemed not be that important in women’s decision to seek care. In these interviews the
anxiety (related to no money, no insurance, and deportation) as well as the woman’s ability to stand up
for herself seemed to be the most important factors delaying her care seeking behaviour (H. Playfair,
personal statement, March 18, 2008; Anonymous, personal statement, April 10, 2008; M. Kreyenbroek,
personal statement, April 18, 2008). The negative status undocumented migrants have in society could
play an important role in the anxiety these women feel.
S3/q9 Is the State in a process of reform, structural adjustment or crisis which influences the
implementation of the policy?
The reform of the health care sector in 2006 meant the end of the private and social insurance system
and had a large impact on the finance system. Health care became more market based, with competition
between health care insurance companies as stimuli for improving the quality of care. The new system
was accompanied by the introduction of the Health Care Insurance Law (ZvW), which obligated
everyone to be insured. In order to check if people were insured an increased control system prevailed
in hospitals; making it more difficult for uninsured patients to access health care (J. Van Amen,
personal statement, March 8, 2008).
Article 87 of the ZvW obliges care providers to ask for identification papers when someone wants to
use their health care insurance to directly pay for the costs. The purpose of this article is to prevent
fraud (J. Van Amen, personal statement, March 8, 2008; Stichting AB, 2005). However, in hospitals
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everyone, thus also undocumented patients, need to be subscribed and need to show their identification
papers in order to receive treatment. This accordingly scares undocumented pregnant women off to
come (back) to Dutch hospitals (Bureau Intake AMC, personal statement, April 18, 2008; M.
Kreijenbroek, personal statement, April 18, 2008; Anonymous, personal statement, April 10, 2008).
Hereby the first reason why the health care reform could influence the implementation of the policy
is explained: how can midwives treat undocumented patients sufficiently when they run away all the
time?
The second reason is that, if the finance system is going to change again (which will be with the
implementation of the draft bill) hospital personnel need to get used to working with a new system
again. This will take precious time for health care providers who prefer being occupied with health care
provision (Anonymous, personal statement, April 10, 2008). If the new system would save time for
health care personnel this would be a good progression, however this seems not to be the case: directly
accessible providers still need to fill in one paper form per patient; and besides they now need to prove
they asked the patient first for payment in order to be able to receive care, which formerly was based on
trust (J. Van Amen, personal statement, March 5, 2008; S. Oudenhuijzen, personal statement, April 22,
2008).
S3/q10 Describe conflicting interests or lack of consistency related to the implementation of the policy.
More uniformity was one of the reasons for the government to design the draft bill (Klink, 2007). On
one hand this is a positive thing: it makes the process of compensation more transparent and equal to all
health care providers. On the other hand, it provides the government more insight into the money spend
on care to for undocumented patients, and therefore the ability to get more control over it. This control
is seen in the money saved by providing less compensation than in the current system in case of directly
accessible care. On top of this, merely contracted not directly accessible providers are able to receive
compensation for care belonging to the not directly accessible, which are less providers than in the
current system, meaning also more insight and control for the government.
It thus remains unclear if the government really wants to make concessions to health care providers,
or wants to control and reduce the costs involved in care to undocumented patients.
S3/q11 Does the government show political will to implement the policy?
Yes, since debates about the implementation of the bill are still going on parliament like this week (in
April 2008) a plenary meeting is arranged.
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S3/q12 To what extent do other governments, international donors and agencies such as the World
Bank, IMF, WTO, UNDP, EU, WHO, ILO, UNICEF, UNFP (A), expand or limit the implementation
capacity of the government?
The Netherlands itself it quite active in providing aid for developing countries through bilateral and
multilateral agreements it has made (as already stated in s2/q4). The Netherlands even has with 0.8%
the highest gross domestic product made available for UN Oversees Development Assistance
(International Monetary Fund (IMF), 2008).
As well the Netherlands as all organisations mentioned in the question are mostly focused on
developing countries, which make it difficult to get attention to problems prevailing within the Dutch
borders.
S3/q13 Which other international actors influence the government? What are their priorities and
interests relating to the policy under analysis?
To be expected is, if the accessibility of health care services in the Netherlands is limited as a result of
the implementation of the draft bill, that undocumented people might be discouraged to go to the
Netherlands. As a consequence these people will settle in neighbouring countries, therefore shifting the
problems involved in treating undocumented patients to others instead of resolving them.
4.3.3 Conclusions
The financial resources reserved for the implementation of the policy seem sufficient and if not adapted
the year after implementation. The same system will be used for the estimated budget of contracted
providers; what will happen if the available budget is spend and more undocumented patients are
asking for treatment? It is clear that this system does not motivate contracted providers to treat more
patients than their budget allows.
The human resources involved in the implementation are: staff from the CVZ, all health care
providers, and maybe the regional platforms. The latter remains unsure since less budget is made
available for the platforms as well as that they need to work under more strict conditions in the future
(when the compensation system in arranged within the law). The knowledgeable platforms made the
current compensation system so successful; what will happen if the intermediary platforms stop
existing? Whatever happens with the platforms the CVZ will be the governing body responsible for the
implementation of the policy and the Ministry of VWS will have the final responsibility.
The different socio-cultural background of undocumented migrants seem not to be very important in
relation to their delayed health seeking behaviours, however stigmatisation in society could have an
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effect on this. Two other factors will more certainly play a limiting role in the implementation of the
policy: the recently reformed health care finance system; and conflicting interests (e.g. cost and
immigration control).
4.4 Lobby
On April 22 was voted upon the draft bill within the House of Commons, which demanded for
preliminary actions based on the results of step1-3. As the model of Kingdon (see 1.3 Theoretical
framework) describes; there was a ‘window of opportunity’.
Before describing the lobby activities and the changes in the draft bill, the Dutch parliamentary
democracy will be explained in order to understand in which ways policy can be influenced.
4.4.1 Dutch parliamentary democracy
The Dutch parliamentary democracy can be seen in figure 6 and consists of the voters, parliament, and
the government and cabinet. The House of Commons and the Upper House belonging to parliament
were focused on, because these are the main actors in the process from designing of a draft bill until the
bill becoming a law and therefore.
Government
Upper Chamber
The Queen
Ministers
Voters Parliament
State
Secretaries
House of
Commons Cabinet
Figure 6. Model of the Dutch parliamentary democracy. Source: Tweede Kamer der Staten-Generaal (2008).
House of Commons
The House of Commons is one part of the Dutch parliament (see figure 6) and is formed by 150
members of parliament, belonging to different parties which represent the Dutch society. The House of
Commons has two main tasks: 1) check upon the government; 2) make laws. The second task is
important in this case and besides that the House of Commons is able to design its own draft bills it is
also able to alterate draft bills designed by the government (Tweede Kamer der Staten-Generaal, 2008).
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The latter was the case here since minister Klink of VWS was the one who introduced the modification
ZvW (31 249) and members of parliament the ones changing the draft bill according to their point of
views.
The changing of a draft bill goes as follows: 1) each party will give several speeches and asks
questions during several debates, in order to influence other parties and the minister; 2) parties can state
motions and/or amendments during these debates when they want to change the content of the draft bill
(amendment) or want to point attention to certain things within the policy (motion). If these motions
and amendments are supported by the majority of the parties then these will be implemented into the
draft bill; 3) parties need to vote for or against the implementation of the draft bill (Tweede Kamer der
Staten-Generaal, 2008).
The first two points of this process in relation to the modification ZvW (31 249) were held on April 2
and April 9 during two plenary debates. The third point, the actual voting, was on April 22.
Upper House
The other part of the parliament is called the Upper House, and its 75 members are indirectly chosen:
voters choose the members of the Provincial-States and these members choose the members of the
Upper House. The Upper House is the one who has the final decision upon a draft bill, which was firstly
accepted in the House of Commons. The members of the Upper House however cannot change the draft
bills’ content, but can only approve or disapprove of it (Tweede Kamer der Staten-Generaal, 2008).
After the approving of the modification ZvW (31 249) in the House of Commons, the bill is handed
over to the Upper House, which held on May 9 its first meeting about this subject.
4.4.2 Lobby activities
The activities in the House of Commons concerning the draft bill as well as the lobby activities of the
WGNRR are seen in table 3 on the next page. The letter (written in Dutch) that was used as main lobby
tool is found in annex 4.
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Table 3. Activities in the House of Common and the lobby activities, accompanied by the dates it took place.
Date Activities in the House of Common and lobby activities
April 2 Plenary debate
April 2 Attend plenary debate, in order to get insight into the opinion of the different parties.
April 3 Email members of the three parties, who showed concern about obstetrician care during
the debate of April 2, if they were interested in the preliminary results of this research
April 7 Send the preliminary results to members of two parties.
April 9 Plenary debate
April 15 Send official letter* (in the morning) to members of the two interested parties and to the
chairmen’s of the Commission VWS of the House of Commons and the Upper House.
April 15 Final vote on draft bill (in afternoon), but was postponed.
April 16 Send emails to other Human and Women’s Rights’ organizations to ask for supporting
the letter.
April 21 Send the edited letter** (by email and post) to minister Klink and the chairmen’s of the
Commission VWS of the House of Commons and the Upper House.
April 22 Final vote on draft bill: accepted
April 28 Send emails, to the ones who should have received the letter, in order to evaluate the
impact of the letter.
* Supported by Aim for Human Rights.
** Supported by Aim for Human Rights, Amsterdam Solidarity Committee Refugees (ASKV), International Federation of Health and Human Rights
Organizations (IFHHRO), Doctors of the World (in Dutch: Dokters van de Wereld), the Dutch League for Human Rights (LVRM) (in Dutch: Liga voor
de Rechten van de Mens).
4.4.3 Changes in the draft bill
As just mentioned, the draft bill was accepted in the House of Commons on April 22, 2008. In favour of
obstetrician care amendment 30 was accepted, meaning 100% instead of 80% compensation for
providers of this kind of care. Motions important for the accessibility of care which were also accepted
are:
• Motion 16: to promote a good distribution of the contracted care for certain groups of aliens.
• Motion 24: to reimburse the costs of information campaigns educating health care providers about
the possibilities to receive compensation for care provided to uninsured and undocumented patients.
• Motion 25: to monitor the arrangement of the fact that directly accessible health care providers (other
than obstetrician care providers like GPs) are able to receive 80% instead of 100% compensation of the
costs for care provided to undocumented patients.
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4.5 Step 4: the impact on human rights
In step 4 was assessed what precisely happened in reality and whether this resulted in violations of
women’s health rights.
In this step the changed draft bill was used as policy under research; in which midwives will receive
100% instead of the mere 80% other directly accessible health care providers receive.
4.5.1 Sources & methods
The methods used in order to answer step 4 were a desk study, interviews and other contacts (short
personal conversations or emails). The most important sources used by applying these methods were:
Desk study
- Documents on pregnancy and nutrition
- Documents on housing of refugees
Interviews
- J. Van Amen from the Coupling Foundation
- S. Oudenhuijzen from the CVZ
- H. Playfair, midwife at the Bijlmermeerpractice
- Anonymous, midwife in an Amsterdam hospital
- M. Kreyenbroek, social worker at the AMC (hospital in Amsterdam)
- Undocumented women
Other contacts
- Emails from: Foundation GPs Services posts Amsterdam, NZa, and the KNOV
4.5.2 Questions
Is timely and appropriate health care a relevant issue?
S4/q1 Is timely and appropriate health care a relevant issue for the policy? If yes, explain why and how.
Timely health care is definitely relevant during and after pregnancy. On average a pregnant women
needs to visit a midwife about 10-15 times in order to monitor the pregnancy sufficiently. In the
beginning of the pregnancy this meeting is recommended to be once every 4 weeks and in later stages
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once every 3 weeks (Bakkum et al, 2006). Some women belong to a higher risk group and need to be
monitored more often which are women who are: older than 36 years (higher chance of child with
Down-syndrome and Spina bifida); HIV-positive; or with certain hereditary diseases in her family like
Diabetes Mellitus and high blood pressure (Bakkum et al, 2006). The latter two reasons are why
undocumented women mostly belong to this higher risk group (M. Kreijenbroek, personal statement,
April 18, 2008; Anonymous, personal statement, April 10, 2008).
Appropriate health care is also very important in order to prevent and/or cure complications
pregnant women might face. In the first consult the following indicators should be at least tested for:
blood type, haemoglobin, Rhesus-D-factor, several antibodies, syphilis, hepatitis-B and HIV. Prenatal
screening and diagnostics could also be of importance for women at higher risk (Bakkum et al, 2006).
During the following meetings the midwife checks normally upon the growth of the uterus, this in
later stages involves listening to the baby’s heart tones. A pregnant woman’s blood pressure is also
important to monitor, since if the pressure is too low or too high certain problems can prevail. Besides
these physical check ups, education of the pregnant woman is essential, since many life styles and
eating patterns could put herself and her unborn child at risk (Bakkum et al, 2006).
The modification of the Health Care Insurance Law (ZvW) does partially take into account the
need for timely and appropriate health care during pregnancy: care during all stages in pregnancy
(including maternity care) are found medically necessary and health care providers providing these sorts
of care will get 100% compensation via the CVZ (Eerste Kamer, 2008). However, how will the
government secure that care is provided during all stages in pregnancy? And how can undocumented
women receive timely health care when they seek care too late in their pregnancies?
Are underlying determinants of health a relevant issue?
S4/q2 Are underlying determinants of health a relevant issue for the policy? If yes, explain why and
how.
The underlying determinants of health are of importance, especially adequate nutrition, education, and
housing.
Nutrition
Healthy and variable nutrition is known to be important for pregnant women and their unborn children.
A healthy nutritional pattern encompasses: sufficient food and many fresh fruits and vegetables. Other
things could be harmful during pregnancy: smoking, drinking alcoholic beverages, dieting, or eating
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liver products (too much vitamin A), raw meats and cheeses with raw milk (listeria bacteria and
toxoplasmosis), certain fishes, too much coffee, certain herbs and medicines etc. (Voedingscentrum,
2008). However: how can undocumented women eat healthy and variable when they have no money?
(see below statement how women solve this); and how do or know about what they should and should
not be eating, drinking or doing when pregnant if no information is available in a language they
understand?
– “From the year 2001 to 2004 I lived undocumented in the Netherlands while I was HIV-positive. A sick woman needs a
place to sleep and to eat…. which could have caused me to infect men with HIV/AIDS” – Undocumented woman 2
(personal statement, June 3, 2008)
Fortunately for one group of undocumented (pregnant) women, HIV-positive women, an
arrangement was made two years ago in 2006: the ‘pocket-money arrangement’. With the arrangement
HIV-positive migrant women get 40-45 euro per week for living (clothes and nutrition), and a
maximum of 200 euro per month or housing. At first merely women who needed medicines in order to
treat HIV were able to apply: women with a very low CD4 count; or pregnant women taking medicines
in order to prevent mother-to child-transmission. Fortunately the AIDS-fund changed this and made it
possible for HIV-positive women who are not (yet) in need of medicines to also be able to receive
money for living and housing (M. Kreyenbroek, personal statement, April 18, 2008; Undocumented
woman 1, personal statement, May 20, 2008).
Education
Education is needed in order to for women to know what to eat, drink, do and not do while pregnant.
Partly midwives take up the responsibility to teach undocumented about these important matters,
however as just mentioned this is not always easy since not always information is available in a
language they understand. And the fact that undocumented women have sometimes problems with
speaking English or are even illiterate makes communicating with them even more difficult.
Education about the Dutch health care system is also needed for undocumented patients since they
are mostly not familiar with this. Education about this matter is important for their accessibility of
health care. Midwives do educate undocumented women about these matters however until a certain
degree (H. Playfair, personal statement, March 5, 2008; Anonymous, personal statement, April 10,
2008).
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Housing
Housing is another underlying determinant, which is important for a pregnant women’s health. It is
obvious that a pregnant woman should be living in a proper house, with heating and sanitation, in order
to stay healthy. The most common forms of housing for undocumented people are:
1) Moving in with family, friends and partners;
2) Renting of rooms and beds in private livings;
3) Illegal renting of flats, rooms and beds of the building cooperative;
4) Roa-housing: these are rented by the municipalities and under supervision of the organization
Refugees Work (Engbersen et al, 2004; Vluchtelingenwerk, 2008). Roa-housing is based upon the
Arrangement Intake Asylum Seekers (ROA).
The Central Organ reception Asylum seekers (COA) provide shelter for pregnant women who seek
asylum and therefore are not (yet) documented, although this is merely for three weeks before and after
the delivery (J. Van Amen, personal statement, March 5, 2008).
Besides the housing, mentioned above, undocumented people also live in specific districts in
Amsterdam (like the Bijlmer); where housing is more easily found and cheaper. These districts are
marked by many social housing buildings, which are cheaper to rent (Engbersen et al, 2004). Some
private buildings are also housed by undocumented people, in sometimes large groups, however these
private buildings are characterized by professionals as ‘inhuman living environments’ (Engbersen et al,
2004), which is not a good environment for a pregnant woman or mother with young children to live in
(as also seen by the statement under here).
– “During these six years I lived in many different places, of which some better than others. At one time I even lived with
seven women, of which all had children, in just two apartments; this caused me a lot of stress” – Undocumented woman 1
(personal statement, May 20, 2008)
Is participation a relevant issue?
S4/q3 Is participation a relevant issue? If yes, explain why and how.
Participation of all stakeholders within the development of the policy is very important, since the
implementation of the policy will have consequences for all of them.
The stakeholders here referred to are: undocumented people, all health care providers, Coupling
Foundation, CVZ, the municipalities, and the ministry of VWS.
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S4/q4 Who participates or participated in the development and implementation of the policy?
The ministry of VWS did the actual designing of the policy; however other stakeholders were allowed
to give their opinion:
• The Coupling Foundation
• The CVZ: closely involved as main implemented of the policy. And some changes were made
according to their opinion (S. Oudenhuijzen, personal statement, April 22, 2008).
• Health care providers: involved in the form of several platforms, which were composed of
organizations like Lampion, Pharos, hospitals and AWBZ-institutions. In Amsterdam two hospitals
were involved in these platforms: West-End and AMC. Lampion and Pharos are organizations involved
in research about the access to health care for undocumented migrants; therefore they represent the
undocumented population in the Netherlands (S. Oudenhuijzen, personal statement, April 22, 2008).
• The KNOV: is the organisation representing midwives in the Netherlands (KNOV, 2008b) and was
also involved in designing the draft bill by showing their concern about the 80% compensation via a
letter to the Commission VWS (KNOV, personal statement, May 6, 2008).
