Introduction
Definition and frame of reference
In this study, policy is defined as a set of objectives, priorities and strategies for future action. Policy development is the process that gives the actual form to the policy-making; it is characterized by the merging of content and structure (Fig. 2.3). Health policy is defined as any explicit government policy related to health status and health care intended to promote the principles of or attain the goals set by the health for all strategy of WHO, taking into account the structural conditions in a given political and administrative environment (Fig. 2.3).
During the session of the WHO Regional Committee for Europe held in September 1984, the Netherlands and the other European Member States endorsed this policy for Europe. Since then the policy has been formulated and implemented in various ways in the Netherlands.
General characteristics of the Netherlands
The Netherlands is located in northwestern Europe and covers an area of 41 864 km2; almost 20% of this is inland water. The capital is Amsterdam and the seat of government is The Hague.
The Netherlands has a developed market economy based largely on financial services, light and heavy industries and trade. The Netherlands has one of the largest reserves of natural gas in western Europe, providing more than half the domestic energy used. The agricultural sector accounts for less than 5% of the gross domestic product and employs a similar percentage of the workforce. The long growing season and excellent grazing lands on the polders, however, put the Netherlands among the top exporters of cheese, butter and eggs.
General characteristics of the population
The Netherlands has a population of over 15 million and is one of the most densely populated countries – 110 –
Fig. 2.3. The Y model for health policy development
•Targets and indicators POLICY DOMAIN OF
This model combines not only the confrontation of content and structure but also the policy cycle (stages A, B, C, and D) and the SWOT model (strong-weak opportunities and threats).
NGOs: nongovernmental organizations; QUANGOS: quasi-autonomous nongovernmental organizations.
Source: Unpublished paper by Bosboom & Hegoner (1979).
in the world (Appendix 1).
The ethnic composition is 90% Dutch with a considerable proportion of Turks, Moroccans and Germans.
Current immigration exceeds emigration and is mostly from Turkey, Morocco, the United Kingdom and Surinam, a former Dutch colony.
Mortality figures are relatively favourable. The average age at death and life expectancy at birth are increasing gradually (Appendix 2).
The long-term demographic trends show not only population growth but also an increasing proportion of older people. This has tremendous consequences for health policy.
General characteristics of health status
The life expectancy in 2010 is projected to be 1–1.5 years longer than in 1990, but only part of this gain in life span will consist of healthy years.
Trends in life expectancy (mortality) are largely determined by a limited number of important causes of death. In 1990 the most important causes of premature death in rank order were: coronary heart disease, stroke, lung cancer, breast cancer, chronic obstructive pulmonary disease (including asthma), road accidents, colorectal cancer, suicide, diabetes mellitus and stomach cancer. These ten causes are responsible for about 48% of the total potential years of life lost through all causes of death.
Trends in health expectancy are largely determined by a limited number of important diseases and disorders, most of which are different from those that determine life expectancy (mortality). Health expectancy is calculated based on data about poor health experienced, long- and short-term functional disability and stays in institutions. Calculated this way, health expectancy is largely determined by the occurrence of chronic diseases and disorders but also by ones of short duration. About 80–85% of those who describe their health as “less good” have had one or more chronic diseases, compared with 30–35%
of those describing their health as “good”.
By 2010, the total number of people with diseases and disorders, especially the chronic ones occurring mostly in old age, is expected to increase by 25–40% above the level in 1990. This increase is especially associated with the growth in and aging of the population and has considerable consequences for health care.
Changes in lifestyle may lead to considerable health gains, especially as regards the reduction of premature death. Smoking makes the biggest demonstrable contribution to total mortality in the Netherlands (calculated at about one quarter), posing numerous challenges for prevention (1).
Increasing the healthy life expectancy and quality of life will also be a challenge. This especially applies
to chronically ill people, including those with mental disorders.
