By Renée Emma Jonkhoff

In the Netherlands, an invisible crisis is developing among students. This crisis generates from untreated mental health issues, fuelled by lacking availability of mental healthcare facilities and a lack of access to such facilities for students. Owing to recent findings from the Court of Audit (Rekenkamer), underinvestment of the Dutch health sector of at least 300 million euros per year has come to light.[i] This begs the question why the country has been struggling with long waiting lists and financial burdens for a long time while a large sum of available funding is not being used to its full capacity. This blogpost will analyse the current failings of the Dutch mental health care system for students with regards to international human rights law.

Mental health among students in the Netherlands

It is undeniable that the COVID-19 pandemic has had a severely negative domino effect on other important aspects of health. In the Netherlands, the deteriorating mental health(care), specifically the access thereto, for students and young adults has become a worrying consequence.[ii] Even though a causal link between the pandemic and the worsening mental health of young adults cannot be proven, figures show an increase from 12,9% to 26,6% in mentally unhealthy people between the ages of 18 and 25 at the beginning of 2021 as compared to the previous years.[iii]  Another study conducted last year by the National Institute for Public Health and the Environment (Rijksinstituut voor Volksgezondheid en Milieu, RIVM) demonstrated that an even higher number of students struggles with psychological issues, namely 51%.[iv] In this study, students mentioned stress, pressure to perform, sleeplessness and loneliness due to the pandemic as possible causes for their mental health problems.[v]

The right to mental healthcare: lacking availability and accessibility in the Netherlands

Several international human rights documents lay down the obligation to respect, protect and fulfil the right to the highest attainable standard of physical and mental health for everyone.[vi] The Committee of Economic, Social and Cultural Rights elaborates on Article 12(2)(d), mentioning the access to medical service and attention,  incorporating equal and timely access to health services, including those that are preventive, curative and rehabilitative.[vii] Specifically, the article covers the highest attainable standard of mental health, meaning mental health care and support must be available, accessible, acceptable and of high quality.[viii] A crucial aspect of the accessibility of health care is that it must be economically accessible. This means that health facilities and services must be affordable for all, including socially disadvantaged groups who should not be disproportionately burdened with health expenses.[ix] The Netherlands have implemented several laws on mental health, including the Compulsory Mental Healthcare Act and the Dutch Health Insurance Act. Unfortunately, a large number of students is currently not being treated as they perceive several obstacles towards mental healthcare, including the high costs for treatment and waitlists.[x] Consequently, the Dutch healthcare system appears to be falling short with regard to the availability and accessibility of its mental healthcare services.

Despite the fact that mental healthcare is addressed within the domestic legal system, the accessibility and availability to such facilities is in practice sub-standard. When it comes to the availability of mental healthcare, the Dutch Court of Audit has expressed deep concern for the present waiting times:[xi] At the beginning of 2022 over 80.000 patients were awaiting mental healthcare, of which half were already waiting longer than the expected waiting period of fourteen weeks.[xii] The Court of Audit concluded in their investigation that some patients would have to wait at least four months before being able to initiate treatment for their mental illness.[xiii] Reasons for such a long waiting period include bed shortages and staff shortages. These issues will only worsen as the effect of the COVID-19 pandemic continues to be felt by the healthcare institutions carrying the burden, negatively impacting the workload and its environment. This is leading to a negative impact on the availability of mental healthcare going against the right to health under the ICESCR, as General Comment 14 explicitly mentions the facilitation of adequate hospitals, clinics and trained medical personnel.[xiv]

Besides the waiting times, mental healthcare facilities are also not financially accessible for all. In principle, the Dutch health insurance system appears to be a well-oiled machine, in which health insurance is mandatory for (almost) all residents.[xv] The government mentions on its website that, in general, such health insurance completely or partially covers the costs of primary and secondary mental health care, while admission to an institution is covered for the first three years of hospitalisation.[xvi] Nevertheless, the system offers the option to accept a higher ‘own risk’ (eigen risico), an excess amount that must be paid before the insurance provider covers healthcare costs incurred, for a lower monthly premium.[xvii] In order to avoid higher monthly insurance payments, many low- and middle income households choose the high ‘own risk’ option, as this will grant them a monthly premium discount, so they save money as long as they keep their healthcare expenses to a minimum.[xviii] In Groningen, for instance, it has been established that at least 14% of citizens avoid seeking care in order to save, as the expenses are too high of an obstacle.[xix] It is important to note that this rate does not only concern the student population of Groningen, as no specified percentage for avoidance by students exists. Fortunately, the government is aware of the problem and several political parties recommend a lower ‘own risk’ premium, or even none at all, as it can be negatively viewed as a ‘fine for being ill’.[xx]

The road ahead

As the Netherlands is still experiencing the consequences of the COVID-19 pandemic in every single area of its healthcare system, the Special Rapporteur on the right to health has stated its concerns regarding the future of mental health services around the world. He emphasised, for example, the neglect and underinvestment of mental health needs that have been exposed by the crisis.[xxi] The future is hopeful, nevertheless. The Dutch government has issued plans regarding the improvement of its bleak mental health figures. The existing healthcare allowance will be raised to compensate for the inflation and the increasing health insurance rates.[xxii] Additionally, it has proposed plans regarding the cooperation and communication between municipalities with regard to mental healthcare.[xxiii] Lastly, the State has also proposed preventive measures, as it wishes to pay closer attention to the promotion of exercise and sports in order to improve its population’s mental health.[xxiv]

[i] ‘Mental Healthcare: The Bigger the Problem, the Longer the Waiting list’ (Rekenkamer, 25 June 2020) <https://english.rekenkamer.nl/latest/news/2020/06/25/mental-healthcare-the-bigger-the-problem-the-longer-the-waiting-list> accessed 6 January 2023.