In practice however not all health care providers were informed of the fact that the government
wants to modify the Health Care Insurance Law; neither all midwives nor all hospital personnel in
Amsterdam were informed (H. Playfair, personal statement, March 18, 2008; Anonymous, personal
statement, April 10, 2008). The design was and is still not very specific since no money was available
for research;, therefore possible future obstacles could prevail (S. Oudenhuijzen, personal statement,
April 22, 2008).
Is violence against women a relevant issue?
S4/q5 Is violence against women a factor in the policy? If yes, explain why and how.
No
S4/q6 If violence is a relevant issue, is the government taking adequate measures to prevent and/or ban
violence against women?
-
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What is the impact on the availability of services, goods and facilities?
S4/q7 Does the policy affect the availability of services, goods and facilities for (certain groups of)
women and how?
The policy affects the availability of not directly accessible (in-hospital) obstetrician care facilities. By
selecting health care providers, the number of obstetrician care facilities for undocumented pregnant
women will decline, which again affects its physical accessibility (see next question).
What is the impact on the accessibility of services, goods and facilities?
S4/q8 Does the policy affect the accessibility of services, goods and facilities for (certain groups of)
women and how?
There are three forms of accessibility that need to be considered here separately: physical, economic,
and information.
Physical accessibility
As just mentioned in s4/q7 the quantity of not directly accessible obstetrician care facilities will decline,
here its impact on the physical accessibility is explained.
Fortunately the CVZ does try to select those hospitals and pharmacies nearby the areas where most
undocumented people settle (S. Oudenhuijzen, personal statement, April 22, 2008). However some will
always be disadvantaged and need to travel longer distances, with higher travel costs. Besides, since
undocumented people try to stay in the background it is very difficult to trace where they exactly live
and therefore to select the hospitals and pharmacies closest by.
At the moment the fact is that some hospitals are more accessible than others for undocumented
people. The more accessible hospitals will probably be the ones to become selected, since the CVZ
selects upon the level of experience with treating undocumented patients, which adds positively to the
quality of not directly accessible care for these patients. However, nothing is stated in the policy about
how to check up on the physical accessibility in the case of emergency care, when the nearest hospital is
not always the selected one. Will not selected hospitals (who will receive 80% compensation) treat
undocumented patients in emergency situations or slide them off to the selected hospitals since they
receive the full (100%) compensation? It is not unlikely that hospitals will slide patients off or even
refuses to treat them, since it is known that the care duty is ignored in the past (Anonymous, April 10,
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2008; Woman at women’s café “de Peper”, personal statement, February 2, 2008; H. Playfair, personal
statement, March 18, 2008).
Economic accessibility
The economic accessibility is one of the most important forms of accessibility which undocumented
women face as a barrier at the moment, delaying their care seeking behaviour. Free services will be
given for medically necessary care, according to the draft bill, however this changes nothing about the
current situation.
The current situation is: the whole fee can hardly ever be paid for by the undocumented women
themselves, since obstetrician care involves a fairly large sum (many acute situations and
complications). In order for these women to receive the care they need they must really stand up for
themselves in order to get a payment arrangement (when they are able to partially pay the fee) or free
services (when they have no money). Moreover this process is very hard and frightening for
undocumented women since many of them speak hardly English and do not know the Dutch health care
system (Anonymous, personal statement, April 10, 2008; M. Kreyenbroek, personal statement, April
18, 2008; Undocumented woman 1, personal statement, May 20, 2008). Below statement shows how
hard it can beis for an undocumented woman to receive the care she needs.
– “A female doctor refused to treat me, and did not give me my medicines in order for my foot to heal. She even came
along with a couple of interns to tell me how much the costs are to be in the hospital and she even threatened to give me
over to the police…. therefore I fled to my sister’s house” – Undocumented woman 2 (personal statement, June 3, 2008)
Why does the new compensation not aim for removing this financial/ anxiety barrier? The policy
will even make it worse since health care providers will need to prove they persuade undocumented
patients to pay first; which at the moment is based on trust.
Another problem is the fact that undocumented women hardly ever receive maternity in the current
situation, because of cost related reasons (Foundation GPs Services posts Amsterdam, personal
statement, March 10, 2008; Undocumented woman 1, personal statement, May 20, 2008). This is of
course unacceptable, since maternity care is important in order to monitor the health of the mother and
her newborn after delivery. The new policy does acknowledge the importance of maternity care (see
amendment 30). However, how will the policy secure that maternity care for undocumented mothers
will be provided in the future?
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Information accessibility
As stated in s4/q2 under ‘education’ midwives are the ones who take the responsibility for informing
undocumented pregnant women about matters like pregnancy, nutrition, and the Dutch health care
system. As mentioned before, midwives face many difficulties in educating and communicating with
undocumented women. The policy does not state anything about improving this matter, leaving this
difficult task for midwives unchanged.
As for the information accessibility concerning the fact which specific not directly accessible
providers are selected will the Ministry of VWS, in corporation with the CVZ, educate all health care
providers (Klink, 2008). However how these providers will exactly be educated and this information
will remain accessible is not clear yet.
What is the impact on the acceptability of services, goods and facilities?
S4/q9 Does the policy affect the acceptability of services, goods and facilities for (certain groups of)
women and how?
The policy will probably positively affect the acceptability of services, goods and facilities for
undocumented women and negatively for health care providers; in which ways this will happen is
described below.
The policy positively affects the confidentiality aspect of undocumented patients, since in the future
no initials of the patient will be asked anymore on the compensation forms (as stated in s1/q7 under
‘directly accessible care’). This means that undocumented women cannot be traced anymore and that
their confidentiality is guaranteed (S. Oudenhuijzen, personal statement, April 22, 2008). This is in
conflict with the statement of J. Van Amen (personal statement, March 5, 2008) from the Coupling
Foundation; women are already untraceable and anonymous in the current system. However the less
personal details the undocumented women need to give the better, since they become easily afraid when
personal details are asked about (Anonymous, personal statement, April 10, 2008). Despite the fact that
the new system will be better (in relation to the acceptability) than the current system this does not
mean that the system is acceptable for undocumented women; how can the new system be acceptable if
it remains difficult for undocumented women to access obstetrician care? Something must be wrong
with the systems’ acceptability if undocumented patients seek care mostly only in emergency situations.
The acceptability of the new system will probably be low for health care providers in relation to their
care duty. The new system decides which not directly accessible providers should treat undocumented
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patients (for not directly accessible care) and which should not; thereby interfering with the care duty
and autonomy of health care providers (J. Van Amen, personal statement, March 5, 2008).
What is the impact on the quality of services, goods and facilities?
S4/q10 Does the policy affect the quality of services, goods and facilities for (certain groups of) women
and how?
The policy could have a positive as well as a negative effect on the quality of the in-hospital obstetrician
care. Positively (as just mentioned) is the selection of the contracted hospitals based on the amount of
experience the hospitals have with treating undocumented patients. It can therefore be expected that the
hospitals are of high quality for undocumented patients. However since undocumented patients will be
concentrated within these hospitals in the future, hospital personnel do need be prepared in order to
cope with this since, as stated before, undocumented patients take more time and effort to treat, and
have a different pathology (Anonymous, personal statement, April 10, 2008). Nothing however is stated
in the policy to support health care providers in coping with higher numbers of undocumented patients.
At least this could form a problem for the AMC hospital in Amsterdam as stated below.
– “The AMC hospital (which will probably be selected by the CVZ) in Amsterdam is now already almost unable to handle
more undocumented women; therefore this will become a major problem” – H. Playfair midwife at Bijlmermeerpractice
in Amsterdam (personal statement, March 18, 2008)
Does the policy have discriminatory effects?
S4/q11 Is the impact of the policy – as analysed in the previous questions – equally felt by all groups, or
are some groups affected more than others?
The longer travel distances (mentioned under ‘physical accessibility’ in s4/q8) will mainly be the case
for undocumented women living in rural areas, since hospitals and pharmacists are mostly located in the
city. From these women the women who need to make use of these services regularly will be affected
the most: the pregnant women. For pregnant women with a high pathology (e.g. HIV/AIDS, high blood
pressure, diabetes) the situation is even worse (H. Playfair, personal statement, March 18, 2008;
Anonymous, personal statement, April 10, 2008).
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As for the ‘economic accessibility’ (s4/q8) the pregnant women with no support base (family or
friends with money) or job will have more difficulties with accessing the hospital. They are not even
able to make a payment arrangement and therefore need to apply for free services: it takes more
difficult and longer discussions at Bureau Intake in order to receive free treatment (Worker at Bureau
Intake AMC, personal statement, April 18, 2008).
The ‘information accessibility’ (s4/q8) is more an issue for women who are not able to speak English
and/or are illiterate, since these women have respectively more difficulties communicating and
information leaflets are of no use. Prior knowledge plays also an important role, since if a woman has
been pregnant before she knows more about it than a woman in her first pregnancy.
Its main implementer will report the precise impact of the new compensation system: the CVZ. On
this reporting will the Dutch government base its evaluation, which will take place two years after
implementation of the policy (S. Oudenhuijzen, personal statement, April 22, 2008).
S4/q12 What is the impact of the policy on stereotypical gender roles?
-
S4/q13 Considering the above, does the policy have discriminatory effects?
Yes, the policy has discriminatory effects: the more an undocumented person needs to make use of the
Dutch health care system, the more she will come in contact with all its downsides. Pregnant women are
one of the groups discriminated against here, because of their close contact with health care (regular
monitoring is needed during and after pregnancy).
Most of these problems are already there at the moment; however the shortcoming of the policy,
modification ZvW, is that it takes no measurements in order to solve these problems. To be clear the
problems here referred to are:
• The difference in accessibility among different hospitals;
• The anxiety/ financial barrier undocumented women face in seeking of care;
• Maternity care is in many cases not provided for undocumented women;
• Not providing undocumented pregnant women with housing and nutrition;
• Not supporting midwives in educating (about their rights, the Dutch health care system, and
pregnancy) these women during their consultations;
• Not supporting midwives in the fact that it takes more time and effort to treat undocumented women;
• Not making the process of compensation easier or faster for directly accessible midwives.
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4.5.3 Conclusions
Timely and appropriate health care is of utmost importance during and after pregnancy. When timely
and appropriate health care is given many complications can be prevented or cured; which is important
for preventing maternal mortality. The draft bill does acknowledge the importance of care during and
after pregnancy; however it does not describe any measures in order to promote early health care
seeking behaviours among undocumented pregnant migrants or to prevent health care providers
refusing to provide maternity care.
The underlying determinants (nutrition, education, and housing) play an important role in the
progression of the pregnancy and health of a pregnant woman. There are some regulations available
(like ‘for HIV-positive undocumented women); however most pregnant women are on their own in
relation to nutrition and housing. As for education undocumented women mostly depend on the
information provided by the midwife they are seeing; it is discussible how effective this information is
in relation to communication barriers and the fact that undocumented women seek care too late in their
pregnancies.
As for the participation of stakeholders the designing of the policy; many stakeholders (Coupling
Fund, CVZ, KNOV, health care providers and human rights organisations in the form of platforms)
were involved however not all of them. For example undocumented patients were not involved;
however Pharos and Lampion could represent these patients as they participated in the platforms.
The availability of in-hospital obstetrician care will decline with the implementation of the policy,
leading to further and more expensive travel distances for undocumented women living in rural areas.
Unfortunately nothing is stated in the policy to secure the physical accessibility, which could really
become a problem for emergency care in not selected hospitals. As for the economic accessibility not
much will change with the current situation since neither any measures are stated in order to reduce the
financial/anxiety barrier undocumented women face when seeking health care nor in order to secure the
provision of maternity care. Also for the information accessibility nothing is stated in the policy to
improve this; leaving this difficult task for midwives. The acceptability of the new compensation
system will improve for undocumented women (less personal details needed) and worsen for non-
contracted health care providers (interferes with their care duty). However despite the minor
improvement for undocumented women the system cannot be regarded as acceptable to them while to
seek care only when really needed. As for the quality of in-hospital obstetrician care as well positive as
negative effects are expected. The CVZ selects on experience with undocumented patients, therefore the
contracted ones are expected of high quality for these patients. However it is questionable if the
contracted health care providers are able to deal with higher numbers of undocumented patients.
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It can be concluded from all the above that the policy has discriminatory effects; pregnant women
are disadvantaged because they need to have regular contact with the Dutch health care system, which
consists of many difficulties and barriers for these women.
4.6 Step 5: state obligations
In step 5 the obligations of the Dutch government were stated as means of the differences found
between its commitments (step 2) and achievements (step 4). For these differences the government can
be held accountable, since the government is directly responsible in taking measures to ensure human
rights.
4.6.1 Sources & methods
The methods used in order to answer step 5 were a desk study and interviews. The most important
sources used by applying these methods were:
Desk study
- Documents from the Minister of VWS
- Document of the Commission Medical Care
- Conventions, declarations and consensus documents
Interviews
- J. Van Amen from the Coupling Foundation
- S. Oudenhuijzen from the CVZ
- H. Playfair, midwife at the Bijlmermeerpractice
4.6.2 Questions
Who is responsible?
S5/q1 Who are the main actors involved in the violations which were noted in step 4?
• Health care personnel or management: this applies mostly for the ones located in hospitals and refers
to the fact that some hospitals are not accessible for undocumented patients and/or refuse to provide
maternity care.
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• Ministry of VWS: by not taking the financial/ anxiety barrier away from undocumented patients; by
not providing housing and nutrition for all undocumented pregnant women; by neither making
concessions to midwives for treating and educating undocumented patients nor making the process of
compensation easier and faster etc.
• GGD Amsterdam: as the actor responsible for the public health of citizens living in Amsterdam.
S5/q2 If the actors other than the government are involved, what is the relation between the violators
and the government? Has the government taken any measures to regulate the activities of the violators?
Are these measures adequate?
The Ministry of VWS is responsible for the Dutch health care system and therefore its accessibility for
all its citizens. The government, by putting up financial barriers for undocumented migrants to seek
care, interferes with their accessibility of health care. The management or personnel of some hospitals
deal with the financial barriers, put up by the government, by sliding patients off to other hospitals
(Klazinga et al, 2007; H. Playfair, personal statement, March 18, 2008). This is against the law;
however nothing is done about this. Moreover the Minister of VWS ignores the fact that this happens
“sliding patients off is not possible, since this is against the professional standard of health care
providers” (Klink, 2007).
S5/q3 What is the role of governments of other countries or international actors in relation to the
violations?
The European Union (EU) is an international actor who is able to form uniform policies to which all
member countries need to conform. The EU is at the moment working on an European immigration
policy: on June 18, 2008 it formed its first regulations concerning undocumented migrants. These first
regulations defined a maximum detention period of 18 months for undocumented citizens, because in
some countries (like the Netherlands) no regulations on this subject were available yet (Europa-nu.nl,
2008). It is good that regulations such as these are available, however despite the fact that 18 months is
still a long period (as human rights organization Amnesty International already stated) the most
important downside of the European migration policy is that its focus is on more strict regulations and
cooperation in relation to illegal migration (e.g. guarding of the borders and deportation). It is strongly
recommended that the EU should focus on the individual reasons for undocumented migrants coming to
the EU in the first place and more importantly to treat them with dignity and respect their human rights.
In short the relation of the EU to the violations is: illegal migration is an issue which crosses the
borders of European countries, therefore the EU should take responsibility in order to form an uniform
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human-rights based immigration policy and stand up for the rights of these migrants instead of shifting
the problem to other countries (e.g. migrants’ countries of origin). More about this recommendation is
found in s6/q3.
For which effects can you hold your government accountable?
S5/4 Which of the following core obligations is relevant for the policy and has not yet been achieved?
The following core obligations are related to the policy, and are totally or partially not met in line with
the right to health of undocumented pregnant women living in Amsterdam:
• Access to health facilities, goods and services on a non-discriminatory basis
• Access to basic food
• Access to basic shelter, housing, water and sanitation
• Equitable distribution of all health facilities, goods, and services
• Education and access to information concerning health
• Reproductive, maternal (prenatal as well as postnatal) and child health care
S5/q5 Does the obligation of progressive realization apply?
Yes, because the Dutch government could do more in order to achieve the undocumented women’s
health rights. The modification ZvW could be changed in order to make more progress towards these,
but more importantly formerly implemented laws (like the Benefit Entitlement Act) need to be changed.
The applicability of progressive realization per effect is stated in the second column of table 4 (under
‘conclusions’).
S5/q6 Does non-retrogression applies?
Yes, because the Dutch government does not do all it can in order to avoid deterioration of
undocumented women’s health rights. Much more can be done in order for undocumented women
living in Amsterdam to obtain their highest standard of attainable health (ICESCR Article 12.1). The
applicability of non-retrogression per effect is stated in the second column of table 4.
S5/q7 Which of the effects of the impact is a result of the government’s failure to meet its obligations to
respect, protect and fulfil health rights?
See second column of table 4.
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S5/q8 Has the government done enough to prevent discrimination in the implementation of the policy
itself or in the impact of the policy?
By the alteration made in the policy via amendment 30 (100% instead of 80% compensation for
obstetrician care providers) the government prevented discrimination on basis of gender, this since
women are the ones giving birth. However, many things still need to be changed and added to the
policy, as well as to other Dutch policies and laws, in order to eliminate discrimination on basis of
residence permit.
S5/q9 Does the policy include effective measures to ensure influence and participation by women?
Undocumented people were not involved in the making of the draft bill, despite the fact that it does
have consequences for them. However it is debatable if undocumented people wanted to be involved
anyway, since they are afraid of being in the picture. On the other hand, organizations that stand up for
the rights of these people (like Pharos) did play a role in the realization of the draft bill, as mentioned in
s4/q4.
S5/q10 Which government commitments are linked to the effects of the policy?
See the third column of table 4 for the government’s commitments. However, while some treaties and
consensus documents apply to more than one effect, they are only mentioned once or twice.
Which are the main obstacles to the government meeting its obligations?
S5/q11 Is lack of resources (rather than, for example, lack of political will) a major cause of the
weakness of the policy and its implementation?
Not specifically, however as stated in s3/q5 it remains unclear if enough resources are available in order
for the local GGDs to still be involved in the new system (S. Oudenhuijzen, personal statement, April
22, 2008). The compensation system, according J. Van Amen (personal statement, February 2, 2008) of
the Coupling Foundation, worked very well via the regional GGDs, because of its direct contact with
the health care providers and knowledge of regional health problems. If in the future the GGDs are not
involved anymore it remains unclear what effect this has on the system.
S5/q12 Did the government attempt to obtain international technical and financial assistance?
No
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S5/q13 Did other (donor) governments or international institutions extend the necessary assistance?
No
S5/q14 Is the government likely to claim that other obstacles caused the weaknesses in the policy or its
implementation?