The political system
The Constitution from 1814 vests legislative power in a bicameral Parliament, the Staten-Generaal, with a 75-member First Chamber and a 150-member Second Chamber. The members of the First Chamber are elected to six-year terms by members of provincial councils; members of the Second Chamber, which has greater authority, are directly elected to four-year terms. Executive power is exercised by an appointed Cabinet under the leadership of the Prime Minister. The judiciary is headed by the High Court.
Governments after the Second World War comprised Roman Catholic and Labour Party coalitions. From the late 1950s until the early 1970s, the Christian Democratic Party, a reorganized Catholic Party that included Protestants, controlled the Government. That control was lost in 1973 to the Labour Party, followed by a succession of various coalitions from 1977 on. Since 1994 the Government has comprised the Labour Party, the People’s Party for Freedom and Democracy (a right-wing liberal party) and the Democrats ’66 (left-wing liberal democrats).
Policy environment
The Netherlands has a pluralistic health system (2). Such systems have long been common in continental western Europe. The pluralistic system in the Netherlands combines two types of decentralization:
functional and geographical (Fig. 2.4). The functional type of decentralization covers cure, care and some preventive aspects of the health system and is therefore a dominant characteristic of the health system.
The pluralistic health system in the Netherlands has a historically embedded liberal tradition combined with the social responsibility of private organizations, especially those with a religious background, thus reducing a potential strong role of government. Government and social actors share responsibility for formulating and implementing policy.
Social insurance is the main source of health care financing. This separates the health and social welfare systems administratively, as social welfare is financed by tax revenues. The social insurance, historically originating from sickness funds and the labour movement, traditionally focuses strongly on protecting the most vulnerable people.
In addition to government administration, the social actors or nongovernmental organizations join forces in quasi-autonomous nongovernmental organizations. This represents the functional type of decentrali-zation (Fig. 2.4). They play a major role in regulating the actual provision of health services. The actors in these quasi-autonomous nongovernmental organizations are care providers, insurers (sickness funds and private insurers), consumer organizations and, in one case, organizations of employers and employ-ees. This characteristic accounts for a relatively strong tradition of consultation and negotiation between all actors, including the Government.
Fig. 2.4. Types of decentralization of the health system in the Netherlands
One of the consequences of this structure is that the agenda for national health policy is mainly dominated by planning, financing and organizing health services and less by health status, equity and intersectoral action. Despite these structural features of the system, the Government of the Netherlands has always endorsed the WHO regional strategy for health for all.
A second characteristic of the policy environment influencing the health for all strategy in the Nether-lands is the ongoing debate since 1986 on health care reform (3). These reforms were described as
“balancing corporatism, etatism and market mechanisms” (4,5). Proposals by the Dekker Committee (6) and subsequent government actions have dominated the policy agenda since then. The social and political debate emanating from restructuring and financing the health care system has mainly focused on cost containment and its financial consequences for the population, especially the most vulnerable groups.
Both pluralism or (neo-)corporatism and care reforms have largely determined the opportunities for developing a health policy leading to health for all (7,8, E. Dekker, personal communication, 1993).
Start of the process
The Netherlands has a relatively long history of health policy development. In 1983, a first step was taken by the establishment of the Steering Committee on Future Health Scenarios. Scenario analysis is a means of forecasting, formulating strategy and allocating resources that has developed in response to the problems of making decisions in complex and rapidly changing societies. It integrates traditional discipline-specific forecasting methods within a multidisciplinary framework and adds qualitative methods that project assumptions about the future. It also integrates plans and future intentions with projections derived from past trends and causes (9).
This step appeared to be of strategic importance, as information on the future of health status and its determinants (including health care) has formed the basis of health policy documents since then.
Moreover, Parliament showed great interest in the health scenarios from the start, thus facilitating the introduction of health policy on the basis of health for all.
