Update 24 June 2025

Summer has definitely arrived. We have had a number of days with pleasant weather and the weather last weekend was scorching. This meant that it was hard work on Saturday to help my eldest daughter and partner with moving house. As always, there is news from the Dutch healthcare sector. In this update we cover:

• Cofinimmo and Aedefica to merge. What are the consequences for the Dutch healthcare sector?
• Bergman and Equipe expand. What does this say about political risks in the Dutch healthcare market?
• IZA, WOZO, ASWA, HLO. What is going on?
• Majority in Parliament for less “commercial activities” in the primary care sector. What are consequences for the further development of primary care?

Cofinimmo and Aedefica to merge

This is a bit old news by now, but the merger of the two Belgian RIETs Aedefica and Cofinimmo is interesting as they are both major investors in the Dutch healthcare real estate sector. Aedefica has 70 properties in the Netherlands with a value of €673 million. Cofinimmo has 46 sites in the Netherlands with a value of €487 million. On a stand-alone basis each company was important for the sector, and as a merged entity they will have an even larger impact.

Is this good news or bad news? It depends on who you are:

• If you are an operator looking for a sale and leaseback it might be negative as it could affect the price you will get (lower) and costs you will pay (higher) as a major competitor has been taken out of the market. On the other hand, it is likely that the combined organization will be even more professional than the two separate organizations, leading to better service
• If you are a competitor looking for investments the picture is also probably mixed. On the one hand, there will be one competitor less looking for investment opportunities. On the other hand, the combined entity will be an even stronger competitor with a larger war-chest and a more professional organization
• For the sector as a whole I think that the impact will be small. The Dutch healthcare real estate market is big and has so many and varied investors that reducing the number by one (even if it is a big one) will not have any major impact on availability of funding, cost of funding, etc.

More and more professional investments in healthcare related real estate is a key success factor for helping the sector meet its many challenges in the coming years, and it has been fascinating to see how healthcare real estate has grown. Hopefully this will continue in the coming years as well.

Bergman and Equipe expand

The last few weeks there has been a fair amount of bad news for commercial healthcare in the Netherlands (See the previous update and the update in March about Parliament wanting to ban private equity from the healthcare sector and the piece in this week’s update about Parliament wanting to ban “commercial organizations” from primary care). As mentioned before, there will always be political parties that want less commercial activity in the healthcare sector. However, we believe strongly that in reality commercial involvement in the healthcare sector is here to stay and the share of healthcare activities that will be provided by commercial operators is likely to grow.

A key example of this is specialized clinics providing plannable care. Officially, these organizations are not allowed to pay dividends (i.e., not be commercial), but everybody knows about the work-around that is used, accepts this, and understand that chains such as Bergman and Equipe (and others) play a significant role in keeping the Netherlands healthy. Two recent examples are:

• Bergman Clinics recently opened its largest clinic to date near Rotterdam with 160 healthcare professionals. In the new clinic Bergman will work closely with GPs, hospitals, physiotherapists, and regional healthcare insurance companies to ensure that appropriate care will be provided to patients. The grand opening of the new clinic was carried out by Queen Maxima
• Xpert Clinics is a subsidiary of Equipe and recently announced that it is opening two new clinics in the north of the Netherlands. The clinics will provide low-complexity plannable care and substantially decrease travel time for patients in the northern provinces. As with Bergman, the new clinics will work closely together with GP, diagnostic centers, and physiotherapists in the region.

IZA, WOZO, ASWA and HLO – an overview

For those of you who are following the Dutch healthcare sector (also these updates) it must feel like that there is an endless number of programs with three of four letter acronyms that are all meant to structurally change the Dutch healthcare system. To help both you as a reader (and myself) the following is an overview of the programs:

• We first wrote about IZA en WOZO in July 2022. IZA (Integraal Zorgakkord – Integral Healthcare Agreement) was developed in cooperation between the Ministry of Health and 48 organizations from the healthcare sector. The program’s main goal was to improve the overall health of the Dutch population and make the sector more efficient with a focus on cure-related activities. It had seven broad themes and was meant to run from 2023 to 2026. The IZA program was financed with a budget of €2.8 billion, and groups of organizations could apply for financing of specific projects that would help IZA reach its overall goals. The program fairly quickly ran into problems related to cooperation between different parts of the sector. It also became apparent that the program had been too tightly defined as reaching the suggested goals would require input from the 342 municipalities (these are responsible for social care). It was therefore decided to expand the program and give it a new name, ISWA, where the “W” was meant to highlight the importance of social care. However, this revised program directly got into problems when the new government decided to reduce the healthcare budgets going to the municipalities, and these refused to continue their participation.
• WOZO (Wonen Ondersteuning en Zorg voor Ouderen) (Housing, Support and Care for the Elderly) was started at the same time as IZA but had a much tighter mandate. The overall goal of WOZOis to give the elderly as much control over their own lives as possible and to provide the elderly with all relevant healthcare services in their homes. It had five main themes, and was meant to run from 2022 to 2027. WOZO was financed with a budget of €770 million, that could be used to finance specific projects. WOZO was less in the news that IZA and seemed to be progressing reasonably well
• AZWA (Aanvullend Zorg en Welzijnsakkoord) (Supplemental Healthcare and Welfare Agreement) is the continuation of IZA but with a stronger focus on welfare and the role of the municipalities. The AZWA program focuses on two key goals: 1) more efficient use of healthcare personnel and 2) making healthcare more accessible and equal for all patients. The financing of AZWA is not yet clarified nor how the available money will be used. Given the recent fall of the government and the new elections in late October, it will be interesting to see how this develops.
• The HLO (Hoofdlijnenakkoord Ouderenzorg) (Mainline Agreement on Elderly Care) is a continuation of WOZO and a component of AZWA and has approximately the same goals as AZWA. The efficiency of healthcare staff will be increased by reducing bureaucracy (for example by simplifying laws and regulations and the use of innovative technology such as voice recognition). For elderly clients there will be an increased focus on reablement, more care in a home setting and more use of informal caregivers (family and friends). As with AZWA the recent fall of the government means that there are uncertainties regarding financing and the next steps.

Majority in Parliament against commercial primary care

In the previous update we described how Parliament voted for decreasing payments to commercial specialized clinics. Last week, Parliament endorsed a proposal from a left-wing member to “stop the commercialization of primary care”. A closer read highlights that most of the things that are suggested are related to making it easier for new GPs to start or acquire independent GP-practices. These are all quite sensible. However, the member of Parliament also believes that commercial chains (Co-Med, Quin, etc.) lead to bad services to patients. Naturally, with these examples, he does have a point, but he does not consider success stories such as Arts en Zorg.

A key goal of the proposal is to “keep public money in the sector”, and suggests that this should be done by tightening the rules related to dividend payments from primary-care activities. This will be quite a challenge, as all primary care practices in the Netherlands are privately owned (typically by one or more GPs). In addition, a report by Nivel (The Netherlands Institute for Health Services Research) highlights that many of the current chains are actually owned by GPs. This will lead to interesting discussions on how a ban on commercial ownership can be structured, and any suggested solution will probably face the same issues as the suggested ban on PE-investments in the healthcare sector.