No
4.6.3 Conclusions
Fact sheet B of annex IV of the HeRWAI (see table 4) was used in order to find out for which effects
(first column) the Dutch government can be accountable for (fourth column). This accountability is
determined by fact whether the government conforms (second column) to the commitments it has made
(third column).
Table 4. Fact sheet about the impact of the policy and the accountability of the Dutch government.
Main effects of the Government obligations Commitments the government Accountable to the
policy on women’s linked to these effects made Dutch government?
health rights
Timely and appropriate • Failure to protect CEDAW (Article 1), Declaration Yes
health care (0)* • Progressive realization of Alma Ata, CRC (Article 24)
Underlying • Failure to fulfil CEDAW (Article 12.2), ESC Yes
determinants (0) • Progressive realization (Article 11), Program for Action
ICPD
Participation • Participation of all Resolution on the Human Rights Yes
stakeholders (0) of Migrants
Availability of • Failure to fulfil MDG 5 Yes
obstetrician care (-) • Non-retrogression
• Non-discrimination
Accessibility of • Failure to protect ICESCR (General Comment 14 & Yes
obstetrician care (-) • Progressive realization Article 12), CEDAW (Article 12.1 &
• Non-retrogression 12.2), MDG 5
• Non-discrimination
Acceptability of • More respect ESC (Article 13) Yes
obstetrician care (+/-)
Quality of obstetrician • Failure to fulfil ICESCR (Article 12.1), Beijing Yes
care (+/-) • Non-retrogression Declaration, MDG 5
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Some groups more • Failure to protect ICERD (General Comment 30) Yes
affected (-) • Non-retrogression
• Non-discrimination
* (+) positive, (0) neutral, and (-) negative impact of policy, (+/-) and for some positive and some negative impact of policy
4.7 Step 6: recommendations and action plan
In this last step the results of the analysis in step 1-5 were used in order to form recommendations and
an action plan which aim to improve the human rights of undocumented pregnant women.
4.7.1 Sources & methods
The method used in this step was a group discussion (see annex 5) among stakeholders. One or more
delegates from the following organisations participated in the discussion: Aim for Human Rights,
Pharos, Doctors of the World, International Federation of Medical Students’ Associations (IFMSA),
Johannes Wier Foundation, Royal Tropical Institute (in Dutch: Koninklijk Instituut voor de Tropen
(KIT)), the Dutch League for Human Rights (LVRM) (in Dutch: Liga voor de Rechten van de Mens),
and Article 1 (organisation concerning article 1 of the Dutch constitution: no discrimination)
4.7.2 Questions
What are your recommendations or demands to the government and/or other actors?
S6/q1 Make a summary of the information in the previous steps.
The conclusions per step or the executive summary can both be used as summary of the previous steps.
Most remarkable, of these research findings, were the differences in theory and reality. By theory is
meant all the commitments the Dutch government has made by signing multiple treaties, declaration,
and consensus documents thereby promoting non-discrimination, equality, and sexual and reproductive
rights of all women. However, the commitments made by the Dutch government do not show in reality,
at least for undocumented women it does not; they are being discriminated against on the basis of their
residence permit as shown by the results of this research.
Human rights are rights of all people, however it seems like the Dutch government refrains from
acknowledging that undocumented migrants have these rights as well and more importantly that it is
their responsibility to stand up for their rights. Especially pregnant women, as an already more
vulnerable group, should be protected. However, before undocumented pregnant women living in the
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Netherlands can attain their highest standard of physical and mental health (ICESCR Article 12.1) many
actions need to be taken. Most importantly is to improve the universal access to reproductive health care
(third target MDG5); therefore actions on local, national, and international level are needed (see s6/q3
for more information).
S6/q2 For each of the violations and unwanted effects listed in step 5, try to formulate a
recommendation to change the policy so that it has a better impact on women’s rights.
It is not possible anymore to change the policy, since it has already been changed by the members of the
House of Commons. However the draft bill (31 249) is still discussed (today June 24, 2008) among the
members of the Upper Chamber, which have the final decision on the policy.
Therefore some recommendations will be formed for these members to take into account when
deciding upon the policy:
! All care, tests, medicines, echo’s etc. needed for obstetrician care (encompassing maternity care) for
undocumented pregnant women should fall under the 100% compensation exception for directly
accessible obstetrician care (amendment 30, Arib).
! The above should apply for all health care providers (encompassing GPs) providing care to
undocumented pregnant women.
! The ‘duration of stay’ is an unusable criterion for determining the necessity of medical care for
undocumented patients and should therefore be omitted.
! Before the policy should be implemented it should clear what kind of care precisely belongs to
directly accessible care and not directly accessible care.
! It should be made clear how the CVZ is going to check on the fact if health care providers ask
patients first for payment. It is namely important that this does not affect the autonomy of the health
care provider or the trust relationship between provider and patient.
! It is recommended that the way in which health care providers can request for compensation (one
paper per patient) will be changed in a more effective system (e.g. electronic) in order to reduce the
administrative load of these providers.
! If undocumented pregnant women suffer from the lower availability of obstetrician care and/or
pharmacies concessions (e.g. provision of a travelling card or money) should be made.
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S6/q3 If a change in the policy is not the solution, what action should the government take?
Before stating general and more specific recommendations, focused on facilitating the policy, the
recommendations from experts will be outlined. Recommendations from experts were derived from
both interviews and group discussions.
Recommendations: interviews
Recommendations derived from the conducted interviews:
• “Everybody should be allowed to obtain health insurance, at least some women (who are able to pay
for insurance) would benefit from this” (H. Playfair, personal statement, March 18, 2008).
• “We are health care providers, not police or hunting for money. We want to keep ourselves occupied
with health care provision and we stand for access to health care for all” (Anonymous, personal
statement, April 10, 2008).
• “The Dutch government will need migrants in the future, since the Dutch population is getting older.
Besides this medical tourism is not prevalent and is only an unrealistic thought among politicians. What
we need is an unambiguous European immigration policy” (M. Kreyenbroek, personal statement, April
18, 2008).
• “To make the whole process easier for women and children is to provide them with residence
permits, since then I will be able to take care of my children” (Undocumented woman 1, personal
statement, May 20, 2008).
• “Help undocumented women who are sick and do not wait too long to make the decision to treat.
Also provide them housing and nutrition, otherwise this will force them make money in other ways. The
decision to stay, via the IND, takes too long” (Undocumented woman 2, personal statement, June 3,
2008).
Recommendations: group discussions
According to the HeRWAI analysis about 10 recommendations were stated and used within the group
discussions held on June 2 (see annex 5 for the summary of the meeting and discussions). In these
discussions two groups of about 6 persons per group were formed and asked to discuss and prioritise the
stated recommendations. These were the outcomes of these discussions:
1. A. Undocumented women should receive information (in a language they understand), about their
health rights, the working of the Dutch health care system, and when and where to seek obstetrician
care.
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B. Also health care providers, social workers and lawyers should receive this information as they can
inform undocumented women on what kind of health services they can get and where.
2. All midwives in Amsterdam need to be trained and supported in working with undocumented
patients.
3. A. The making of a draft monitoring protocol is recommended, in order for the government to
properly monitor the consequences of the implementation of the policy. Civil society should be part of
this monitoring, since they are the ones working with the undocumented people and they could
represent the undocumented patients.
B. A general lobby should be created to realize equal rights for undocumented women in line with the
rights of all women in the Netherlands for reproductive healthcare. Furthermore, there should be a
system in place to measure this. This can be the general message of the fact sheet.
Recommendations: general
As stated before actions are needed on as well local, national, as internation level. Some general
recommendations concerning these levels will be outlined here.
By actions on local level are meant health care providers taking their responsibilities by putting the
patient first (Dutch physician oath) and only deviate from the guidelines in benefit of the patient
(WGBO). This may sound very obvious, but in the case of undocumented patients it is found by many
different sources that in reality health care providers to not act according to their responsibilities. Costs
for treatment, which undocumented patients have difficulties to pay for, seems to be the most important
reason for refusing or sliding these patients off to other providers. As a consequence to this: more
(expensive) acute situations endangering the health of the undocumented women’s and her unborn
child. In short, health care providers should act according to their responsibilities, which is not always
easy because of the barriers put up at national level.
On national level laws should be changed and actions should be taken which facilitate health care
providers in treating undocumented patients instead of making their jobs more difficult. Hereby is it
important, as stated earlier, that the Dutch government acknowledges the rights of undocumented
migrants and acts accordingly; by removing the barriers experienced by undocumented (pregnant)
women to access health care. By access to health care is meant access to all forms of care as well as the
determinants of health; prenatal (e.g. contraception, abortion), natal (e.g. consults midwife,
medications), postnatal (e.g. maternity care). At all times access to the determinants of health (nutrition,
education, and housing) should be secured.
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Actions on international level are very important since illegal migration crosses the borders of
countries. For the Netherlands as part of the EU it is best to start making improvements here. The EU
will remain attractable to migrants all over world; border and immigration control is therefore no
solution. A solution is however to really listen to undocumented migrants thereby knowing the reasons
why they migrate in the first place, which gives the opportunity to take actions in their countries of
origins (before sending them back). Besides this it is really important that the undocumented migrants
situated in the EU will be treated with dignity and in respect of their human rights.
Recommendations: specific
Since the analysis focused on national policy more specific recommendations can be stated in order to
facilitate the implementation of the policy. Here the focus is mostly on national level. The
recommendations are all accompanied by a goal, an idea how to put this into practice and how the
government and/or other stakeholders involved are able to measure the attainment of the goal
(benchmark).
! Undocumented women should receive an information brochure (in a language they
understand), about their health rights, the working of the Dutch health care system, and when
and where to seek obstetrician care. This brochure should also be distributed among
professionals coming in contact with these women (e.g. health care providers, social workers,
lawyers).
- Goal: to directly improve the educational-level of undocumented women and professionals and to
indirectly improve the access to obstetrician care.
- In practice: in places where is known many undocumented people live or come to and in all health
care facilities brochures, with the above information, need to be spread. Also websites can be useful in
spreading the information.
- Benchmark: each year questionnaires should be taken among X undocumented women, of
reproductive age, in order to test their knowledge of the above information and its effect on health
seeking behaviour during pregnancy.
- Stakeholders: undocumented women and health care providers (receive brochure); Pharos (design
brochure via expert-meeting in 2008); government (final resources).
! All midwives in Amsterdam need to be trained and supported in working with undocumented
patients.
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- Goal: to facilitate midwives in Amsterdam in working with undocumented patients, thereby making
the treatment of these patients easier and less time consuming for midwives.
- In practice: midwives in training need to have a course in treating undocumented patients within
their curriculum; practicing midwives in both hospitals and midwife-practices need to have a X day
training in treating undocumented patients; the declaration system for unpaid bills needs to be electronic
(instead of the paper version).
- Benchmark: each year questionnaires should be taken among X midwives from various practices and
hospitals (definitely the selected ones) within Amsterdam in order to test their knowledge about
communicating to, treating, and supporting undocumented women as well as their experience with the
declaration system.
- Stakeholders: midwives (receive training); government (responsible for course ‘undocumented
patients’ within curriculum midwives in training & appointing trainers and sessions for practicing
midwives; financial resources); CVZ (electronical declaration system).
! The implementation of the modification ZvW (31 249) should be monitored within a rights-
based approach and involving civil society.
- Goal: to form a protocol in order to monitor the implementation of the policy, thereby making sure it
has a rights-based approach as well as that all stakeholders (e.g. human rights organizations
representing undocumented women, midwives, GPs, gynaecologists) are involved.
- In practice: a human rights organisation, with expertise on the area of undocumented migrants and
their access to health care, needs to be assigned in order to write the protocol and supervise the
monitoring process of the government.
- Benchmark: each year questionnaires should be taken among X midwives from various practices and
hospitals (at least the selected hospitals by the CVZ) within Amsterdam in order to test their knowledge
about treating, communicating and supporting undocumented women.
- Stakeholders: human rights organisation (design protocol; supervise monitoring); government
(monitor according protocol).
! The registration processes in hospitals need to be adapted to the needs of undocumented
women: create a safer and more comfortable environment.
- Goal: to prevent scaring undocumented women off because of their obligation to get registered in
hospitals, which against prevents complications during pregnancy.
- In practice: a protocol should be made about how to deal with undocumented patients like how to
ask for payment (which providers are obliged to) without scaring these women off. This protocol then
needs to be distributed among personnel of the contracted hospitals.
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- Benchmark: the CVZ can monitor if pregnant women receive regular care during their pregnancies
(on basis of the declarations); an independent organisation should measure the implementation of the
protocol and its effects on the access to obstetrician care.
- Stakeholders: health care providers (implement protocol); CVZ (monitor regularity of obstetrician
care); government (financial resources); independent organisation (measure implementation protocol &
its effects).
! More measurements should be taken when undocumented pregnant women are refused
treatment (encompassing maternity care) and/or when providers slide them off to other health
care providers.
- Goal: to prevent undocumented pregnant women being refused treatment and/or providers sliding
them off to other health care providers, thereby improving their access to health care and delays in
receiving treatment.
- In practice: undocumented women should be educated about where to go for complaints (Pharos)
when they face problems in accessing health care; as a consequence measures (e.g. fines) can be taken
in order to prevent health care providers in hospitals or practices from making the same violations.
- Benchmark: different organisations (e.g. Pharos, JWS, and Doctors of the World) are already
occupied in researching the access to health care for undocumented patients: their data should be used
in order to determine the possible improvements in the access to health care if more measures will be
taken.
- Stakeholders: Pharos (educate undocumented women; report to NZa the complaints); NZa (give
fines to health care providers who refuse women or slide them off); government (financial resources).
! Maternal mortality among undocumented women needs to be measured.
- Goal: to gain insight into the maternal mortality rate among undocumented women, therefore being
able to measure its decline or increase within the next years. These numbers are of importance in order
to lobby in the future for improving the maternal health of these women.
- In practice: an effective system needs to be developed which counts the MMR among undocumented
women and its causes. The Central Bureau for Statistics (CBS) (2008), as statistical information
facilitator of the government, could be the implementer of this system.
- Benchmark: each year the MMR among undocumented women and its causes need to be published.
- Stakeholders: government (appoint organisation to measure MMR; financial resources).
! The time-span from an undocumented woman arriving in the Netherlands and receiving a
residence permit should be shortened, thereby conforming to human rights.
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- Goal: to prevent undocumented women living for a long period of time without a residence permit
which restrains them from (legally) working, social security, education and obtaining health care
insurance.
- In practice: the Alien policy needs to be changed and based upon human rights, and its
implementation by the IND needs to be monitored by an independent human-rights organisation.
By more human-rights-based it is meant: the time-span of the whole process needs to be much
shorter (>5 years is unacceptable); the process needs to be simpler and more accessible to the women;
women need to be allowed to work legally and have education while waiting for their permit (otherwise
they are forced to receive money in illegal ways); women who are able to pay for health care insurance
should be allowed to obtain one while waiting for their permit; undocumented women who become
pregnant, while waiting for a permit, should receive social housing and money for nutrition during their
pregnancy and maternity care period.
- Benchmark: an independent organisation needs to develop recommendations for the IND in order to
improve the human rights of undocumented women who are in the process of requesting a residence
permit.
- Stakeholders: government (change Alien policy); IND (implement policy); lawyers (act according
policy); independent organisation (monitor IND).
! An uniform human-rights based European immigration policy should be designed and
implemented.
- Goal: to form a guideline for the immigration policies of EU member countries, thereby protecting
the rights of undocumented migrants.
- In practice: human rights conventions and declarations should form the basis of the EU immigration
policy, thereby making uniform regulations concerning for example the right to health (access to health
care, safe water and nutrition, sanitation, and shelter), right to non-discrimination (no discrimination of
any kind, like on residence status or gender), and right to life, liberty and security (freedom of speech
and choice of job, protection etc.).
- Benchmark: different human organisations (e.g. Amnesty International) already lobby at the EU for a
more human-rights based immigration policy, thereby research done by these organisations could form
an important source for measuring the process of the recommendation.
- Stakeholders: European Commission (design policy); European parliament & Council of Ministers
(make final decision on policy); EU member countries (implement EU policy).
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S6/q4 To what extent is your organization willing and able to assist the government or other actors in
the further development and implementation of the recommendations?
The WGNRR will facilitate the expert meeting of Pharos, taking place this year. In this expert-meeting
different stakeholders (e.g. midwives, gynaecologists, GPs) will come together in order to discuss how
health care providers should deal with undocumented pregnant patients. A brochure or leaflet will then
be made based upon the recommendations made in the meeting; the materials will in the future be
spread among health care providers. This meeting will also discuss if it is possible to develop a
brochure for the undocumented patients themselves.
As for the other recommendations the extent of the WGNRR participation in this will depend on its
future abilities. It is recommended however that the WGNRR will appoint an intern or volunteer to
watch over the implementation of the recommendations.
What will your action plan to lobby for improvement of the policy be?
S6/q5 Which national government department, person or procedure might be most helpful in achieving
implementation of the recommendations and demands?
The Ministry of VWS is responsible for the access to health care in the Netherlands; therefore members
of parliament and/or commissions (House of Commons and Upper Chamber) within this department
might be most helpful in achieving the recommendations.
As one of the recommendations concerns the Alien policy it is also important to contact members of
the Ministry of Justice. And for the recommendation concerning the EU migration policy it is needed to
contact the European Commission.
S6/q6 Which other governments, funding agencies or other actors do you want to approach, to point out
how their funding or actions should/could contribute to the improved impact of the policy?
Doctors of the World, Pharos, JWS, Amnesty International, NZa, CVZ, IND, CBS, KNOV, midwives.
S6/q7 What is the most suitable time to present the findings?
The most suitable time to present the findings of this analysis is at least before the members of the
Upper Chamber will vote upon the policy.
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S6/q8 Which options are available to increase pressure on the government (if needed)?
It is an option to make use of the ‘citizen initiative’; however at least 40.000 signatures need to come
along with the proposal (Tweede Kamer der Staten-Generaal, 2008), which makes this option not
realistic.
Another option is to lobby together with other human rights organisations in order to increase
pressure on the government. Especially cooperation with organisations highly valued by the
government could form an important link.
S6/q9 When and how will you know if the government has taken action corresponding to the
recommendations?
As mentioned is s6/q4, it is recommended that the WGNRR will appoint an intern or volunteer to watch
over the implementation of the recommendations. It will probably take some time for the government to
start implementing the recommendations; however within one year from now at least the start of its
actions should be visible. More research is then needed in order to define if the government takes
actions.