The scenarios, together with the launching of the European regional strategy for health for all by WHO, were the main sources of inspiration for the first health policy document in the Netherlands, the Health 2000 memorandum (10). The document was prepared by the staff responsible for health policy develop-ment using informal consultation with experts. The docudevelop-ment mainly described the health status of the population, the policy component being very modest. The Government only committed itself to start changing in the direction of health policy, but did not implement the health for all principles with a visible reorientation of the existing policy towards care-oriented health.
Main stages of the health policy process
In 1987, Parliament debated the Health 2000 memorandum. The Parliamentary Commission on Health endorsed the policy commitment to develop health policy, but expressed disappointment about the content of the memorandum, suggesting that it should be more oriented towards policy. In the same year, the Dekker
Committee published its proposals for restructuring the financing and organization of health services (see below).
In response to this criticism, the Ministry of Welfare, Health and Cultural Affairs prepared a new health policy document in 1989, the Target document on health policy (11). This included quantitative targets on cancer, cardiovascular disease, accidents and the use of alcohol and tobacco. This policy approach was strongly supported by new scientific studies (12) quantifying the health gain of possible health policy measures. Specific measures were designed to meet the targets, but budget proposals were not included.
Soon after a draft version of the document was issued, the Government fell and the new Government did not continue the proposed health policy.
As the Target document on health policy did not acquire the status of a policy document, a third national health policy document was prepared in 1991: A strategy for health (13). This document represented a more modest approach and appeared to be more in line with the existing health care policy. It also contained some new priorities for intersectoral policy relating to people’s incapacity for work.
Parliament debated A strategy for health in 1992. Although the Parliamentary Commission on Health expressed disappointment about the modest scope of the policy proposals, the Parliament approved the document as it was and it became accepted policy. In the same year, the Dunning Committee published Choices in health care (14), thus starting a national debate on criteria for setting priorities in health care.
The health status orientation of health policy was strengthened by a new document: Public health status and forecasts (1). This document integrated all available information on the health status of the population, its determinants and on socioeconomic differences in health, thus forming an adequate basis for new health policy proposals.
A new Government used this document to formulate a comprehensive framework for health policy in 1995, embracing a broad health policy agenda for the current Cabinet period (1994–1998). The latest health policy document, Healthy and sound (15), used the new data on health status to introduce general health objectives such as extending healthy life expectancy, and covered such traditional issues as pricing policy for pharmaceuticals.
Criteria used in defining the policies, objectives and targets
The criteria used in defining the content of the health policy have shifted over the last decade. The first two (draft) policy documents focused on preventing premature death, and measures to prevent the main causes of death – cardiovascular disease, cancer and accidents – were prominent policy measures. As statistics on mortality caused by these diseases and the underlying determinants (such as nutrition and alcohol and tobacco use) were readily available and the documents did not have a real political impact, quantitative health targets (like the European regional targets for health for all) could be used.
At a later stage, the emphasis shifted from “adding years to life” to “adding life to years”. This new approach was based on the increasingly favourable health status of the population; consequently, chronic
diseases, mental and psychosocial disorders and the health problems of elderly people require more attention.
The criterion of extending healthy life expectancy clearly scored higher than avoiding premature death in multi-criteria analysis. In this process the most important policy-makers of the ministry were asked to rate, based on epidemiological data, the most urgent priorities of health policy, using general objectives and criteria. The interactive nature of the process (computerized scores shown on a central display and subsequent discussion) greatly enhanced the quality of this method of preparing policy.
The latest health policy document, Healthy and sound (15) describes the Government’s general health policy objectives as:
• increasing healthy life expectancy
• preventing avoidable deaths
• increasing the quality of life.
This case study describes the implementation of the principles of health for all in the Netherlands, except for the principle of reorientation to primary health care, because there are no striking changes. The health system already emphasizes primary health care.
Equity
General principles
Equity in health and equal access to health care play an important role in health policy. Equal access to health care services is a traditional cornerstone of the neo-corporatist health system. Sickness funds play a major role in such systems. With their tradition of solidarity, they greatly contribute to the principle of equal access. Private insurers are required by law to follow this principle, although during the last few years both types of health insurance have tended to offer all kind of extras to the consumer on an unregulated basis.
