Update 4 November 2025

Welcome back to another update on the Dutch commercial healthcare market. In this update we cover:

• Election results. What are the consequences for commercial healthcare in the Netherlands
• Growing demand for companies providing informal care. What are the reasons?
• Court ruling related to prohibition on dividend payments for specialized clinics. Will the rules against dividend payments be relaxed?
• In our snapshot we give an overview of CityKids, a provider specialized in providing medical care for children

What are the consequences of the election results for commercial healthcare?

In our update of 16 September we analyzed the background of the recent forced elections and likely outcomes. In the previous update we explained how healthcare spend had become a hot them in the election process. The election took place last Wednesday and the results were in some respects as expected and in other aspects quite surprising. As expected, the parties in the previous coalition all lost seats. NSC was the biggest loser, going from twenty to zero seats, while VVD only lost two seats. As expected, the right-wing populist party PVV lost many seats but is still (almost) the biggest party based on number of voters. In addition, the PVV lost many votes to other populist right-wing parties, and the number of seats in Parliament from these three parties actually increased by one seat.

The process leading to a new coalition government will be long and difficult as the two realistic options both involve parties going back on statements that they would “never” enter a coalition with one of the other three parties needed for a majority in Parliament. Both possibilities are based on two centrist parties that did very well in the elections and the VVD (conservative). The left-leaning possibility would include the labor-oriented GL/PvdA (with a strong majority in Parliament) while the right-leaning opportunity would include Ja21 (right-wing populist party) and probably another party to get a majority.

GL/PvdA is the only party in the equation that has made clearly negative statements about commercial healthcare. However, in the left-leaning coalition their views would be balanced by the positive views of the other parties. Given that healthcare is not going to be the highest priority of a new government, any changes are likely to be minimal. The same will be the case if the right-leaning coalition comes out of the process to be followed in the coming months.

Growing demand for companies providing informal care

In the Netherlands, a growing number of elderly clients are having to stay longer at home due tightened rules for admission to nursing homes. While they are often able to get some care from municipalities (WMO) and healthcare insurance there is a growing need for informal care from family and friends (in Dutch “mantelzorg”). According to recent data, one third of the Dutch population claim to provide some form of informal care, and 820.000 have provided care for eight hours per week for (at least) the last three months, and 460.000 informal care providers feel that they are overburdened. In the coming years, the number of elderly people requiring informal care will increase by 70%

A growing solution to the challenges resulting from trying to combine work, children a busy social life and informal care is to outsource this to commercial providers. Sometimes, these services are provided by, or in cooperation with, traditional providers of medical home care or domiciliary care. Other providers include commercial parties such as Saar aan Huis, Zorgmies, Senior Service, and Handen in Huis. These companies typically provide staff that keep elderly client company, help with shopping and chores, light administrative tasks, etc. A specific niche is providers of live-in healthcare au-pairs (typically from Eastern Europe). Sometimes, the services can be paid via WMO or healthcare insurance (but typically with a PGB), but often the informal care providers are paid out-of-pocket by the client or the family of the client.

This is clearly a growing market, and it will be interesting to see how it develops under the twin pressures of demographics and stricter rules for getting nursing home care. In every stereotype about nationalities there is always a grain a truth, and this is certainly the case for the Dutch being careful with their money. This might put a limit to the growth of services paid out-of-pocket, so growth might be dependent on some type of public financing.

Court ruling related to prohibition on dividend payments

One of the key challenges that many first-time investors in the Dutch healthcare system worry about is that in many interesting sub-segments of the market (specialized clinics, intramural elderly care, etc.) it is by law forbidden to pay dividends to owners. This is based on the history of healthcare in the Dutch market where traditionally all care was provided by non-profit foundations. Through the years there have been discussions in Parliament either to loosen or to tighten these rules, but the compromise solution has always been to keep the rules as they are. A new law that is in the process of going through Parliament (Act on Ethical Business Operations for Healthcare and Youth Care Providers (Wibz)) is intended to put limits on when and how dividends can be paid in sub-sectors where it is currently allowed.

A recent court case might upend the general ban on dividends and the new law (Wibz). The Council of State (the highest general administrative court in the Netherlands) has made a ruling for Belgian radiology firm that wanted to start a subsidiary in the Netherlands. It was refused an authorization to start activities in the Netherlands because it was a commercial company. The Council of State agreed with the Belgian company that this is against European rules related to freedom of establishment and capital.

The main issue for the Council of State is that the Minister of Health cannot provide a consistent and coherent argument for why and when (for which type of sectors and companies) a prohibition of dividends is required for securing quality and continuity of care. The Minister now has a challenge as he can either give the radiology firm a authorization in spite of it being a commercial company (weakening the overall case for the prohibition) or he has to find “consistent and coherent” arguments for a situation that is riddled with exceptions and work-abouts (such as commercial clinics using a foundation for the authorization and invoicing, but outsourcing all work (and profits) to a commercial company). It will be interesting to see what happens, but the probable outcome is another compromise/ work-around.

Snapshot of a commercial Dutch healthcare provider – CityKids

CityKids is a specialized provider of healthcare services to children and youth (0 to 23 years). CityKids was established in 2012 by Maritza Russel, who also owns a chain of childcare centers in the Rotterdam area. Services provided by CityKids include provision of day care to children between 0 and 8 years with complex healthcare needs, daycare for children with developmental needs, ambulant programs for youth with autism or intellectual disabilities, protected housing for young people (up to 23 years) with autism or intellectual disabilities, etc.

The company provides healthcare related services to 700 children and youth. CityKids does not appear to have contracts with insurance companies, services are financed through the PGB system where parents have to get access to alternative financed care from healthcare insurance companies. The company has almost 200 employees across fourteen locations. CityKids has had a robust growth in both revenues (up 44% from 2023 to 2024) and profits with EBIT reaching €3.7 mln in 2024 ( up 26% from 2023)