S6/q10 When and how will you check whether the changes have really led to an improvement of
women’s enjoyment of their right to health?
As stated in the previous question it will probably take some time in order for the government as well as
other actors to implement the recommendations, therefore it will take an even longer period of time in
order to see improvements of the undocumented women’s enjoyment of their right to health. It is
therefore again recommended for the WGNRR to appoint an intern or volunteer who is able to measure
these changes.
Probably 5 years from now (in the year 2013) changes should be measurable. In order to measure
these changes it is recommended to use an existing tool like “The right to health: a toolkit for health
professionals” (Asher, Hamm & Sheather, 2007).
Which awareness-raising activities are you planning?
S6/q11 How will the community be informed about the findings and recommendations?
An article will be made about the findings displayed in this report. This article will be displayed in the
next WGNRR newsletter in August 2008. This article and report will also be sent to different human
rights organisations, which will be advised to situate both documents on their websites.
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What does your organization need in order to implement the above plans?
S6/q12 How much time and which resources (financial and in terms of skills) does your organization
need to implement the action plan? Can these be made available?
As mentioned in s6/q9 and q10 the WGNRR should hire two interns or volunteers (one in 2009 and one
in 2013) in order to implement the action plan. These persons should of course have the right
knowledge base and skills in order to perform the job. It is expected that the WGNRR will have
sufficient financial resources available within these two periods in order to hire these persons for about
3-5 months.
4.7.3 Conclusions
It is not possible anymore to change the draft bill; however the Upper Chamber still needs to decide
upon the implementation of the policy. As a consequence the recommendations are mainly focused on
other actions the government and other actors should take. These recommendations concern:
information provision for undocumented women and health care providers; training of midwives;
rights-based monitoring of the policy; measurements for treatment refusal or sliding off; measure MMR
of undocumented women; and human-rights based Alien policy and EU immigration policy.
The WGNNR will have a role in the recommendation concerning the information provision and it is
recommended that the WGNRR hire two interns or volunteers (one in 2009 and one in 2013) in order to
do research on the progression of the recommendations and the right to health for undocumented
women.
Collaboration and allocation of responsibilities with other human rights organisations, as well as the
approaching of the just members in Dutch parliament and the EU, is very important in order to stand up
for undocumented women, secure their access to obstetrician care, and to place their human rights on
the political agenda.
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5 Discussion
In this chapter some final conclusions will be stated, the reliability and validity of the conducted
research will be critically discussed, and recommendations will be made for future research.
5.1 Final conclusions
In this paragraph the results in relation to the theoretical framework was discussed.
Overall it can be concluded that this research has added value concerning the knowledge about the
access to obstetrician health care for undocumented women living in Amsterdam, since not many
research has been reported yet on this specific subject.
Delays in health seeking behaviors of the undocumented women played an important role in their
access to obstetrician care as the ‘three delays model’ (see 1.3 Theoretical framework) already
explained. Many factors seemed to be important in their decision to seek care (phase I) and to identify
and reach the obstetrician facility (phase II). According to this research the most important factors
remained: lack of knowledge (concerning their rights and the Dutch health care system) and the high
financial barriers (requests from providers for contribution of health care, and paying upfront), both
closely related to fear (providing personal details, not receiving care, or deportation) (H. Playfair,
personal statement, March 18, 2008; Anonymous, personal statement, April 10, 2008; M. Kreyenbroek,
personal statement, April 18, 2008; Undocumented woman 1, May 20, 2008; Undocumented woman 2,
May 27, 2008; Foundation GPs Services posts Amsterdam, personal statement, March 10, 2008; Bureau
Intake AMC, personal statement, April 18, 2008; NZa, personal statement, May 15, 2008).
The reason why the lobby, held April 21, was successful can be explained by the ‘three streams
model’ (see 1.3 Theoretical framework). The problems stream explains why the access to obstetrician
care occupied the attention of members of the Dutch government during the debates concerning the
policy (31 249). The lowered expected access to obstetrician care, caused mainly by the fact that
directly accessible midwives were merely able to get 80% compensation for treating undocumented
patients, was found important by the members of government because it would violate different treaties
(Eerste Kamer der Staten Generaal, 2008). The most important sources here used by the visible and
hidden participants, also called the politics stream, were the report of the Commission Klazinga and the
official letters of the KNM, JWS and KNOV in which they showed their concerns. Here also to be
mentioned is of course the official letter sent by the WGNRR and its supporting organizations. All these
sources contributed to the fact that obstetrician care was one of the problems selected to become a
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motion and thereby changed the policy: 100% instead of 80% compensation for providers of
obstetrician care. This selection process took place in the policy stream.
5.2 Research quality
The scientific quality of the research was discussed by mentioning its benefits and limitations.
Research benefits
• The HeRWAI is a very practical for policy analysis concerning human rights. The instrument was
easy to use (just follow the questions), all encompassing (all aspects of the problem and policy were
questioned), and time saving (questions to be asked were present in the instrument, as well as possible
sources and methods to use) and is recommended for future research.
• Different stakeholders (representatives from the CVZ, and the Coupling Foundation, a social worker,
two midwives, and two undocumented women) were interviewed, thereby getting a broad perspective
of the problem.
• The stakeholders were all interviewed in an environment of their choice, which was mostly at their
work. An environment of their choice positively affects the quality of the interviews, since people feel
mostly more comfortable and therefore to speak openly in familiar environments.
• Before conducting all the interviews the confidentiality was explained as well as the possibility to
stay anonymous (which was used by one midwife and of course the undocumented women), which
heightens the chance for respondents to be open and tell the truth.
• The method used for recalling the matters said during the interviews was note taking and the benefit
of this method is that mostly interviewed people feel more comfortable (and therefore to speak openly)
than while a recorder was used.
• Fact checking was used after the interviews were summarised, which positively affects the internal
validity of the interviews and it limits confounding factors like reasoning of the researcher.
• Many highly diverse materials (triangulation of sources) were consulted as part of the desk study;
thereby the research is build upon existing knowledge. The reliability of the consulted materials is
difficult to determine however some were scientifically based or from large organisations; which are
expected to be of sufficient quality.
• The use of different methods (triangulation of methods) is an important benefit of this research since
the results found in one-method complements and checks the results found another method.
• During the group discussion 14 delegates from many different human rights related organisations
(Doctors of the World, Aim for Human Rights, LVRM, Article 1, JWS, Pharos, IFMSA, and KIT) were
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prevalent. Their input heightened the quality of the recommendations and action plan stated in this
report.
Research limitations
• As mentioned in the paragraph 2.3 the reliability and validity of the HeRWAI are difficult to
determine, therefore some recommendations are stated for future users of this instrument. These
recommendations can be found in annex 6.
• Note taking was used as method for summarising the interviews which could have caused recall bias
from the researcher since it is hard to listen and write all the facts down; despite of the fact that the
summarising took place as quickly as possible after the interviews.
• Recall bias could also have affected the information provided by the interviewed undocumented
women concerning their experiences with the Dutch health care system since both women have
delivered their child (ren) some time ago.
• Fact checking was not possible for the interviewed undocumented women; therefore the summaries
of their interviews might have been biased by the interviewer’s perception.
• The level of English of undocumented women 2 was not very high and she spoke with a French
accent; which might have influenced the quality of the notes taken during the interview.
• The external validity of the interviews, the extent to which the results can be generalized, is
uncertain. The reason for this uncertainty is that at first not so many respondents were interviewed; a
higher number of undocumented women and midwives in Amsterdam would have been preferred. The
problem was that it was very difficult to get into contact with undocumented women, and then it even
remained unsure if she shows up; which happened one time for still unknown reasons. In the case of
midwives it became clear that many contacted obstetrician practices in Amsterdam had no or hardly any
undocumented patients. The reasons for this fact could be: the selective accessibility of obstetrician
practices and the specific areas undocumented women settle in.
• During the group discussions only delegates from human rights related organisations were prevalent.
It was preferred that persons from more diverse backgrounds (e.g. governmental, medical) participated,
which might have caused a selection bias. It remained unclear why these persons did not attend the
meeting on June 2.
• As mentioned in table 2 of the lobby activities on April 28 the effect of the lobby was evaluated by
sending emails to the actors the letters were directed to; unfortunately only one actor responded (saying
that the letter was spread among staff of the Commission VWS of the Upper Chamber) which makes it
difficult to determine the precise effect.
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5.3 Future research
As mentioned in the action plan, future research is needed concerning the implementation of the
recommendations stated in step 6 of the results. One year from now (July 2009) the actions taken by the
government should be assessable, and five years from now (July 2013) hopefully the improved access
to obstetrician care (related to the right to health) can be identified.
Besides this, future research is needed which is focused on the determinants of health. Current
research does mention the difficulties undocumented women have to buy healthy nutrition, find proper
housing, and have education (see s4/q2); however more research is needed in order to find out the
precise problems these women experience in accessing these determinants of health. Hereby is it is
interesting to research another area in the Netherlands than Amsterdam.
More research is also needed in the area of preventative health care for undocumented patients.
Preventative health care is very important, as also stated in the national health strategy (see s2/q10), for
preventing sickness and therefore the more expensive curative health care. However, preventative care
is not always regarded as medically necessary; because it is not found efficient to provide this kind of
care to a population of which the duration of stay is uncertain. Duration of stay though, is no valid
reason for refusing the provision of preventative care and even violates the human rights of
undocumented patients. It is very important that preventative health care for undocumented patients will
be promoted; however at first more research is needed in order to determine the extent and precise
consequences of the non-provision of this type of care.
Many policies (as seen in question 2 of Chapter 3: Quick scan) influence the undocumented pregnant
woman’s access to health care, with the Benefit Entitlement Act as most influential. Therefore it is
recommended that more research will be conducted in relation to the effect of other (inter-) national
policies.
At last it is recommended that future research is done about how the three levels of actors (local,
national, and international), mentioned in s6/q3 under ‘recommendations: general’, can best work
together in order to have the most impact on the universal access to (reproductive) health care. Fast
action is needed to improve the worldwide maternal health since the year 2015 is coming closer and
MDG 5 is far from being attained.
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Acknowledgements
Without the help of others I was not able to conduct this research in its current form, therefore I would
like to thank several people.
First I would like to thank my two supervisors: Corine Otte thank you for your supervision, guidance
and motivation during my internship; Ivan Wolffers thank you for your supervision and scientific input.
Second I would like to thank three persons from Aim for Human Rights: Saskia Bakker for your
guidance in working with the HeRWAI; Marije Nederveen for your positive input (during the lobby);
Loeky Droessen for your facilitation during the presentation-discussion.
Third I want to thank the organisations supporting the lobby held on April 21, 2008: Aim for Human
Rights, ASKV, IFHHRO, Doctors of the World, and LVRM.
Fourth I would like to thank all the interviewed persons for their time and effort as well as their
honesty and information: Jasper van Amen, Henna Playfair, Anonymous midwife, Marion
Kreyenbroek, Sjoerd Oudenhuijzen, and two undocumented women.
Fifth I would like to thank all the other persons I had short conversations or email contact with for
their information and help.
Sixth I want to thank all the people who were able to come to the presentation-group discussions for
their critical questions and their feedback in the formation of the recommendations.
Last I want to thank my colleagues of WGNRR for their support, and above all for their contribution
in making my internship memorable.
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Annexes
Annex 1 Women’s Global Network for Reproductive Rights
The Women’s Global Network for Reproductive Rights (WGNRR) is a network of 2000 autonomous
organizations and individuals spread over 157 countries. Within all continents members are to be
found: Latin America and the Caribbean (8%), Pacific Asia (24%), Africa and the Middle East (23%),
North America (7%), and Europe (18%) (WGNRR, 2008b).
The WGNRR aimed, since its start in 1984, to achieve and support reproductive and sexual health
rights (RSHR) for women. RSHR is defined by the WGNRR as interrelated, basic human rights which
enable women to have safe, responsible and fulfilling sex lives and the self-determination to freely
decide if, when and how often to have children, free from coercion, discrimination and violence. This
includes the right of access to safe, legal abortion (WGNRR, 2007).
The WGNRR played, by its focus on RSHR, an important role in the running up to and aftermath of
the ICPD Cairo and Beijing Conferences by placing women’s reproductive rights in a socio-political
context. The WGNRR network is able to do this by bringing many worldwide grassroots organizations
together, raising their voices, and therefore increasing their impact in international, regional and local
advocacy (WGNRR, 2007).
Interaction between its members is thus very important and done mainly via the website, periodic
newsletters (containing articles from members), campaigns (e.g. Women’s Access to Health Campaign
and the Call for Action), international forums, solidarity actions, workshops and trainings, regional
consultation meetings, global networking and advocacy, specialized archives, and via personal phone
and email contact (WGNRR, 2007; WGNRR, 2008c).
Vision
A world where women can enjoy their reproductive and sexual rights, free from social, political,
cultural and economic oppression, in keeping with their personally held values, in dignity and in good
health (WGNRR, 2007).
Mission
To inform, link, engage and strengthen organizations and individuals worldwide in order to effectively
promote and improve reproductive and sexual health and rights for all women and girls.
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Objectives
To fulfil its mission the WGNRR will do the following:
• Provide a platform for collecting, exchanging and disseminating information on RSHR. Through
diverse communication tools, members will share their experiences, lessons learned, and perspectives
on the linkages between RSHR and related crosscutting issues.
• Enable collaboration and networking at different levels – grassroots, local, national, regional and
global – strengthening the Network across regions through linkages to global commitments.
• Build capacity of its members to advocate for RSHR trough toolkits, training, workshops and
specific materials.
• Take action and facilitate and initiate campaigns to advocate for RSHR to influence the global
development agenda and to create enabling social, economic, and cultural conditions to achieve these
rights at all levels.
• Influence policymaking to ensure that women’s reproductive and sexual health and rights are
incorporated in broader social and political movements with increased political, financial and technical
support (WGNRR, 2007).
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Annex 2 Interviews
1. J. Van Amen from Bureau Coupling Foundation, March 5, 2008 (pp. 97)
2. H. Playfair, midwife in Bijlmermeerpractice, March 18, 2008 (pp. 104)
3. Anonymous, midwife in Amsterdam hospital, April 10, 2008 (pp. 106)
4. M. Kreyenbroek, social worker in AMC, April 18, 2008 (pp. 109)
5. S. Oudenhuijzen from the CVZ, April 22, 2008 (pp. 112)
6. Undocumented woman 1, May 20, 2008 (pp. 116)
7. Undocumented woman 2, May 27, 2008 (pp. 118)
J. Van Amen from Bureau Coupling Foundation, March 5, 2008
After introducing myself and asking about the way he wanted me to present the interview
(confidentiality), Jasper van Amen started to tell me about the history of the foundation and the way is
works. I wanted to keep the interview more open and used the stated questions only as check if
everything is said.
A week after the interview Jasper van Amen corrected the interview I had written out, most of his
corrections are seen between “”.
History
The purpose of the Benefit Entitlement Act was to act upon the appearance of legality of some
undocumented persons living in the Netherlands ten years ago. The Dutch government meant to make a
clear distinction between illegal en legal residents in relation to the access of social services. It is part
of a policy to discourage an illegal stay in the Netherlands. The Coupling Foundation was founded by
private initiative to give financial support to health care providers. The budget was and still is provided
by the Dutch government. The private initiative, the board of the foundation, was formed by people of
the field, like (former) employees of the health insurance fund and the GGD.
The whole financial support system is also formed by the regional GGDs, who are in direct contact
with the health care providers. The GGDs get a yearly budget; decide immediately if the request of a
care provider for compensation fulfils the conditions of the “Arrangement Coupling Foundation”, and
if so pays out the refund. The foundation only asks for a financial justification at the end of the year.
The GGD themselves are responsible to make the actual payments; collect the money from the
foundation; transfer it to the providers again. “The money will follow the care”.
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The decentralized system, by making use of the regional GGDs, has proven to be very effective,
since they are close to where the problems are. More importantly, the access to health care has
improved for undocumented people after the setting-up of the Foundation. Since then the providers
were able to lessen their income loss caused by uninsured treatments which beforehand was not
possible.
There seems to be a consensus among the Dutch political parties that healthcare providers should be
compensated, when they suffer a loss of income in a situation when they are obliged to give vital care
to someone without a residence permit. “That doesn’t mean that all political parties agree that the alien
policy shouldn’t be used on the health care system. On the contrary I would say”. That’s why it’s
always a sensitive subject. Changing or improving existing financial arrangements will also start the
debate on alien policy and the relation to health care. Until now the coalitions who took part in the
actual government were indeed of the opinion that it is not wise to have an active alien policy on the
healthcare system or at least not to change the existing practice. This comes down to not taking any
illegal persons into custody while they are making use of health care services. Health care providers
therefore can keep their confidential relationship with their patients, in which the residence status is of
no importance, and undocumented people should not be afraid to seek care.
In 2006 the Health Care Insurance Law (ZvW) obligated everyone to be insured. This had a large
impact on the health care system, since the whole finance system was changed. Also some other
measures in the health care system had impact on the finance system, such as the introduction of the
DBC system for example. More important was a combination of two subjects. Everyone has an
obligation to obtain “basis insurance”. It doesn’t go automatically. A person has to act. The system of
private and social insurance came to an end. And everyone pays at least a nominal premium, which is
not depending on income. This nominal part of the premium is much higher than the one used before in
the social insurance system. Because of this combination the government was a bit afraid of the so
called “freeriders”, people who willingly chose to be uninsured knowing that when they get sick
medical vital care will be given anyway. There was also a fear that the existing financial arrangements
for illegals could become more vulnerable for abuse. The temptation to use the existing arrangement to
solve other problems not related to migrants without residence permits could increase. If that is really
the case one could not tell, but in the opinion of the government it is better to prevent the opportunities.
“The ZvW was not meant to change the position of illegal immigrants and it didn’t change the
access to healthcare for migrants without a residence permit. And I think you also can’t successfully
plead for the argument that this law is meant for the government to increase its supervision. On the
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contrary, one of the purposes of this law is to increase the working of a free market in the healthcare.
The opposite one might say. Yes there is however an article, which obliges care providers to ask for
identification papers, but only when someone wants to use their health insurance pas to pay for the
costs. The purpose is to prevent fraud. One can hardly argue that by preventing financial fraud, the
government is blocking the access to healthcare? The ZvW did not change the existing financial
arrangements directly. What it did was unintentionally put some pressure on these arrangements.
Therefore the government has the desire to restructure the existing arrangements into one financial
arrangement.”
Money
The budget is reserved yearly at the Ministry of VWS for the foundation to divide among the health
care providers in the Netherlands. This budget is estimated at 5 million euros yearly. The government
provides the money on a non-obligatory base.