Equity, in the sense of equal opportunities for health for different socioeconomic, regional and ethnic categories of the population, did not play a role in health policy for a long time. Awareness of existing differences in health started to increase in the 1980s and was especially promoted by the launching of the WHO strategy for health for all.
Equity programme
The Health 2000 memorandum (10) described extensively the known socioeconomic differences in health. The following year the Scientific Council for Government Policy organized a national confer-ence. Actors within and outside the health system attended. This conference, initiated by the Ministry of Welfare, Health and Cultural Affairs, ensured a favourable political and social context for the subsequent programme. The main conclusion was that there is enough evidence about socioeconomic differences to
justify a specific effort by government and social actors to reduce these differences. A special programme committee was set up, and a five-year research programme started in 1989. The broad political support for equity in health was shown, for example, in the fact that the chairperson of the programme committee was a well known member of a right-wing political party. Part of the programme was (and still is) a long-term research project together with several smaller projects concerning, for example, lifestyle factors and socioeconomic position and health. Within the programme a special documentation centre (which evolved into a WHO collaborating centre) was set up, and a series of research reports drew national and international interest.
In 1991 the Scientific Council for Government Policy organized a second national conference. The original actors from the first conference were now invited to report on the progress made in putting equity on the agenda and on the specific measures taken in various sectors. The research programme ended with an international conference in 1994, but it had become clear that equity should remain a policy priority.
Thus, a second equity programme started, now focusing on implementation of the research results, particularly in distressed areas in large cities.
A strategy for health (13) recognized vulnerable groups: people incapable of working, homeless people and, to a lesser extent, ethnic minorities. Special measures were taken, such as intersectoral action to protect the position of those incapable of working and support for local initiatives, including subsidizing local support groups and taking national action to prevent the exclusion from work of people with physical or mental disabilities or chronic illness.
In conclusion, the equity programme is a successful spin-off of health policy. Awareness of existing inequities has increased; for example, this now plays a role in the debate on reforming the law on sick leave. Protecting the position of people with chronic illness and mental disorders is at stake. Neverthe-less, the equity issue has clearly shown the limitations of health policy relative to other policy domains.
First, economic interests are often more dominant in the political debate. Second, health policy in the Netherlands, because of the policy environment, does not have a strong tradition of intersectoral policy aimed at improving social conditions outside the health care sector.
Participation
Participation in policy preparation
The pluralistic nature of the health system includes a strong tradition of involving social groups in preparing government policy. After the Health 2000 memorandum (10) was issued, five national conferences were organized to discuss the strengths and weaknesses of the proposed new policy approach.
These conferences focused on sectors of health care, such as primary care (general practitioners and health centres), mental health, hospitals and administration. These conferences showed strong support for the empirical underpinning of the document but mostly scepticism towards the feasibility of the new policy, especially in dealing with the strong vested interests of hospital organizations, medical specialists and health insurance organizations. As explained previously, the policy environment is dominated by care suppliers and
insurance organizations and therefore tends to focus on health care services instead of improving health status.
In the following stages of policy development, this pattern of responses appeared to continue. The draft Target document on health policy (11) was discussed informally with about 80 organizations, clustered according to the subject, and later about 100 formal written responses were sent to the Government.
No special participatory processes were organized for the third and fourth draft health policy documents, but special national meetings were organized to focus on the quality of care, preventive policy, local health policy, health impact assessment and, as mentioned, equity.
At the local level, the WHO Healthy Cities project has enhanced participation by the population. About 20 municipalities have entered the Netherlands National Network of Healthy Cities. Since 1995, the Netherlands Union of Local Authorities has formally recognized and supported the Network (16).
Participation is promoted on a wide range of issues, often broader than health care services; for example,
Participation is promoted on a wide range of issues, often broader than health care services; for example,