Since she hails from a family of doctors, student Prateeksha knew it was vital that she made sure she was eligible for proper medical care when she came to Rotterdam from New Delhi, India, last August to get a degree from the Rotterdam School of Management (RSM). “In September a friend and I started looking for a general practitioner together, but not a single practice would accept us as patients. Now I’ve made a deal with a GP under which I can walk in as a non-patient in the event of an emergency, but if I’m so sick that I can’t even leave the house, the GP will not come and see me at my home.”

Marta from Poland, who attends Rotterdam University of Applied Sciences, went on a similarly unsuccessful quest. She just started hers a bit later. When she came down with tonsillitis, she urgently needed a GP. “I must have called twenty GPs at the time. They all said they weren’t accepting any new patients because they had too many already, or that I wasn’t welcome due to my type of insurance,” she says, sighing. “In the end, I ended up going to the hospital’s emergency department.”

Prateeksha and Marta’s problems are not uncommon. Many Rotterdam-based general practitioners will only accept students as walk-in patients, which means that students must pay their bills on the spot, even if they have the right kind of insurance. This being the case, students sometimes decide not to seek help, or even to fly home and see a doctor there. An Erasmus University spokesperson confirmed that the International Office, deans, student psychologists and student societies often hear that international students are unable to see a general practitioner. So why is it so hard for international students to find a GP?

Update Tuesday 19 January 2021: The university is looking into students’ access to general practitioners in Rotterdam. Read more or join the survey.

The Dutch healthcare system is hard to fathom

The first barrier, we find when we hear the students’ stories, is the fact that the Dutch healthcare system is quite complicated. “I had a European Health Insurance Card. I thought that would suffice to get help anywhere,” says Marta. In actual fact, things turned out to be more complicated than that. “Unfortunately, it’s not that easy,” says Arti Pancham of risk mitigation and insurance company Aon. Aon – an organisation that originated in the US – is the market leader in insurance for international students attending higher education institutions in the Netherlands. Pancham is a contact person for Aon Student Insurance, in which capacity she maintains contact with universities and universities of applied sciences.

Pancham tells us things don’t work the same way for all international students. “It depends on your country of origin and on whether or not you have a paid side job in the Netherlands. If you work in the Netherlands and so contribute to the Dutch healthcare or tax system, you have to take out health insurance with a Dutch health insurance company, just like any Dutch person, and you can apply for a health insurance allowance paid by the government.”

“Students have a bit of a tendency to think: we’re young, we’re fit, nothing will happen to us.”

Yolande Pleune - manager of a Rotterdam general practice

International students who don’t have a side job are not part of the Dutch system, and therefore aren’t eligible for Dutch health insurance. Citizens of the European Economic Area (EEA) may be eligible for a European Health Insurance Card (EHIC). “Only the card’s expiry date and what it allows you to do differs from one country of origin to the next, which makes the system quite complicated. And generally speaking, the card only applies to temporary emergency care,” says Pancham. She advises students who hold an EHIC to take out private supplemental insurance. “For instance, Aon does cover whatever medical conditions or mental health issues you may have brought from home, and you will receive medications for a longer period of time.”

All students from outside the European Economic Area who do not have a side job should take out private health insurance, says Pancham. “Since they don’t have an EHIC, they are not entitled to healthcare in the Netherlands, unless they have taken out private health insurance.”

Students being lax

The Netherlands’ complicated healthcare system is part of the problem, as is a lack of urgency on the students’ part. As the university’s spokesperson put it in an e-mail: “We have found that students don’t try and find a general practitioner until they actually need healthcare, which makes the situation more urgent. This means that students are more likely to go to the hospital’s emergency department or an after-hours service provider. This isn’t always covered by their insurance, and it’s not how after-hours service providers are meant to be used, either.”

Yolande Pleune, who manages a Rotterdam general practice, has noticed the same thing. Every week a few students will ask to be seen by the doctors working at her practice. “In fact, I had two students just this week. One had already called ten other GPs. The other had as well, and had ended up going to the hospital’s emergency department, only to be referred to us. Students have a bit of a tendency to think: we’re young, we’re fit, nothing will happen to us. And I do understand that, at that age.” But when these students do fall ill, they are in trouble. International students have to arrange so many things before coming to the Netherlands that they sometimes ‘forget’ to take out insurance, according to Pancham.