“Our foundation has no authority, nor the aspiration, to dictate what kind of healthcare should be
considered as vital ‘medically necessary’. The guidelines of the foundation refer only to the possibility
of obtaining compensation by care providers within our arrangement. One of the preconditions is that
the care provider has suffered a loss of income, because he was forced to give vital care; ‘medically
necessary’ to an uninsured patient without a residence permit. The definition used by the foundation for
‘medically necessary care’ is that it is up to the care provider to decide whether the care is vital, but
within the boundary of the basis insurance”. Thus the foundation thinks it is very important to keep the
health care providers responsible for the care they provide and not to interfere with their care duty. The
provision of the money is based on trust: no measurements are taken to check on the necessity of the
request (only when suspicious); it is trusted that the provider first asks the patient to (partly) pay for the
aid; and the patient files are anonymous, merely the initials, age, gender and nationality of the patient
are needed and a stamp of the practice. Especially the questioning of the patient about the payment of
his or her own health care is found to be important: it is not free insurance. Also not every
undocumented woman is unable to pay for her own health care: she could have a job, family who is
able to provide money etc.
In the Netherlands, Amsterdam gets a large percentage of the yearly budget. Possible reasons for
this large percentage are: the city has more work opportunities which attracts migrants; migrants seek
each other to form a network in order to survive, this is more easy in a large city; some migrants come
from HIV/AIDS endemic areas, therefore a fairly amount of money is for HIV/AIDS medication. Also
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drug related infections could be a cause. In Amsterdam large migrant populations live in the Bijlmer,
which are mostly thought to have an African background and now outnumber the Suriname population,
which used to be the largest population.
Besides Amsterdam, other large cities like Rotterdam and The Hague have similar problems. In
Friesland many asylum seekers centres are established and when the asylum seekers lose their permit
some settle in the area, therefore also many undocumented people live in Friesland.
It was difficult to say how many requests the foundation gets on a yearly basis. The cause of this is
that not all the health care providers ask for compensation for their treatment: some treat undocumented
people for free; or ask for compensation only when this is a fairly large amount; and there are
immigrants who can pay for their own care.
When I asked about the possibility of allowing undocumented people to have preventative health
care, since I always was told that prevention is in the end more cost-effective than to cure, Jasper said:
“in his opinion one cannot copy paste the knowledge about cost reducing effects of preventive care in
an regular insurance surrounding on this system of compensating the cost of healthcare to illegal
migrants. We are talking about a variable population; you are dealing with seasonal immigrants, former
asylum seekers, and so on. As a government one has neither the intention nor the responsibility to
create and finance a healthcare system for non-residences. By the way, this doesn’t mean they want to
block the access to healthcare. When you are creating a financial system to support the healthcare to
citizens, you have also the responsibility to be responsible with the money you put into this system.
After all it is tax paid money. As a government you ought to control the expenditure in health care and
therefore you look at cost reducing systems. When you work with a vast population you can invest in
prevention in order to reduce the cost of healthcare. Is it also profitable with the variable population of
immigrants? That depends, some aspects of prevention could be cost reducing, as for example to
convince pregnant woman to go to a midwife in an early state of the pregnancy. But you can also argue
differently and say that it is doubtful that prevention could be cost reducing, because the more the
patient without a residence permit knows about existing diseases the more unlikely it is that he will
leave the country and therefore it’s expanding the cost of the healthcare. What may be, I think that one
shouldn’t use prevention in this case as an instrument of controlling finances; one should do it out of
humanity. That is why I indeed have the opinion that prevention could be part of the strategy,
especially in the case of pregnant woman and children as they are more vulnerable”.
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Health care providers
He talked about the different health providers.
Hospitals and institutions
The budget for hospitals is arranged differently. They have the dubious debtors (in Dutch: ‘dubieuze
debiteuren’) arrangement with the insurance companies they have a contract with: a budget yearly
estimated. “The hospitals try to stay in the agreement. But if one hospital overspends then of course
this becomes part of the negotiations with the insurance companies. It is not by law that they cut in
their own budget it’s a possibility. Does this arrangement cause financial trouble for a hospital? I
wouldn’t dare to say that. I leave it up to the hospitals”.
“The free Diagnosis Treatment Combinations (DBCs) are new phenomena, at this moment it hasn’t
much influence on the financial arrangement ‘dubious debtors’. The DBCs are only a small part of the
care in the hospitals, which is totally ruled by the free market system. That means that the hospital can
put their own price on a certain medical treatment and with this price compete with other hospitals. In
this system one cannot defend a dubious debtors system. It would worsen a hospital’s competitive
position. But in the future this portion of free DBCs will become a larger part of the healthcare
provided by hospitals. Then it could become a problem”.
“In Amsterdam the AMC hospital is probably accessible for undocumented migrants, which is
mainly because of their location, and therefore needs a sufficient budget (which in seen by the
foundation). It’s probably larger than most other hospitals, but I’m not sure, because none of the
hospitals are open about this financial post”.
For institutions (mainly for mental care) the budget is arranged by the AWBZ. From the AWBZ
mainly care for documented people is paid, therefore it is difficult to estimate how much money goes to
treatment for undocumented people.
General Practitioners
In Amsterdam, since there are many undocumented people, they have an efficient system to
compensate for their income loss. By using a carbon-copy paper of which one can be used for the GP
itself and one for referral to the pharmacists.
Mid-wives & maternity care
”It is plausible that pregnant woman without residence permits tend to postpone an appointment with a
midwife. But it goes too far to presume that in most cases pregnant woman only ask for care when they
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are in labour. That is not the case. In our statistics it’s also not possible to see if it’s only the natal or
postnatal care that is compensated. There is no distinction in our statistics in prenatal, natal and
postnatal care and we do have the signals from midwives that they are providing the whole care; pre to
postnatal”.
The payment is sometimes (partially) paid by the pregnant women themselves.
Undocumented women are quite often from countries where epidemics are prevalent, like HIV/AIDS.
Since this increases risk of complications a lot of these women are referred to a gynaecologist in the
hospital.
Problems
• It very much depends on the professionalism and the policy of the regional GGD how much time it
takes before the money is back to the providers of the care. Also the amount of money seems to be
important for the speed of the transfer: goes well with large amounts and less with small amounts. The
Foundation is said to be fairly fast with their part in this system, therefore much depends on the local
GGD. “I meant that the payment of the GGD is part of the regional agreements of the platforms. And,
to be a little bit provocative, I suggested that the payments of some GGDs are actually faster then the
payments by insurance companies in general. I personally think it’s a non-discussion. The argument is
used as if the foundation or the GGD is responsible for the decision to give care to a person in need.
We aren’t, care providers. This financial arrangement doesn’t dismiss care providers from that duty. By
the way, the foundation only pays twice a year, one advance in the beginning of the year, one in the
second half. It’s not directly related to the compensations of care providers. But of course if our
foundation doesn’t succeed to get the full budget, it will effect the payments to the care providers. The
question is will they still provide the vital care when there is no financial backing. Is the oath of
Hippocrates only symbolic or does it actually means something? Do care providers still think that there
is no distinction between an insured patient or an uninsured patient and act to it or is it in the end
always about the money? I don’t know what would happen if there isn’t a financial arrangement, but
you know what: let’s not find out”.
• It is not very clear if the obligation for identification has discouraged illegal migrants from coming
to the Netherlands. There do was a decline in foreign migration. (“It’s also not my job to decide
whether the foreign policy is successful in fulfilling the goals put by the government. By the way, the
obligation for identification in the healthcare is not meant to discourage illegal immigrants. That’s a
misconception as I mentioned above”.)
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• Forms have to be filled in per patient.
• The Foundation was given too much responsibility by the government, and has been found in
retroactive effect by the courts a governmental managing body. “This court decision changed the
position of the foundation. Suddenly the board, formed by volunteers, sees themselves put into a
position where they are part of the government and ought to fulfil governmental policy. That conflict
with their intentions and their personal reasons for the choice to put their free time and effort in this
foundation. It pops the question whether the board members are willing to continue in this changed
environment. But it isn’t necessary to make that decision, because also the health department has come
to the conclusion that they can’t maintain this new governmental managing body. Mainly because it’s
against the wishes of Parliament to have governmental managing body’s outside the official
government in the first place. It’s confusing for the citizen. That’s a part of the reason why a new
arrangement is necessary”. Since the foundation ought to be neutral and is formed by board of
volunteers, they do not want to be part of government. Therefore things needed to change: a new
proposal was set up (see below). In the meanwhile the foundation is assisted in its work by the CVZ.
Draft bill
A new draft bill, for the financing of the income loss for providers for care to undocumented people,
has recently been set up. In this proposal the three budgets (Coupling fund, dubious debtors, and
AWBZ-fund) will become one budget, which will be the responsibility of the government. In this
proposal a distinction is made between two kinds of care:
1) Acute (vital) care: 80 % compensation
2) Care that can be planned: on basis of contracts with certain health care providers
The downsides of the new proposal are:
• The care duty of the health care providers has been comprised, since the care is only compensated
for if the providers have a contract.
• When the government is responsible it is inevitable that more measures will be taken to check up on
the health care providers, which puts more pressure on the providers and could damage the basis of
trust that the system was build upon.
• The new system could form an even higher barrier to the access of health care for undocumented
people, since they can only go to contracted hospitals, GPs and midwives. This barrier is caused by
possible longer travel distances and higher travel costs (especially in rural areas).
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• Especially the midwives will suffer the most from this new arrangement; since they have a vast and
fairly high amount they ask for a delivery and care among the birth. When they only get 80% back
from the government they will suffer a high-income loss.
There have already been negative comments on the new proposal. Besides this, the GPs have a reserved
policy on the matter and the midwives hardly have been heard of yet, not even the KNOV has
commented yet.
H. Playfair, midwife in Bijlmermeerpractice, March 18, 2008
The Bijlmermeer Obstetrician Practice is the largest practice in the Netherlands, which treats
undocumented and uninsured women. Undocumented women from all parts of the country come to this
practice, because of its reputation among undocumented people to treat these women without much
questioning. Therefore about 30% of the women in the practice are undocumented, another 30%
consists of teenage girls, and the other 40% are insured women.
Current policy
The policy she and her colleagues maintain is: not too much bragging about money, because this will
scare them off; comfort the patient and say very clearly that they need to come back for the sake of the
health and life of their unborn child and herself. She says this is the only rule they maintain and that all
patients need to be seen as individual persons, with their own background and problems.
Especially the money issue seems to form a large barrier for undocumented women to seek care,
since they are not able to get a health insurance. In order to overcome this barrier, Henna assesses the
wealth of a woman or couple (by looking at clothes and the way they behave). If she thinks the woman
is able to pay she will ask, but if she thinks not then she won’t ask the woman, because this will scare
her off. As a result she won’t be coming for any more consultations, which again causes more serious
complications and sometimes even death of mother and child.
More serious complications cost the government even more money. Henna does not understand the
policy of the government, “they spend lots of money on housing for undocumented women, but they
economize on health care for these women”. The government is also inconsistent about the
reimbursement of health care providers in poor areas like the Bijlmer: General Practitioners got an
extra fee and obstetricians did not.
Despite their careful policy, lots of undocumented women disappear after three consultations: they
fled somewhere else.
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Whether a patient is insured or not, or is able to pay or not, all the women get the same amount and
quality of care in the Bijlmermeer Practice. The difference is that undocumented and uninsured women
take more time to care for: provision of information about the Dutch health insurance system and
possible complications related to pregnancy; some speak hardly any English which makes it hard to
communicate; some are illiterate, therefore education material are of no use; pathology is more
prevalent among these women, therefore more consultations are needed; they seek care more often at a
later stage in which some preventable diseases cannot be prevented any more; they mostly are not able
to pay for their own care, therefore she needs to fill in lots of forms in order to get money back from
the Coupling fund. The latter she experiences as a downside of her job. It takes a lot of time (one
weekend a month) to fill in all the forms, which she needs to send to the Coupling fund within 2
months after the moment the care was provided otherwise she cannot get her money back, which takes
another waiting period of 3 months.
Health of undocumented women
The pathology among undocumented women is higher than among documented women. The pathology
or complications they experience more often are for example: high blood pressure and diabetes
(especially among Surinam women); infectious diseases like HIV/AIDS and hepatitis; early birth
(especially among African women); ‘pregnancy poisoning’; caesarean section (especially among
women from Thailand and Africa). All these complications again cause the child and maternal
mortality to be higher among undocumented women.
The reasons why the pathology of undocumented women is higher are mainly because of their deprived
living conditions: bad housing; hard working; lot of stress (anxiety); and poor nutritional pattern. The
hard working is caused by the fact that some women even have three jobs in order to survive. These are
of course illegal jobs in which the women are being exploited. The hard working, but also the anxiety
of being caught by the police, causes the high stress levels. In the Bijlmer once in a while razzes take
place: undocumented people are being sought and put into jail, even pregnant women (until a certain
period in their pregnancy). The bad housing and poor nutritional status are caused by a lack of money.
Other reasons for a higher pathology are: genetic deviations, which are more common within ethnic
populations; and the more active attitude of the women, which sometimes causes them to refuse certain
recommendations from specialists.
Some women she treated were in war situations, gang-raped, sex workers, or trafficked. Several were
not even in the possession of their passport, since this was taken from them.
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Men are very often not involved during the pregnancy of these women. Some women were even only
by themselves during pregnancy (especially among African women) or in some cases supported by a
friend or relative. These women however did not experience this very negatively, she thought.
Future expectations
Henna had already heard something about the new draft bill about the modification of the Health Care
Insurance Law, but not yet officially. She expects the situation of her job as an obstetrician to become
even worse if the draft bill will be implemented. Her practice belongs to the first-line care; therefore
only 80 % of their expenses will be compensated for in the future. Since her practice treats so many
undocumented women, she fears a large income loss for her practice.
As a response she will probably in the future refer the women to the second-line: the AMC-hospital
which also, like their practice, has the reputation to treat undocumented women without much
questioning. The AMC-hospital is, according to her, already almost unable to handle more
undocumented women (has the highest ‘dubious debtors’ fund in the Netherlands); therefore this will
become a major problem. She knows that she has a care duty and therefore is not allowed to slide
women off to other health care providers, but she will of course not work for free. Her boundaries will
be crossed if the draft bill will be implemented in its current content (only 80% compensation for direct
accessible care). The entrepreneurs’ risk will then become too large for her practice in the future.
About the ‘duration of stay’ as a criterion for medically necessary treatment she says that the
government does not get what the obstetrician care is about. A pregnancy takes a set period of time; as
well prenatal, natal, as postnatal care (10 days after birth) is all medically necessary.
Her recommendations to the government were very clear: the first-line needs to be fully
compensated for. The undocumented women need to receive the care they deserve and it is the
governments’ responsibility to protect these women. A pregnancy is seen as medically necessary, since
two lives depend on it. If the obstetrician care only gets 80% compensation the child and maternal
mortality will rise even more. As a possible solution she gives “everybody should be allowed to obtain
a health insurance”, at least some women (who are able to pay for insurance) would benefit from this.
Anonymous, midwife in Amsterdam hospital, April 10, 2008
I interviewed a midwife working in a hospital in Amsterdam and since she preferred to stay anonymous
no names will be mentioned. On a regular basis she deals with patients who are undocumented.
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Current policy
Every pregnant woman will be helped in the hospital. No difference is made between undocumented
and documented women. They receive the same quality of care. The only difference is that since
undocumented women are not insured and therefore obligated to pay their own care, they are extra
critical on the medicines, test and care they provide. If the care is not necessary then it will not be
provided, this only when it does not affect the health of the women, since their health is of course
number one priority.
Therefore it can be said that the midwives do look at the costs of the care given and take this into
account, especially since care at a hospital is more expensive than first-line care. As a solution to this
problem they cooperate intensively with first-line care midwives: when care can be given at the first-
line they will refer to this line and vice verse, since most undocumented women start their care in first
line. Another solution she mentions to ‘keep the bill low’ is home monitoring: tests and care is given at
the undocumented pregnant women’s homes, in case of complications. Normally a woman is taken care
of in a hospital. Deliveries on the other hand are almost never given at the women’s own homes: they
mostly live under poor conditions, not suitable for a delivery; and have more often pregnancies, and
therefore deliveries, with complications. This is so for women in first-line care as for women in
hospital care.
The hospital has special procedures for the payment of care for undocumented people. The health
care providers refer all undocumented people to ‘Bureau Intake’, where they need to discuss the
payment of care and fill in forms. This discussion leads sometimes to the making of payment
arrangements. Undocumented people are not always immediately referred to the Bureau, like in an
emergency situation first the care will be given and afterwards the payment will be discussed. The
midwives always need to report the care provided to undocumented women to Bureau Intake and the
medical direction. Although this is just a call, she prefers not needing to do this, since it adds to the
administrative load. An advantage for midwives in a hospital is that they do not need to have the
complicated discussion with their undocumented patients, since this is a task of workers from Bureau
Intake.
Despite the careful talk midwives have with all undocumented women about payment and Bureau
Intake, many women do not appear at the Bureau. She, herself, thinks that women fear for deportation
from the Netherlands. Some women therefore do not come back to the hospital, and what happens to
them nobody knows.
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Health of undocumented women
She said that undocumented women are often not so healthy. Therefore they can have more
complications in pregnancy than documented women have. The complications she mentioned were
high blood pressure, HIV/AIDS, and (very) early childbirth. These complications raise the costs of the
care, for example when the baby is born too early the baby needs stay in the hospital. The constant
considerations about the necessity of the care and the costs involved have resulted in many discussions
among midwives and remain a difficult issue.
The most important factor, relating to the higher prevalence in complications among undocumented
women, is the delayed seeking of care. The women mostly seek care in a stage of emergency.
According to her the reduced access to obstetrician care is caused by the fear women experience about
the costs of care and deportation.
Obstetrician care given to undocumented women takes more effort by midwives than care given to
other women. Already mentioned are the obligated conversations about payment and Bureau Intake,
and the higher prevalence of complications. Not yet mentioned are poor knowledge about the Dutch
health care system, language barrier (poor English), and the feeling being of discriminated against.
Solutions midwives have for these problems are respectively: informing people from Ghana (since they
have many people from this country) via radio about the Dutch health care system; usage of interpreters
(not possible in emergency situations); and talking with the women about their feelings of
discrimination and that this is not their intention (according to the midwives themselves no
discrimination takes place in the care they provide, it is the system of healthcare in the Netherlands that
makes the difference).
The difference in accessibility of hospitals in Amsterdam for undocumented people is known among
the undocumented population. Some hospitals are more accessible than others. These rumours are also
heard among the obstetricians of this hospital, but if they were true, she would not know.