[ii] Carin Reep and Christianne Hupkens, ‘Ervaren Impact Corona op Mentale Gezondheid en Leefstijl’ (Centraal Bureau voor de Statistiek, 2 September 2021) <https://www.cbs.nl/nl-nl/longread/statistische-trends/2021/ervaren-impact-corona-op-mentale-gezondheid-en-leefstijl?onepage=true> accessed 10 March 2023

[iii] ‘Mentale Gezondheid in Eerste Helft 2021 op Dieptepunt’ (CBS, 3 September 2021) < https://www.cbs.nl/nl-nl/nieuws/2021/35/mentale-gezondheid-in-eerste-helft-2021-op-dieptepunt> accessed 6 January 2023.

[iv] ‘Monitor Mentale Gezondheid en Middelengebruik Studenten Hoger Onderwijs 2021’ (RIVM 2021) <https://www.rivm.nl/documenten/monitor-mentale-gezondheid-en-middelengebruik-studenten-hoger-onderwijs-deelrapport-1> accessed 6 January 2023.

[v] ‘Mentale Gezondheid Studenten Onder Druk’ (Rijksoverheid, 11 Novembebr 2021) <https://www.rijksoverheid.nl/actueel/nieuws/2021/11/11/mentale-gezondheid-studenten-onder-druk#:~:text=Ruim%20de%20helft%20van%20de,cannabis%20voor%20veel%20studenten%20normaal>  accessed 6 January 2023.

[vi] International Covenant on Economic, Social and Cultural Rights 1966, Article 12(1).

[vii] CESCR General Comment No. 14: The Right to the Highest Attainable Standard of Health (Art. 12) on 11 August 2000 E/C.12/2000/4, para 17.

[viii] ibid. para 12.

[ix] ibid.

[x] ‘Hoger Onderwijs Moet Werk Maken van Mentale Gezondheid Studenten’ (Trimbos, 18 January 2022) <https://www.trimbos.nl/actueel/nieuws/hoger-onderwijs-moet-werk-maken-van-mentale-gezondheid-studenten/> accessed 6 January 2023.

[xi] (n.i).

[xii] ‘Informatiekaart Wachttijden GGZ Juli 2022’ (Nederlandse Zorgautoriteit, 7 July 2022) <https://puc.overheid.nl/nza/doc/PUC_716176_22/1/> accessed 6 January 2023 ; Jan Kloeze, ‘Wachttijden GGZ Stijgen Ondanks Maatregelen’ (Zorgvisie, 18 July 2018) < https://www.zorgvisie.nl/wachttijden-ggz-stijgen-ondanks-maatregelen/> accessed 10 March 2023.

[xiii] (n.i).

[xiv] GC 14, para 12.

[xv] ‘Health Insurance’ (Rijksoverheid) <https://www.government.nl/topics/health-insurance> accessed 6 January 2023.

[xvi] ‘Where Can I Get Help for Mental Health Problems?’ (Rijksoverheid) <https://www.government.nl/topics/mental-health-services/question-and-answer/help-for-mental-health-problems> accessed 6 January 2023.

[xvii] ‘Wanneer Betaal Ik een Eigen Risico Voor Mijn Zorg?’ (Rijksoverheid) <https://www.rijksoverheid.nl/onderwerpen/zorgverzekering/vraag-en-antwoord/eigen-risico-zorgverzekering> accessed 6 January 2023.

[xviii] Menno de Haan, ‘Nederlanders Dreigen Zorg te Mijden Vanwege Geldgebrek’ (Zorgkiezer, 12 October 2022) < https://blog.zorgkiezer.nl/laatste-nieuws/nederlanders-dreigen-zorg-te-mijden-vanwege-geldgebrek/> accessed 6 January 2023.

[xix] ‘Zorgkosten Belemmeren Toegang tot Zorg voor Een op de Zeven Groningers’ (Armoede Groningen, 11 June 2018) <https://armoedegroningen.nl/zorgkosten-belemmeren-toegang-tot-zorg-voor-een-op-de-zeven-groningers/> accessed 6 January 2023.

[xx] ‘Merendeel Kamer Wil Lager Eigen Risico Uit Angst voor Zorgmijding’ (Skipr, 29 June 2022) < https://www.skipr.nl/nieuws/merendeel-kamer-wil-lager-eigen-risico-uit-angst-voor-zorgmijding/> accessed 6 January 2023.

[xxi] Final Report of the Special Rapporteur on the Right of Everyone to the Enjoyment of the Highest Attainable Standard of Physical and Mental Health [16 July 2020] A/75/163, p. 17.

[xxii] ‘Plannen voor Zorg, Gezondheid en Sport’ (Rijksoverheid) <https://www.rijksoverheid.nl/onderwerpen/prinsjesdag/zorg-en-gezondheid> accessed 6 January 2023.

[xxiii] ibid.

[xxiv] id.