Image credit: Rachel Sender

Shortage of general practitioners

But that is not the only reason why students are failing to get the care they need. Rotterdam also suffers a shortage of general practitioners, says a spokesperson for the National Association of General Practitioners. This is a common problem in shrinking rural regions, but it is also an increasingly common problem in big cities. A general practitioner called Thao Nguyen recently sent the Rotterdam Municipal Authorities an incendiary letter stating that more people will go without healthcare if the municipal authorities don’t start doing something about it soon. For its part, the Rotterdam Association of General Practitioners recently said the same thing in a letter to the municipal government.

“Waiting lists are getting longer, more practices are rejecting new patients, and the number of people looking for healthcare is growing,” Nguyen said in De Telegraaf. The main cause? “We have erected a lot of new buildings in the city. The city centre and Kop van Zuid are increasingly densely populated, but the number of GPs has lagged behind,” says Nguyen. The fact that home prices in Rotterdam are rising has also contributed to the problem. “GPs have a limited budget for the buildings they use for their practices. Since real estate is becoming unaffordable, GPs are not keen to have practices in the city centre.”

International students require more administrative duties

Moreover, some general practitioners just aren’t very keen on international students, even if their practices welcome new patients and the students have the right type of insurance. A GP who does not wish to be named, but is recommended by the university on Erasmus MC’s website, says that his/her practice’s policy is only to accept international students as walk-in patients, and that his/her practice is not the only one to do things that way. “They come and go, just like that, and it simply takes us too much time to create complete medical records for them,” the practice’s doctor’s assistant tells us. Pleune understands this argument. “Smaller general practices have to perform additional duties for international students, which takes up more of their time. They tend to prefer patients who stick around. Moreover, some GPs will reject international students partly because of the language barrier. Having to speak English makes things just a bit more complicated.”

Martin Blok of the International Institute for Social Studies (ISS) – who arranges healthcare for ISS’s international PhD and Master’s students – has noticed that general practitioners are less keen to accept international students as patients because their lists of patients get muddled up. “Students who register with a practice often forget to deregister when they leave. This means that GPs don’t have as many patients as they think they do, while being unable to accept any new patients.”

“I spoke to a student who decided against a consultation because she would initially have to pay for the medicines and consultation herself.”

Martin Blok of the International Institute of Social Studies

In other words, students are having to settle for being accepted as walk-in patients, and can only hope that their GPs will have time to see walk-in patients on any given day. As general practice manager Yolande Pleune says, “We have one day off this week, and we are seeing so many registered patients that we hardly have any time to see walk-in patients.”

Such walk-in patients have to pay to see a doctor out of hand. “This is because the GP has not established direct billing with their health insurer [meaning that the GP cannot directly forward the bill to the insurer – ed.]. So the students have to foot the bills themselves initially,” says Pancham. ISS’s Martin Blok adds, “Which constitutes an additional barrier for students.” Students with urgent symptoms will be provided with the care they need, but students with less urgent symptoms will often find themselves rejected. “Last Monday I spoke to a student who decided against a consultation because she would initially have to pay for the medicines and consultation herself. I see the same thing happening with students with less urgent but nevertheless serious problems, such as mental health issues or depression.”

Potential solutions

So what can be done to solve this problem? “First we have to address Rotterdam’s shortage of general practitioners,” says Pleune. “But that is a complicated problem that will mainly have to be addressed by government agencies.” The political parties CDA and GroenLinks have put the subject on the Rotterdam Municipal Council’s agenda. The two political parties have presented questions to the Mayor and Municipal Executive. “The Mayor and Executive are aware of the problem and are seeking to find solutions in consultation with the parties involved,” a spokesman for the Municipal Council stated with respect to the city’s shortage of general practitioners.

For now, the university and Aon are seeking to enter into arrangements with general practitioners. “This will allow GPs to forward bills directly to Aon, meaning students won’t have to pay the costs on the spot, but the GP shortage is posing a bit of a problem,” says Pancham. In addition, both EUR and Aon will continue to provide students with more information on the Dutch healthcare system.

However, more information will have to be provided on the other end, as well. For instance: “Healthcare providers must be given more information on private health insurance.” Some other universities have their own GPs on campus, e.g. the Universities of Amsterdam and Groningen. Previous attempts by EUR to get its own on-campus GP proved unsuccessful. According to Martin Blok, the ISS has advanced plans for getting its own GP on its campus in The Hague, due to the problems its international students have encountered.

However, for the time being, general practice manager Yvonne Pleune expects it to remain hard for students to register with a general practice. “And we have the Eurovision Song Contest coming up. There will be so many visitors with twisted ankles and other issues.”

Prateeksha does not have much of a choice – she has had to accept the current situation. Marta had medication flown over from Poland to solve her tonsillitis, which helped her get well again. “But it’s by no means a perfect situation, and that’s an understatement.”