Draft bill
She has not yet heard about the draft bill, modification Health Care Insurance Law, and its possible
consequences for her as midwife. After explaining her about the draft bill she expected that the hospital
she works at has a large chance of being contracted by the CVZ, since they treat many undocumented
patients. About the contracting of selective hospitals itself she said that this was not a good case if the
underlying excuse is cost reduction. This should not be the principle; improving health should be the
main goal. Besides, what is the cost reduction if more personnel are needed, because of more
complications and complicated pregnancies and deliveries?
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The fact that first-line midwives in the future only receive 80% compensation and the reasons the
government gives, that 100% compensation would take the urge away to ask for money and that the
20% is part of the risk of being a health care provider, she thought this was nonsense. She explained
her opinion by an example: what if an obstetrician practice is founded in an area where many
undocumented pregnant women live, this practice is more at risk for loss of revenue than a practice
which is founded in an area where not many undocumented women live. This is not logical she says:
care given must be paid.
She did not support the ‘duration of stay’ as a criterion for treatment and perceived it as an
unwanted development. She said that it was not possible to make a distinction on this base.
As for recommendations to the government she stated: “we are health care providers, not police or
hunting for money. We want to keep ourselves occupied with health care provision and we stand for
access to health care for all”.
M. Kreyenbroek, social worker in AMC, April 18, 2008
I spoke with a social worker for HIV-positive pregnant women in the AMC. Every year she has a few
patients who are undocumented.
Current work policy
Good care for all pregnant women is their aim. Everybody is treated according to the same medical
protocol, since 2004, and the costs of this provided care should not be looked at.
All pregnant women are being tested within their pregnancy for HIV/AIDS. The HIV-positive
women are all referred to her, therefore also all HIV-positive undocumented pregnant women. In 2003
she treated 18 women of whom 8 were undocumented, this was a very large amount.
For infected women it is very hard to tell this to their partners, especially since many are afraid that
their partner does not want to live with them anymore. They are afraid, because some women are
dependent upon their partners, since they came to the Netherlands to reunite with them. Unfortunately
some partners of HIV-infected women do not want have anything to do with them anymore when the
women tell they are infected. Women do not transfer HIV as easily as men do: only 30% of the men
were infected when their partners were tested positive for HIV during pregnancy. Since these men are
still young and do not want to have sex with a condom for the rest of their lives they leave their wives.
She supports women from the moment HIV is detected until one year after the birth of the child.
Besides her function as social worker she has a coordination function over all the psychosocial care
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provided to an infected woman. She therefore works closely together with paediatricians,
gynaecologists, and doctors of internal medicine.
In total 22 hospitals in the Netherlands are assigned by the minister of health to treat HIV infected
women, of which the AMC in one of. The hospital’s pharmacological department at first provided HIV
medication, this however changed with the introduction of the Coupling fund.
Payment of care
All uninsured people who come to the hospital for the first time are referred to Bureau Intake. This is
the first barrier undocumented pregnant women face: at the Bureau personal details are needed to make
a registration. At the Bureau it becomes clear which of these people are really undocumented, and
therefore not able to be insured, and which people are obligated to get insured. For the former group
sometimes payment arrangements can be made: the undocumented people who are not able to enter
insurance or to contribute to their hospital bill.
To the outside world however the image should remain that hospital care is not for free. There
should remain a stimulus for patients to pay for their own care, since some are able to pay for it. For
obstetrician care a fairly large amount of money needs to be paid (many acute situations and
complications), which therefore makes it impossible to pay the whole bill. Then the ability of the
undocumented woman to speak up and to demand care seems important for the care that she can
receive. For most women this is a second barrier: some speak hardly any English, and most of them do
not know the Dutch health care system.
HIV-infected women are first sent to the social worker before referred to Bureau Intake. This is
done in order to prevent HIV-infected women to be scared of by the fact they need to register. The
social worker will explain the process of registration to the women and offer her support. The social
worker is in close contact with the Bureau, in order for this registration processes not to interfere with
the provision of good medical care. As a social worker, she therefore also has a monitoring function:
when continuous problems prevail in the registration process she needs to inform the Medical
Direction.
Asylum procedure
The asylum seeker is insured for health care during his or her procedure. This however ends from the
day that the request to seek asylum is dismissed.
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The asylum procedure takes many years and in these years the asylum seekers live in uncertainty
and fear. There are numerous reasons why some procedures take longer than others. Fortunately at the
moment the procedures seem to take less long than years ago.
The other side of the asylum procedure is that when the asylum seeker is ill and the request is
dismissed, the process of a residence permit based on medical grounds can be started.
Residence permit based on medical grounds
Undocumented HIV-positive women could be eligible for a permit based on medical grounds.
The AMC has contact with lawyers in Alien Rights, to whom patients are referred when an
undocumented HIV-positive woman wants to get the mentioned permit. No costs are attached to these
lawyers, however to start the whole process the Immigration and Naturalisation Force (IND) need to be
paid hundreds of euros. In order to pay the IND funds need to be found. The Bureau Medical
Advisement (BMA), composed by doctors, is the actor who will look at the request for permissions on
medical grounds, which can take up to 1.5 years. The BMA will look at how serious the disease is, and
whether the care is available in country of origin. Based on the findings of the BMA, the IND will give
the final judgment. This final judgment will be most likely positive if:
1) The disease is serious
2) The disease is chronic
3) The care to treat the disease is not available in the country of origin
The first two points are always applicable to HIV/AIDS, since it is serious and chronic, but the third
point sometimes becomes a problem. Medicines to treat HIV/AIDS are very often available in country
of origin, but are often not obtainable or sustainable by patients because they are not able to reach the
hospitals that provide these medicines. The accessibility is not taken into account by the BMA. The
availability of medicines in country of origin therefore often ends in a negative verdict. However, the
lawyer is able to file an appeal to this. The experiences show that most of the time the appeal turns out
positively, because mother and child are a vulnerable group. A positive verdict means that the patient is
permitted to stay for 1 year in the Netherlands. This permit is valid from the moment that the request
was submitted, since the whole process could take up to 1.5 years this first permit may cover 2 years.
After this whole process of 2 years, there is the possibility to request for a residence permit for
restricted time (3 years). Within this time frame, the undocumented woman has been in the Netherlands
for more than 5 years, she is able to apply for the Dutch nationality.
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She commented on the discouraging policy in the Netherlands: the Dutch government will need
migrants in the future, since the Dutch population in getting older. Besides this she said that medical
tourism is not prevalent and that this is only an unrealistic thought among politicians. As a solution she
stated that an unambiguous European immigration policy is needed.
She explains the difference in accessibility for undocumented people between different hospitals by
the fact that superiors within hospitals maintain their own opinion about care given to undocumented
people and that they influence their staff (power conflict).
According to her the AMC does act within the boundaries of the law and their financial report shows
that they make a lot of effort to provide care to the uninsured and undocumented. Medically the AMC
acts well, but non-medically not so much: legal help is much more difficult to obtain. The government
raised this legal barrier to prevent undocumented people from claiming their rights.
The pocket-money arrangement
Nutrition and housing are important for compliance in treatment, and since many undocumented
women do not have the money for this, they have difficulties taking their medication.
In the past no support was given to undocumented HIV-infected pregnant women. However in 2006
in Amsterdam a bread-bed motion for these women was accepted. This therefore only applies to
women living in Amsterdam, since it is a local policy. The motion was called the ‘pocket-money
arrangement’ and health care providers who treat undocumented HIV-infected women are allowed to
request for this arrangement. The amount of money provided by the arrangement is: 40- 45 euro per
week for living (like clothes and nutrition); and a maximum of 200 euro for housing per month. The
institution responsible for the provision of the pocket money is the Diakonie. A downside of the
arrangement is that it only applies for undocumented pregnant women who need medicines to treat
HIV, apart of being pregnant. The women who do not yet need medicines were excluded after birth.
This was resolved by the AIDS-fund, who gave money to the Diakonie in order for the excluded
women to have pocket money as well.
S. Oudenhuijzen from the CVZ, April 22, 2008
The Colleges for Health Care Insurances (CVZ) will get the task to take care of the financial part of the
implementation of the modification ZvW (31 249). At the CVZ I talked to Mister S. Oudenhuijzen
project leader of the financing of care to illegal migrants.
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Draft bill
The CVZ, as most the important implementer of the new financing system for health care providers
suffering revenue loss from care provided to undocumented migrants, was involved in designing the
draft bill (31 249). The ministry of the VWS did the actual designing, but the CVZ was asked if they
thought they were able to implement it and therefore some changes were made. The design is still not
very specific, since no money was available for research; therefore possible future obstacles could
arise.
Health care providers were also involved in the forming of the draft bill. Several platforms were
formed, which were composed by organizations like Lampion, Pharos, hospital and institutional
personnel. In Amsterdam two hospitals were involved in these platforms: West-End and AMC.
Lampion and Pharos are organizations involved in research about the access to health care for
undocumented migrants; therefore they represent the undocumented population in the Netherlands.
From this undocumented population, which is about 150.000 people, around 7.000 seek care, which
is a much lower percentage than the care seekers within the documented population.
There always remain people who abuse the special regulations for undocumented people to receive
free health care when they are not able to pay for it themselves, by saying they belong to this group
while they do not.
Directly accessible care
The way in which health care providers are able to request for compensation of revenue loss will at the
moment be the same as in the old system, thus via the local GGDs. The problem is however that not
much money is left within the budget to spend on the platforms; therefore is remains uncertain if the
GGDs still want to perform the job for less money. Besides this in the future even more will be
expected from the GGD, since its relating to the compensation system will in the future be arranged via
law, meaning more strict conditions will be set.
Foundation Coupling will stop existing and be taken over by the CVZ.
Somewhat different information from health care providers is needed in the future in order to
receive compensation: no initials anymore (merely gender, age and nationality), since otherwise
persons are traceable and not anonymous; it needs to be clear that at first the patient was asked to pay
the bill.
The draft bill states that 80% of the uncollectable bill can be compensated for via the CVZ, this is
however not 80% from the whole account. Therefore even when 20% is collected from the
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undocumented patient, merely 80% from the uncollectable is compensated for by the CVZ and the
whole account will never be paid for. Thus the health care providers never profits from care given to
undocumented patients.
The duration from requesting for compensation to the actual receiving of the compensation will
probably remain the same as it is at the moment: it depends on the health care provider and the time
taken by the local GGD. Since it remains unclear how much money is involved in health care for
undocumented people, in the coming years the GGD will be paid each half a year after the money is
spend. This however is not formally stated yet.
The CVZ knows exactly what is in the basic insurance package and therefore seems competent for
the job. At least care encompassed by this package is medically necessary and care that falls not within
this package will be tested for necessity. The CVZ however, does not have the intention to decide what
medically necessary care is and what not: the health care provider remains the expert in this area.
There is already an arrangement for general practitioners within deprived areas who receive more
money for treating patients, this in order to stimulate care within these difficult areas. For midwives,
however, no such an arrangement is prevalent. Mr. Oudenhuijzen acknowledged that they will suffer
the most from the new finance system and that this will heighten the chance of sliding patients off,
while it would not cost that much more to make full concessions to midwives. Therefore, at the
moment in parliament for such an arrangement is being voted on.
Not directly accessible care
The making of contracts between health care providers will take a lot of time and effort from CVZ
personnel. At first it is difficult to select the best hospitals, since no criteria were mentioned in the law.
It is not possible to select based upon care offers while no data is available on what sorts of care
undocumented people need the most. It is also impossible to select based upon care rates, since rates do
not define what is best for the undocumented population. The criteria used will therefore be:
1. Are there large concentrations of undocumented migrants living nearby the hospital?
2. Does the hospital have experience with treating undocumented patients and reports on this?
3. Does the hospital have protocols available for treating undocumented patients?
4. What did the health care provider do to receive money from the patient and what other possible
options have been tried out first?
5. Does the hospital make a clear distinction between directly and not directly accessible care?
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In order to answer these five questions for all health care providers in the Netherlands research needs to
be done, for which the CVZ is responsible.
Second, it remains unclear the exact numbers of undocumented people living in the Netherlands,
their distribution and how many of them will be needing health care. The reasons for this are:
undocumented people are not registered; from the dubious debtors and AWBZ fund many other things
are paid than that of care provided for undocumented people and is therefore difficult to estimate.
Third, the discussion remains what exactly directly and not directly accessible care encompasses and
therefore what precisely needs to be contracted for and what not.
The fourth reason why contracting of health care providers is difficult is found within the fact that
ambulances work within a specific area and if an undocumented patient lives outside this area he/ she
cannot be transported. The CVZ found a solution for this problem by making an open contract for
ambulance services, which can be signed by all who want compensation.
When all contracts are set, the selection of providers will actually save time and administrative costs
for the CVZ, since the number is less than all providers in the Netherlands.
Within the contracts it is made clear how much of the not directly accessible care is compensated
for, which will most likely be the full 100%, as well as for the directly accessible care. The latter will
probably be more than the 80% non-contracted providers receive, therefore the CVZ expects all health
care providers who can be contracted to want to be contracted and that this will go together with much
arguing on the provider’s side.
Less than 10 employees from the CVZ will be doing the selection of the health care providers and
making up the contracts. These are not that many people, because the CVZ does not want to go over its
budget. Therefore it will take more than 6 months to get ready for implementation, which will possibly
be in January 2009.
Monitoring
The CVZ will be the authority that is going to report upon everything and the government will be the
one evaluating the whole implementation. The first two years of implementation of the new system will
therefore act as a sort of pilot. In order to do this evaluation thoroughly the ministry of VWS and the
CVZ will closely be working together.
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Opinion of new financing system
Mr. Oudenhuijzen does not think that the new financing system will form a barrier to seeking care for
undocumented people. However he does think that a shift will take place from directly to not directly
accessible care: care will be stated as not directly, despite of the fact it actually belongs this form of
care and it will get fully compensated for.
He does not think that the fact that the distance could grow to contracted not directly accessible care
will form a problem, since the distribution of undocumented migrants is a criteria for selection and
many people need to travel longer distances for specialized care. Their aim is to keep care as accessible
as possible, besides this, acute care in emergency situation is always nearby which is most important.
The budget of 44 million arranged per year for implementing the new law and financing system is a
very crude estimation. The future will show what the exact budget needs to be as well as the problems
accompanied by the implementation.
Undocumented woman 1, May 20, 2008
I talked to an undocumented woman who is living in the Netherlands for six years now. She has two
children (a boy from of 5 years and a girl of almost 1 year old). She is HIV-positive and therefore
allowed to stay in the Netherlands, however this until she is able to return to Africa.
Access to health care
In the year 2002 when she arrived in the Netherlands, she found it much easier to access the Dutch
health care than at the moment. At the moment there are many more rules, bills and question asked
when she needs treatment. She has no work, no money and is not able to get insurance for herself or her
children, which both are undocumented as well (their father also), therefore she is not able to pay any
of the bills she got and still gets from the hospital.
Bureau Intake, to which she is referred to when wanting treatment, had occasionally said to her she
was not able to receive any treatment. She also gets calls from the hospital about her unpaid bills,
which sometimes make her afraid.
She finds this all very difficult; however the social workers of the Amsterdam hospital take good
care of her and make sure she and her two children get their treatment. She ended up receiving social
work because of her suicidal thoughts, caused by her HIV-infection.
As an HIV-positive person she needed every three months a check-up, in order to monitor her CD4
count, which fortunately is good at the moment.
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Pregnancy
When she was pregnant she came to the midwives in the hospital, she never received obstetrician care
via the first-line of care. During both of her pregnancies she had prenatal care, with regular check-ups
and medication. Her deliveries took place at the hospital, which both went without any complications.
However she never received any form of maternity care.
The social workers even take effort for her to have housing and food during her pregnancy, which is
very important while pregnant and even more while taken medicines in order to prevent mother-to-
child transmission of HIV/AIDS.
However after her pregnancy she was on her own again. During these six years in the Netherlands
she lived in many different places, of which some were better than others. At one time she even lived
together with seven women, whom all had children, in just two apartments; this caused her a lot of
stress.
Positive points
• The quality of the health care was good: the health care providers all treated her nicely and her
children are always welcome.
• She never felt discriminated against during her pregnancy.
• She speaks the English language fairly well and therefore did not have so many difficulties with
understanding the health care providers. If she did, she was able to call somebody who spoke her own
language.
• The medicines against mother-to- child transmission were effective for certain for her son, and today
her daughter had her last test for HIV (which probably is ok).
• She is happy to be in the Netherlands, where she gets good treatment and medication for her disease.
In Africa HIV-positive women are being stigmatised and she probably would not be able to received
medications, which are only accessible to rich people. She even thinks she may have died when still in
Africa.
And now
The father of the children will probably get a permit very soon, which makes the children become legal
as well and get insurance. Her son needs to go to school, for which insurance is needed as well. She
does not know what will happen to her if her children are able to stay here, she is afraid she needs to go
back to Africa without them.
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At the moment she has no housing, and just stays in various places. Since she is not able to work,
she keeps herself occupied with walking. She really enjoys this, as well as singing at the church. She
really hopes for better times, especially for her children.
Recommendations to the government
To make the whole process (of applying citizenship) easier for women and children is to provide them
with residence permits. Then she is also able to work, pay for her bills and more importantly take care
of her children, just like any other person.
Undocumented woman 2, June 3, 2008
I talked to formerly undocumented woman, who came, together with her boyfriend at that moment, to
the Netherlands in the year 2001. At the moment she has a residence permit for 6 months, but before
that she was mostly undocumented.
Access to health care
She first came into contact with the Dutch health care system when she became ill. Her foot became
bigger every day; therefore she went to the nearest hospital. In that hospital the doctor took blood
samples of her, in order to find out the specific cause of the disease. The reason that caused her leg to
increase did not become clear to me; however, it is important that the blood tests indicated that she was
HIV-positive.
Therefore she was referred to another hospital in Amsterdam, which is specialised in HIV-treatment.
There she first saw a doctor at the policlinic, where the doctor at first did not want to treat her, since
she had no health care insurance. Fortunately the doctor changed his minded and referred her to the
main hospital for an intake of one day. However the female doctor there refused to treat her and did not
gave her the medicines she needed in order for her foot to heal. This same doctor even came along with
a couple of interns in order to tell her how much it costs in order for her to stay for one or several
nights and threatened to give her over to the police.
She became really afraid of all these things this doctor said, so she fled to her sisters’ house (who
lives in Amsterdam as well and is married to a Dutch man). There however, she fell down and became
unconscious: the ambulance brought her to the same hospital again. In the hospital they give her blood
and fluids, and she woke up three days later: fortunately another doctor took care of her at that moment.
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She told to an authoritative person of the hospital about the way she was treated by the female
doctor. This doctor as a result needed to apologize to her, which never happened: she merely said “did
you come again?” and that “she did not want to excuse for her reputation” (she probably meant by this
comment that the doctor did not want to apologize to her for reputation related reasons). This
confrontation made the undocumented woman really afraid, causing her to untruthfully say to the
authoritative person that the doctor had apologised.
Besides all this, her boyfriend left her when he found out she was HIV-positive and he was not.
Pregnancy
She really wanted to have a child, but was afraid of HIV-transmission: her doctor recommended to her
to try insemination. A friend of her offered to be the donor, but did not want to take care of the child,
which she found to be a positive thing. After one insemination she already became pregnant.
During her pregnancy she was cared for really well by all the health care providers: at that time she
had a 6 months permission and health care insurance.
She never felt discriminated during that time and thought of the hospital as very good.
Housing and nutrition
From the year she arrived in the Netherlands (2001) until the year 2004 she had no position and no
knowledge about possible organizations, which were able to help her.
She could not stay very long at her sister’s house, despite this her sister made very clear to her that
she would not take care of her baby when she dies. After this stay she lived everywhere. For one week
she was allowed to stay at the place of a woman at church. An African organization was her place to
eat every evening, however sleeping there was not allowed.
She also said that a sick woman needed a place to sleep and eat, which could have caused her to
infect men with HIV/AIDS.
Permits and money
The hospital offered her an advocate, who already started several legal procedures for her in order to
receive a residence permit. Her advocate says she is not able to return to her country of origin, since
she has no access to HIV-medication there. However the IND still, until this moment, refuses to give
her a permit to stay for a long period of time. During this period she felt really insecure and afraid.
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On October 2007, when she was 8.5 months pregnant, she fortunately got a permit for six months
from the IND, pressured by workers of the hospital as well as workers from another organisation. This
really changed her life, since she was now able to pay for housing, nutrition and health care (via health
care insurance).
Because of her disease she had to visit the hospital very often: for monitoring and medications.
Every time she came for an appointment she had to visit Bureau Intake first in order to discuss the
payment of the bill, where she each time had to explain she had nothing to spend. After this discussion
she did was able to go to her appointment and get her medicines. After she got the permit, there still
was a large bill to pay to the hospital. Nonetheless, again via pressure by certain health care providers,
her debts were gone.
Besides this a nurse gave her a “strippenkaart” (travelingcard) during her undocumented period, in
order for her to travel to the hospital and back. When the “strippenkaart” was full, she got a new one
again.
The document she had however expired in May 2008, leaving her feeling scared and insecure again.
She does not know when they will stop the money; therefore she lives by the day and is scared for the
days to come, especially for her child’s future.
Country of origin
She said to have no life in her own country, her life and that of her child are know here in the
Netherlands.
In her country of origin she has no family anymore: as an HIV-positive woman she is banned by her
family.
Recommendations to the government
Help undocumented women who are sick, and do not wait too long to make the decision to treat.
Also provide them housing and nutrition, otherwise this will force them make money in other ways.
The decision to stay, via the IND, takes too long.
As a last thing she wanted to say, “thank you very much” to all the health care providers who helped
her. “These people really saved my life and give me hope”.
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Annex 3 Other contacts
1. Women’s cafe “de Peper”, February 2, 2008 (pp. 121)
2. Talk with a friend who is GP, February 27, 2008 (pp. 122)
3. Email: KNOV, March 4, 2008 (pp. 123)
4. Email: Foundation GPs Services posts Amsterdam, March 10, 2008 (pp. 124)
5. Talk with worker from Bureau Intake of the AMC, April 18, 2008 (pp. 124)
6. Email: Dutch Health Care Authority, May 15, 2008 (pp. 125)
7. Email: KNOV, May 6, 2008 (pp. 125)
Women’s cafe “de Peper”, February 2, 2008
The diner was set up by the idea to get undocumented and documented women together around the
table. It is an informal way to meet each other and learn from each other. The diner is held every last
Saturday of the month.
Two organizations founded the dinner at the women’s cafe “de Peper”: Support group Women
Without Residence permit (SVZV); and Amsterdam Solidarity Committee Refugees (ASKV).
First impression
My first impression about the women’s café was: a bit chaotic (children running around); relaxed
atmosphere (lots of different people talking to each other and having a drink).
Woman from Uganda
After putting my jacket on a pile I sat down on one of the big couches and started talking to a woman
from Uganda (about 50 years old). She said she came to the café more often, to meet similar woman.
She was undocumented and found it really hard to find a place to live. At first she lived in the Bijlmer
(South-East) and moved to Amsterdam North, where she lives with other undocumented women. She
told me that a lot of people like her found a place to live through the assistance of the church.
Dinner
While the dinner was being served I sat at a table with two German women. One of the women was a
social worker and worked with homeless and undocumented people. She could give me more specific
information. She said that most women do not have difficulties with going to a General Practitioner
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(GP). These women heard from others which GP did treat undocumented women and which did not.
The access problems were mainly for hospitals, but this also depended on the hospital itself. For
example the AMC did treat undocumented immigrants.
Movie
After dinner everyone was asked to sit around the screen, where few minutes of film were displayed.
The film was about an undocumented woman from Eastern Europe who cleaned houses as her job. She
hardly ever met the people she worked for; she only saw the lists they made about the chores she had to
do. After a while (when getting almost depressed) she asked, also by a letter, is she was allowed to
make pictures of their houses. She did this in the houses where the people reacted positively to her
note. When documented she quite her job and started working as a photographer, which she still is, and
is earning enough.
The purpose of this movie and the explanation given was to stimulate the women at the café to be
creative themselves. The moviemaker wanted to organize workshops for them to learn to photograph,
write a poem or to do something else creative, this in order for them to show to the world that they are
there (by putting it on the web). Some of them were very enthusiastic and willing to participate on this.
After this talk, the evening came to an end.
Talk with a friend who is GP, February 27, 2008
On February 27, 2008 I had a short conversation with a friend, who has a job as a General Practitioner
(GP). She works as an observer for other GPs in the area of Amsterdam.
She told me that undocumented women are going to certain GP-practices, because the GPs as these
practices are less difficult about helping undocumented women as GPs in other practices. Foundation
the Cross-post she gave as an example of a practice that helps undocumented women.
She also mentioned that the difficulties in relation with pregnant undocumented women are mostly
found within midwife-practices, because midwives in these practices have difficulties with getting
money for their services. The Benefit Entitlement Act made this situation worse, because of the
complicated process of declaration of the money. The GGD was responsible for these declarations and
therefore the provision of money for the midwives.
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Email: KNOV, March 4, 2008
An email from the KNOV, in Dutch, which is about their policy according to the way in which
uninsured and undocumented pregnant women should be treated, which does not differ much from
insured and documented women.
Illegalen hebben recht op noodzakelijke medische zorg
In ons land verblijven illegalen en andere vreemdelingen, die zich op grond van hun verblijfsstatus door de Koppelingswet
niet kunnen verzekeren tegen ziektekosten. Vaak kunnen ze de nodige zorg ook niet zelf betalen.
Toch hebben zij recht op medisch noodzakelijke zorg. Medisch noodzakelijke zorg is alle zorg die een arts of verloskundige
noodzakelijk acht. In de Vreemdelingenwet (artikel 8b, lid 2) wordt een aantal gevallen van 'medisch noodzakelijke zorg’
zelfs expliciet genoemd:
• In geval van levensbedreiging of verlies van essentiële functies
• In het belang van de volksgezondheid, bijvoorbeeld behandeling van infectieziekten of acute psychiatrische zorg
• Voor zwangerschap en geboorte, preventieve jeugdgezondheidszorg en vaccinaties
En wat als de baby er is?
Ieder kind dat geboren wordt, moet volgens de Nederlandse wet binnen drie dagen na de geboorte aangegeven worden.
De aangifte moet plaatsvinden in de gemeente waar het kind geboren is. Het aangeven van de geboorte kan zonder het
adres van het kind op te geven.
Wat wel vermeld moet worden:
• Naam van het kind
• Geboortedatum van het kind
• Naam en geboortedatum van de moeder
• Land van herkomst van de moeder
Iedereen die aanwezig was bij de geboorte kan het kind aangeven, dus ook de verloskundige als de ouders niet willen of
durven.
Als adres kan zelfs het adres van de verloskundigenpraktijk gebruikt worden. Het gevolg daarvan is wel dat de ouders
geen aanspraak kunnen maken op het eventuele recht op kinderbijslag en dat het kind ook bij de GG&GD en het
consultatiebureau aangemeld moet worden om gebruik te maken van het recht op de hielprik en de JGZ-vaccinaties.
Het is dus belangrijk dit recht op zorg te bespreken met de ouders. Soms zal uw cliënte bang zijn om een adres op te
geven. U kunt haar dan verzekeren dat alle zorgverleners, dus óók de artsen en verpleegkundigen in een
consultatiebureau, geheimhoudingsplicht hebben en dat adresgegevens deel uitmaken van het medisch dossier.
Daarnaast is het van belang goed door te praten over de status is van de illegale moeder. Wellicht is haar adres toch al
bekend bij instanties als de IND of de politie. Als zij nog midden in een procedure zit zal zij doorgaans niet het land worden
uitgezet. Het kan dan voordeliger zijn om de aangifte met de juiste adresgegevens te doen. Bij onduidelijkheid is het
raadzaam om Vluchtelingenwerk of de desbetreffende advocaat om informatie te vragen.
In het Tijdschrift voor Verloskundigen van maart 2005 heeft hierover een artikel gestaan met de titel: “Betere zorg voor
illegalen met persoonlijk medisch dossier”.
Veel gebundelde kennis over knelpunten en oplossingen in de (gezondheids)zorg aan illegaal in Nederland verblijvende
personen, met informatie medische en gezondheidskwesties, over verblijfsrecht, opvangmogelijkheden en financiën,
antwoorden op vragen en verwijzingen naar andere instanties, vindt je op de website van Lampion.
Ook op www.vluchtelingenwerk.nl/83-Regionale_Afdelingen.html kun je informatie vinden.
Onverzekerde cliënten hebben recht op medisch noodzakelijke zorg, ongeacht hun financiële situatie.
Onverzekerden moeten zelf hun rekening betalen, indien nodig door een betalingsregeling te treffen. Overigens is het bij
wet verplicht dat iedereen zichzelf voor ziektekosten verzekert. Toch wordt er rekening gehouden met het feit dat een
aantal mensen zichzelf niet zal verzekeren.
Lees ook de website www.zra.nl. De ziektekostenregeling asielzoekers (ZRA) is een verplichte ziektekostenregeling voor
asielzoekers die verblijven in de centrale opvang van het Centraal Orgaan opvang asielzoekers (COA) en voor bepaalde
categorieën vreemdelingen.
De ZRA wordt in opdracht van het COA uitgevoerd door de VGZ - IZA groep. De ZRA website biedt verzekerden en
zorgverleners informatie over de ZRA. Voor meer informatie kunt u van maandag tot en met vrijdag van 8.30 tot 17.00
uur contact opnemen met de Helpdesk ZRA, telefoon: 015-2607239. Meer informatie over de opvang van asielzoekers
door het COA is te vinden op www.coa.nl.
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Email: Foundation GPs Services posts Amsterdam, March 10, 2008
Email, in Dutch, from the Foundation GPs Services posts Amsterdam about their policy about the
health provision to undocumented pregnant women (question 1); which problems prevail, since these
women are uninsured (question 2) and if there are specific laws which have a bad influence on the
accessibility of obstetrician care (question 3).
1. Hoe ziet uw beleid eruit met betrekking tot de hulp aan zwangere ongedocumenteerde vrouwen?
In principe wordt exact hetzelfde beleid gevoerd als bij vrouwen die niet illegaal zijn. Er wordt in de regel gevraagd om een
eigen bijdrage voor de geleverde zorg, indien mensen dit niet kunnen missen, wordt de zorg gedeclareerd bij het
Koppelingsfonds. Gestreefd wordt zo veel mogelijk naar een thuisbevalling, omdat poliklinisch bevallen zonder medische
indicatie veel kosten met zich meebrengt. Indien er echter een medische indicatie ontstaat wordt hetzelfde doorverwijs
beleid gevoerd als bij alle andere zwangeren.
2. Tegen welke problemen loopt u aan omdat deze vrouwen onverzekerd
zijn?
-Mensen komen vaak laat in de zwangerschap op controle omdat ze niet weten dat ze gewoon zorg kunnen krijgen.
-Kraamzorg wordt vaak geweigerd vanwege de kosten.
-Soms is het lastig om in geval van ontstaan van een medische indicatie mensen in het ziekenhuis geplaatst te krijgen
omdat de ziekenhuizen vaak staan op betaling vooraf.
3. Zijn er bepaalde wetten die uw hulp aan ongedocumenteerde
vrouwen vermoeilijkt heeft en waardoor de toegang voor hen tot verloskudige zorg verminderd is? (bv. Vreemdelingenwet,
Koppelingswet,
Zorgverzekeringswet) Zo ja, op welke manier?
In de praktijk blijkt dat niet. Verloskundigen weten goed om te gaan met deze problematiek. Ze bieden bijvoorbeeld aan
zelf de baby aan te gaan geven als mensen dat niet durven (omdat ze bang zijn opgepakt te worden). Dan wordt het
partijkaders opgegeven als woonadres.
Talk with worker from Bureau Intake of the AMC, April 18, 2008
Bureau Intake of the AMC hospital in Amsterdam is the one who makes the payment arrangements
with undocumented patients. The difficult discussions about these arrangements therefore lay with
workers of Bureau Intake and not with the health care providers.
I had a short talk with a female worker from Bureau Intake who deals with undocumented patients on a
daily base to ask about her job.
She always makes very clear to uninsured patients of the hospital that the care given to them is not
for free and that they should pay for it. In some situations, when patients really do not have any money,
payment arrangements can be made.
She acknowledged that obstetrician care is quite expensive and therefore for this form of care many
arrangements were made. For an echo however she asks patients to pay upfront.
She was not very comfortable talking to me, because she looked and sounded very defensive.
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Email: Dutch Health Care Authority, May 15, 2008
The Dutch Health Care Authority (NZa) watches over all the Dutch health care markets and therefore
checks up on health care providers and insurance companies (NZa, 2008).
The email below, in Dutch, was written by one of the workers of the authority and is about the
financial barriers undocumented migrants experience in relation to access to health care.
De Nederlandse Zorgautoriteit (NZa) heeft dit voorjaar een signaal ontvangen over financiële
drempels die worden opgeworpen voor illegalen voor de eerste hulp, zij moeten vooraf betalen.
Daarnaast zijn er ook signalen dat onverzekerden eerst de behandeling moeten betalen
alvorens ze worden behandeld. Op grond daarvan hebben wij onderzoek ingesteld en bij een
aantal ziekenhuizen, verspreid over Nederland, informatie opgevraagd.
Op grond van de regelinggeving mag een instelling voor medisch specialistische zorg wel een
voorschot vragen als iemand onverzekerd is. Reden hiervoor is dat het, gezien de stijgende
kosten in de gezondheidszorg, bijdraagt aan de betaalbaarheid van de zorg op langere
termijn. Belangrijk daarbij is dat verzekerde consumenten meebetalen voor onverzekerden
als er geen bijdrage wordt gevraagd. Diverse ziekenhuizen erkennen dat zij een bijdrage
vragen.
Wat niet mag is het declareren van een volledige dbc, vooraf. Ook dit heeft de NZa (overigens
niet op grote schaal) geconstateerd. In dat geval is er sprake van een overtreding en kan de
NZa handhavende maatregelen nemen (zoals het opleggen van een boete).
Email: KNOV, May 6, 2008
In the email below the KNOV answers that the organisation was aware of the draft bill and that they
were involved in the realization of it. In February they wrote their own letter about their worries
concerning the 80% compensation, therefore they were glad that amendment 30 was accepted.
1) Ja, de KNOV was van het wetsvoorstel op de hoogte. Wij monitoren nl. wijzigingen in wet- en regelgeving.
2) Ja, de KNOV is betrokken geweest bij de invulling hiervan. Hiertoe heeft de KNOV bij brief van 21 februari 2008
aandacht gevraagd voor de problematiek en een pleidooi gehouden om de 100%-regeling te handhaven (zie bijlage).
KNOV is blij dat dit resultaat met vele inspanningen van verschillende partijen tot stand is gekomen. Overigens treft u ons
bericht op de website van de KNOV hieronder aan.
Tweede Kamer heeft gisteren in het kader van de Wijziging van de Zorgverzekeringswet besloten
verloskundige zorg aan illegaal in Nederland verblijvende vrouwen volledig te blijven vergoeden. Het
amendement van kamerlid Khadiya Arib (PvdA) werd hiermee aangenomen. De KNOV is verheugd over het
besluit.
Het wetsvoorstel Wijziging van de Zorgverzekeringswet beoogde om alle medische zorg aan illegalen, waaronder de
verloskundige zorg, voortaan slechts voor 80% te vergoeden.
Twintig procent van de verloskundige zorg zou volgens het voorstel voor rekening komen van de illegale vrouw zelf. Ook
zouden alleen vooraf gecontracteerde tweedelijns verloskundige voorzieningen toegankelijk worden voor illegalen.
De KNOV heeft in reactie op het wetsvoorstel in februari een brief gestuurd naar de Vaste Commissie voor
Volksgezondheid Welzijn en Sport, met het verzoek om de huidige wetgeving te handhaven, waarbij de verloskundige zorg
volledig wordt vergoed. Met als argumenten dat financiële drempels illegale vrouwen er toe kunnen brengen om het
prenatale spreekuur te laat of helemaal niet te bezoeken. Bovendien is het onaanvaardbaar als het risico van niet (kunnen)
betalen op rekening van de verloskundige komt te staan.
Met het Kamerbesluit is bepaald dat de 'bijdrage voor direct toegankelijke zorg in verband met bevalling en zwangerschap,
verleend door een verloskundige of arts 100% bedraagt, in plaats van 80% voor de begeleiding tijdens de zwangerschap
tot en met de bevalling'.
Bron: Tweede Kamer
125

Annex 4 Lobby tool
Letter send on April 21, in Dutch, to the Commission of VWS of the House of Common and the Upper
House as well as to minister Klink (only different header of the letter).
Aan: De Leden van de Vaste Commissie voor Volksgezondheid, Welzijn en Sport
Betreft: Wetsvoorstel Wijziging Zorgverzekeringswet (31 249)
Amsterdam, 21 april 2008
Geachte Commissieleden,
Graag zou ik aandacht vragen voor het wetsvoorstel wijziging Zorgverzekeringswet (31 249).
Ik ben namens het Women’s Global Network of Reproductive Rights bezig met een onderzoek naar de consequenties van
de implementatie van dit wetsvoorstel op de toegang tot de verloskundige zorg voor onverzekerde en ongedocumenteerde
(illegale) vrouwen in Amsterdam.
Spoedig zal er over het wetsvoorstel gestemd worden in de Tweede Kamer. Daarom zou ik graag de voorlopige resultaten
met u willen delen en u willen verzoeken dit in overweging te nemen bij uw uiteindelijke besluitvorming over de wijziging
van dit wetsvoorstel.
Van hulp rond de zwangerschap hangen twee levens af. Wij, Women's Network for Reproductive Rights, Aim for
human rights, Amsterdams Solidariteits Komitee Vluchtelingen, International Federation of Health and Human Rights
Organisations, Dokters van de Wereld en de Liga voor de Rechten van de Mens onderschrijven net als de Nederlandse
overheid heeft gedaan - met de ondertekening en erkenning van internationale verdragen en consensus documenten - dat
de overheid geen enkele barrière mag vormen in de toegang tot de gezondheidszorg voor vrouwen, zoals met het
wetsvoorstel waarschijnlijk wel wordt gecreëerd. Ten eerste wordt er bij implementatie van het wetsvoorstel
gediscrimineerd op basis van verblijfsstatus en sekse (UDHR, ECHR, CEDAW). Ten tweede zal vaak niet de hoogst haalbare
zorg verkregen wanneer slechts acute zorg wordt verleend (ICESCR, Declaration of Alma Ata). Ten derde wordt er geen
rekening gehouden met de kwetsbare positie van vrouwen (CEDAW) en hun ongeborene (CRC). Zwangere vrouwen zijn
een kwetsbare groep waarvoor de overheid juist op moet komen, ongeacht hun verblijfsstatus. Goedkeuring van deze
wetswijziging zoals deze er nu ligt is daarmee in strijd met hun recht op gezondheid.
Twee voorlopige conclusies uit het onderzoek zijn hierbij van belang:
! Niet direct toegankelijke zorg: de toegankelijkheid tot verloskundige zorg zal in de toekomst afnemen omdat zwangere
ongedocumenteerde vrouwen verder moeten reizen voor zorg in het ziekenhuis. Een verhoogde reistijd zal voor meer
complicaties zorgen in acute situaties, evenals verhoogde reiskosten terwijl ongedocumenteerden vaak over beperkte
middelen beschikken.
! Direct toegankelijke zorg: als in de toekomst de compensatie slechts 80% zal zijn dan zullen de verloskundigen
genoodzaakt zijn:
1) Meer eigen bijdrage bij de ongedocumenteerde vrouwen te gaan claimen;
2) Of zelf inkomsten derven.
Geen van beide is een oplossing. De eerste ‘oplossing’ schrikt ongedocumenteerde vrouwen af, waardoor ze
hoogstwaarschijnlijk niet meer terug komen voor verdere controle en zorg. Dit heeft weer verhoogde gezondheidsrisico’s
voor deze vrouwen tot gevolg en is bovendien tegen de morele instelling van de verloskundige praktijk.
Het tweede punt is ook geen mogelijke oplossing, omdat bijvoorbeeld een praktijk in de Bijlmer 30% ongedocumenteerde
vrouwen heeft. De meeste vrouwen kunnen daarvan geen eigen bijdrage leveren aan hun zorg, en zal de verloskundige
praktijk een zeer hoge inkomstenderving ondervinden. Bovendien werkt dit afschuifgedrag naar niet direct toegankelijke
zorg in de hand.
Twee aanbevelingen voor verbetering van de wijziging van het wetsvoorstel zijn daarom de volgende:
! Niet direct toegankelijke zorg: meerdere ziekenhuizen zullen gecontracteerd moeten worden door het CVZ, dan slechts
30 in heel Nederland, om de reisafstand en de bijbehorende kosten gering te houden. Bovendien zullen er maatregelingen
genomen moeten worden om te voorkomen dat de werkdruk voor verloskundigen in deze geselecteerde ziekenhuizen
126

teveel gaat toenemen. Een oplossing zou zijn om meer personeel aan te nemen in deze ziekenhuizen en al het personeel
goed voor te lichten op de extra zorg omtrent ongedocumenteerde patiënten.
! Direct toegankelijke zorg: aanbevolen wordt om in ieder geval voor de verloskundigen een uitzondering te maken en
een volledige (100%) compensatie te geven bij inkomstenderving, veroorzaakt door zorg aan ongedocumenteerde
zwangere vrouwen die geen eigen bijdrage kunnen leveren.
Wij verzoeken u om deze conclusies en aanbevelingen in acht te nemen, om het recht op gezondheid voor elke vrouw in
Nederland te behouden.
Met vriendelijke groet,
Aniek Wubben
Namens:
Women’s Global Network of Reproductive Rights Dokters van de Wereld
Aim for Human Rights
iga voor de Rechten van de Mens
Amsterdams Solidariteits Komitee International Federation of Health and
Vluchtelingen Human Rights Organisations
127

Annex 5 Report meeting June 2 (2008)
The report of the meeting on June 2 as sent by email to all the stakeholders present at the meeting as
well as all the stakeholders who were invited, but not able to come.
Report meeting ‘Outcome of the HeRWAI/MDG study on the access to obstetrician care for undocumented
pregnant women
WGNRR, 15-17.30, June 2, 2008
1. Opening: The coordinator of Women’s Global Network for Reproductive Rights (WGNRR), Aika van der Kleij,
introduced herself and thanked everyone for coming.
2. MDG-HeRWAI1 toolkit: Corine Otte, the policy officer of WGNRR, explained why the study was held. The study was
done to pilot the MDG-toolkit WGNRR currently is developing. In 2005, WGNRR implemented the GCAP1 project. WGNRR
found through its activities2 within this project that the following barriers are preventing members (which most consist of
grassroots organisations) from using the MDGs in their work:
" The grassroots organisations often work in isolation; they work in a way that is mostly not integrated with work being
done at national, regional or international levels.
" There is a lack of accessible information showing the links between the work of the grassroots organisations and the
global policy thinking and planning on sustainable development and poverty reduction.
" Most MDGs do not specifically address RSHR issues, including unequal power relations, which can be worsened through
the achievement of the MDGs.
" The MDGs do not take into account the different local realities on the ground. By only focusing on numerical goals, the
MDGs ignore the larger power imbalances within society.
Based on the above, members requested the Coordinators Office (CO) of WGNRR to make the MDGs more useful for
monitoring, development of initiatives, and advocacy for women’s RSHR at the local level. Also they requested the CO to
build up their capacity on relevant issues and approaches regarding the MDGs.
To link the daily work of the organisations that advocate for women’s RSHR with the global MDGs, the user-friendly Health
Rights of Women Assessment Instrument (HeRWAI) developed by Aim for human rights (AIM)! is inserted in the toolkit.
Coming August the first MDG/HeRWAI in Latin America is planned and in 2009 in Asia and Africa in each region at least
one training will be held. More trainings and ToTs are in the pipeline depending on funding.
3. HeRWAI: Loeky Droesen from the organization Aim for Human Rights told about HeRWAI. HeRWAI is a tool that
assists organisations to identify the gap between the local reality organisations face on a daily basis and the (inter)
national policies and human rights treaties. The tool provides structural guidance for a six step process to analyse the
health rights effects of a policy. The six steps are accompanied by several questions. These questions make the tool very
practicable, since you do not need to think for yourself about all the questions you need to ask in order to eventually
describe rights-based recommendations and an action plan for the problem you are researching. During the process,
actors such as the community and governmental personnel are involved. Through their involvement, they provide
information, become aware of certain issues, and can influence the possible recommendations at the same time. Once the
six steps are completed, there will be strong; rights based arguments for an improvement of the current reality through a
policy change. The organisation also has prepared an action plan to advocate for these recommendations at the specific
governmental institution. The HeRWAI has been developed and used by different organizations all over the world and she
gave some examples of former analysis.
4. Outcome analysis: Aniek Wubben, intern at WGNRR presented the outcome of her study she carried out for the last
four months: the consequences of the draft bill, the modification Health Care Insurance Law (31 249), on the access to
obstetrician care for uninsured and undocumented pregnant migrants living in Amsterdam. The presentation is found in
the added power point.
1
Millennium Development Goal- Health Rights of Women Assessment Instrument
2
The Global Call for Action against Poverty is a world-wide alliance of civil society actors committed to forcing world
leaders to live up to their promises to end extreme poverty and realise the MDGs. More information about the GCAP can be
found at www.whiteband.org.
3
See for information, www.wgnrr.org
4
See for more information, www.aimforhumanrights.nl
128

5. Questions:
- number of resources/interviews
- discussion on accessibility of the Dutch health care
- opinion about usage of the HeRWAI
- the number of undocumented women who suffer from the lower accessibility
- discussion on the possible positive impact of the policy
6. Break
7. Group discussions: Two groups were formed in order to discuss the already made recommendations and to prioritise
them. Afterwards per group one person told about their findings:
Group 1:
1. Undocumented women should receive information (in a language they understand), about their health rights, the
working of the Dutch health care system, and when and where to seek obstetrician care.
2. All midwives in Amsterdam need to be trained and supported in working with undocumented patients.
3. (New recommendation) a draft monitoring protocol should be made, in order for the government to properly monitor
the consequences of the implementation of the policy. Civil society should be part of this monitoring, since they are the
ones working with the undocumented people and they could represent the undocumented patients.
Group 2:
1. See group 1 + also health care providers, social workers and lawyers should receive this information as they can inform
undocumented women on what kind of health services they can get and where.
2. See group 1
3. (New recommendation) a general lobby should be done to realize equal rights for undocumented women inline with the
rights of all women in the Netherlands for reproductive healthcare. Furthermore, there should be a system in place to
measure this. This can be the general message of the fact sheet.
Interesting from the discussion that both groups thought recommendations one and two were the most important and for
the third they both came up with some sort of monitoring/ measuring system.
Steps that can be undertaken to take these recommendations forward:
1) Helena Kosec from Pharos will organize an expert meeting on request of Maria van den Muijzenbergh, where they will
discuss how health providers can deal with undocumented pregnant women. Aniek Wubben is invited to take part in this
meeting. Furthermore, materials will be developed to inform health care providers (midwives, gynecologists, and general
practitioners) about this issue that can then be distributed. The materials will need to be distributed.
2) Organize an expert meeting on how to monitor the implementation of the bill (include grass roots) and develop a draft
monitoring instrument that can be proposed to the Dutch government to monitor the actual implementation of the bill.
3) Develop a fact sheet with the outcomes of the analysis and the recommendations and distribute this among the
participants so as they can use this where ever they can and link this to their advocacy actions
# WGNRR (Aniek) will take on this task
4) Develop an information brochure for health staff and undocumented women
5) Include the outcomes of the analysis in CEDAW shadow report; this will be taken on by Aim for human rights.
6) IFMSA is drafting a letter (by July) towards the deans of the medical faculties to include information on undocumented
patients in the curriculum for medicine. Other organizations can support this letter. IFMSA could see as well whether they
can reach the midwife education on this.
CONCLUSION:
Many important stakeholders were prevalent and informed about the MDG-toolkit, the HeRWAI, and the
results of the MDG-HeRWAI study about the access to obstetrician care for undocumented women. On top of
this the questions asked by the stakeholders, as well as the group discussions held, were very helpful for the
study and will be used in the process of it.
For more information on the study, contact Aniek Wubben: intern1@wgnrr.org / aniekwubben@hotmail.com
(After half of July please use the second email address)
For more information on the MDG/HeRWAI toolkit, contact Corine Otte: capacitydevelopment@wgnrr.org
For more information on HeRWAI, contact Marije Nederveen: m.nederveen@aimforhumanrights.n
Interesting websites:
- Women’s Global Network for Reproductive Rights www.wgnrr.org
- Aim for Human Rights www.aimforhumanrights.nl
- The downloadable HeRWAI http://www.humanrightsimpact.org/resource-
database/toolsets/resources/view/39/user_hria_toolsets/
- More information on the HeRWAI and case studies http://www.humanrightsimpact.org/themes/womens-human-
rights/herwai/herwai-home/
129

Annex 6 Recommendations HeRWAI
Despite the practicality of the HeRWAI some recommendations can be stated in order to improve the
future use of the instrument:
• In the quick scan it can be difficult to choose a policy that has the most impact on the problem.
Hereby it is recommended to ask yourself: what do you want to achieve with your research? In this
case it was to influence policy, thereby the decision was made to focus on the draft bill, since this
policy was still under development and therefore able to be changed. More recommendations,
concerning the policy choice, are to talk with stakeholders in order to get more insight into the problem
and its relating policies, and/or to contact the organisation who designed the HeRWAI (Aim for Human
Rights).
• Besides just talking to stakeholders, it might be helping to conduct some interviews, which can be
very helpful to get the right information. Besides this, the respondents of the interviews can be used in
order to get into contact with other people (as in this case: midwives were very helpful in order to get in
contact with undocumented women).
• For the quality of the research it is important to answer all the questions of the HeRWAI. However it
is recommended to be flexible in answering the questions: some questions overlap each other and in
order to save time it is recommended to refer, in the overlapping questions, to particular sections in
which these questions were answered; when it is difficult to answer a question (e.g. interviews need to
be conducted first) it is recommended to skip the question and move on with the next, later on you can
always come back to the question. If this remains difficult just leave it open or write down the reasons
why you were not able to answer it.
• The sites mentioned in the HeRWAI (to be found at the beginning of each step under ‘where to find
the information’ as well as in annex V) are very useful and save you a lot of time, so it is recommended
to make use of them.
• It is recommended to plan your interviews well ahead, in order to prevent getting stuck at one point.
This planning can be done by writing down at the beginning of the analysis, which persons needs to be
contacted in order to answer each (key) question.
130

Annex 7 Concepts
The most important concepts used within this report are outlined here in alphabetical order. All
concepts can also be found as footnotes on the pages these words were first introduced.
Amendment = a statement from members of the House of Commons in order to change the content of a
draft bill (Tweede Kamer der Staten-Generaal, 2008).
Congenital disorders = a defect which is present at birth (Medical Dictionary, 2008b).
CD4 count = a measure of the number of helper T cells per cubic millimetre of blood, used to analyse
the prognosis of patients infected with HIV (Medical Dictionary, 2008).
Colleges for Health Care Insurances (CVZ) = a professional independent managing body who watches
over the Dutch health care system. The citizen is central in CVZs work: it secures and develops the
conditions of the health care system, in order for the citizens to realize their right to health care (CVZ,
2008).
Coupling Foundation = a foundation founded by private initiative to give financial support to health
care providers. The budget (Coupling Fund) is provided by the Dutch government. The private
initiative, the board of the foundation, was formed by people of the field, like (former) employees of
the health insurance fund and the GGD (J. Van Amen, personal statement, March 5, 2008).
Directly accessible care = not yet precisely stated, however sort of similar to first-line care (see first-
line care for more information).
Dubious debtors trust = a variable budget for hospitals in the Netherlands from which income losses
(like undocumented patients unable to pay for their own care) can be compensated for. The height of
the trust is arranged in the contracts hospitals have with their insurance companies (J. Van Amen,
personal statement, March 5, 2008).
131

First-line care = care directly accessible for people in need of care and encompasses the care provided
by, for example, the following people: general practitioner, dentist, physiotherapist, pharmacist,
psychologist, and midwife. As the first contact person for patients, first-line care providers are very
important link in the health care system: these providers are the ones to refer patients to the more
expensive and specialised second-line care (see second-line care for more information) (NVSHV,
2006).
General Law Special Sickness Costs (AWBZ)-care = the AWBZ is a national insurance for special
health care risks which are not individually insurable. The health care which belongs to this insurance
are: personal maintenance, nursing, different forms of guidance, residence and treatment (Ministry of
VWS, 2008).
Live birth = the complete expulsion or contraction from its mother of a product of conception,
irrespective of the duration of the pregnancy, which, after such separation, breathes or shows any other
evidence of life, such as beating of the heart, pulsation of the umbilical cord, or definite movement of
voluntary muscles, whether or not the umbilical cord has been cut or the placenta is attached; each
product of such birth is considered live born (WHO, 2006).
Maternity care = care for mother and child from childbirth until the first days after. Maternity care
includes: assistance during birth; nursery of mother and child; early detection of complications;
education of mother in caring for the child; if needed household tasks (Encyclo.nl, 2008).
Maternal mortality = the death of a woman while pregnant or within 42 days of termination of
pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or
aggravated by the pregnancy or its management, but not from accidental or incidental causes (WHO,
2006).
Maternal health = the health of women during pregnancy, childbirth and the postpartum period (WHO,
2008).
Maternal mortality ratio = the number of maternal deaths per 100.000 live births, during a certain
period of time (WHO, 2006).
132

Motion = a statement from members of the House of Commons in order to point attention to certain
things within a draft bill (Tweede Kamer der Staten-Generaal, 2008).
Municipalities’ Health Service (GGD) = the GGDs execute instructions of their municipalities. The
GGD is responsible for the public health of its citizens (GGD, 2008).
Not directly accessible care = not yet precisely stated, however it sort of encompasses second- and
third line care (see second- and third-line care for more information).
Second-line care = care not directly accessible for people in need of care: referral by a first-line health
care provider (see first-line care for more information) is needed in order to access this sort of care.
Second-line care consists of hospital and mental health care (Tweede Kamer der Staten-Generaal,
2008b).
Third-line care = care not directly accessible for people in need of care: referral by a first-line health
care provider (see first-line care for more information) is needed in order to access this sort of care.
Third-line care consists of top clinical facilities in academic hospitals (Tweede Kamer der Staten-
Generaal, 2008b).
Obstetrician care = the whole continuum of care around the birth of a child: before pregnancy (family
planning) during pregnancy (prenatal), the delivery (natal), after delivery (postnatal) (Countdown
Coverage Writing Group, 2008).
Undocumented (or commonly called ‘illegal’) immigrant = a person whom conforms to one of the
following phenomena: a) A third-country national who enters the territory of a Member State illegally
by land, sea or air, including airport transit zones. This is mostly done by using false or forged
documents, or with help of organized criminal networks of smuggles and traffickers; b) Enters the
Member State legally (with a valid visa or under visa-free regime), but stay longer or change the
purpose of stay without the approval of authorities; c) Former asylum seekers who do not leave after a
final negative decision (Commission of the European Communities, 2006).
133

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