Fellow travellers in transformative times: a reflection on 21 years membership of the European Health Policy Group.

It must have been early 2000, around the start of the new Millennium. I was working as a junior lecturer/researcher at the then Institute for Health Care Policy and Management at Erasmus University in Rotterdam, the Netherlands. Still barely familiar with Dutch health care as a policy system, let alone with European health care policy systems I decided that it would be a good idea to attend a seminar of the recently established European Health Policy Group. I had heard good stories about this new multidisciplinary group, founded by Elias Mossialos and Adam Oliver. My PhD thesis supervisor, Tom van der Grinten, also went there, as did some of my colleagues from the Department of Health Economics and Health Insurance, people like Erik Schut and Wynand van de Ven for example. They were close colleagues of me, although our respective disciplines from which we studied health care policy were different.

Qualitative modelling of social determinants of health using group model building: the case of debt, poverty, and health.

BACKGROUND: Social determinants of health (SDoH) are known to have a large impact on health outcomes, but their effects are difficult to make visible. They are part of complex systems of variables largely indirect effects on multiple levels, constituting so-called wicked problems. This study describes a participatory approach using group model building (GMB) with stakeholders, in order to develop a qualitative causal model of the health effects of SDoH, taking poverty and debt in the Dutch city of Utrecht as a case study. METHODS: With GMB we utilised the perspective of stakeholders who are directly involved in policy and practice regarding poverty, debt, and/or health. This was done using system dynamic modelling, in three interactive sessions lasting three hours each. In these sessions, they constructed a model, resulting in a system of variables with causal relationships and feedback loops. Subsequently, the results of these GMB sessions were compared to scientific literature and reviewed by a panel of researchers with extensive experience in relevant scientific fields. RESULTS: The resulting model contains 71 causal relationships between 39 variables, 29 of which are present in feedback loops. The variables of participation in society, stress, shame, social contacts and use of services/provisions appear to hold prominent roles in the model's mechanisms. Most of the relationships in the model are supported by scientific literature. The researchers reviewing the model in the scientific meeting agreed that the vast majority of relationships would concur with scientific knowledge, but that the model constructed by the stakeholders consists mostly of individual-level factors, while important conditions usually relate to systemic variables. CONCLUSIONS: Building a model with GMB helps grasp the complex situation of a wicked problem, for which it is unlikely that its interrelationships result in a fully intuitive understanding with linear mechanisms. Using this approach, effects of SDoH can be made visible and the body of evidence expanded. Importantly, it elicits stakeholders' perspectives on a complex reality and offers a non-arbitrary way of formulating the model structure. This qualitative model is also well suited to serve as conceptual input for a quantitative model, which can be used to test and estimate the relationships.

Unmasking a health care system: the Dutch policy response to the Covid-19 crisis.

The Covid-19 pandemic has put policy systems to the test. In this paper, we unmask the institutionalized resilience of the Dutch health care system to pandemic crisis. Building on logics of crisis decision-making and on the notion of 'tact', we reveal how the Dutch government initially succeeded in orchestrating collective action through aligning public health purposes and installing socio-economic policies to soften societal impact. However, when the crisis evolved into a more enduring one, a more contested policy arena emerged in which decision-makers had a hard time composing and defending a united decision-making strategy. Measures have become increasingly debated on all policy levels as well as among experts, and conflicts are widely covered in the Dutch media. With the 2021 elections ahead, this means an additional test of the resilience of the Dutch socio-political and health care systems.

Increasing the Legitimacy of Tough Choices in Healthcare Reimbursement: Approach and Results of a Citizen Forum in The Netherlands.

BACKGROUND: Some studies in the Netherlands have gauged public views on principles for healthcare priority setting, but they fall short of comprehensively explaining the public disapproval of several recent reimbursement decisions. OBJECTIVE: To obtain insight into citizens' preferences and identify the criteria they would propose for decisions pertaining to the benefits package of basic health insurance. METHODS: Twenty-four Dutch citizens were selected for participation in a Citizen Forum, which involved 3 weekends. Deliberations took place in small groups and in plenary, guided by 2 moderators, on the basis of 8 preselected case studies, which participants later compared and prioritized under the premise that not all treatments can or need to be reimbursed. Participants received opportunities to inform themselves through written brochures and live interactions with 3 experts. RESULTS: The Citizen Forum identified 16 criteria for inclusion or exclusion of treatments in the benefits package; they relate to the condition (2 criteria), treatment (11 criteria), and individual characteristics of those affected by the condition (3 criteria). In most case studies, it was a combination of criteria that determined whether or not participants favored inclusion of the treatment under consideration in the benefits package. Participants differed in their opinion about the relative importance of criteria, and they had difficulty in operationalizing and trading off criteria to provide a recommendation. CONCLUSIONS: Informed citizens are prepared to make and, to a certain extent, capable of making reasoned choices about the reimbursement of health services. They realize that choices are both necessary and possible. Broad public support and understanding for making tough choices regarding the benefits package of basic health insurance is not automatic: it requires an investment.

Policy, politics and public health.

If public health is the field that diagnoses and strives to cure social ills, then understanding political causes and cures for health problems should be an intrinsic part of the field. In this article, we argue that there is no support for the simple and common, implicit model of politics in which scientific evidence plus political will produces healthy policies. Efforts to improve the translation of evidence into policy such as knowledge transfer work only under certain circumstances. These circumstances are frequently political, and to be understood through systematic inquiry into basic features of the political economy such as institutions, partisanship and the organization of labour markets.

Fair Processes for Priority Setting: Putting Theory into Practice Comment on "Expanded HTA: Enhancing Fairness and Legitimacy".

Embedding health technology assessment (HTA) in a fair process has great potential to capture societal values relevant to public reimbursement decisions on health technologies. However, the development of such processes for priority setting has largely been theoretical. In this paper, we provide further practical lead ways on how these processes can be implemented. We first present the misconception about the relation between facts and values that is since long misleading the conduct of HTA and underlies the current assessment-appraisal split. We then argue that HTA should instead be explicitly organized as an ongoing evidence-informed deliberative process, that facilitates learning among stakeholders. This has important consequences for whose values to consider, how to deal with vested interests, how to consider all values in the decision-making process, and how to communicate decisions. This is in stark contrast to how HTA processes are implemented now. It is time to set the stage for HTA as learning.

The crisis as catalyst for reframing health care policies in the European Union.

Seen from the perspective of health, the global financial crisis (GFC) may be conceived of as an exogenous factor that has undermined the fiscal sustainability of European welfare states and consequently, their (expanding) health systems as well. Being one of the core programs of European welfare states, health care has always belonged to the sovereignty of European Member States. However, in past two decades, European welfare states have in fact become semi-sovereign states and the European Union (EU) no longer is an exogenous actor in European health policy making. Today, the EU not only puts limits to unsustainable growth levels in health care spending, it also acts as an health policy agenda setter. Since the outbreak of the GFC, it does so in an increasingly coercive and persuasive way, claiming authority over health system reforms alongside the responsibilities of its Member States.

The importance of order and complements: a new way to understand the Dutch and German health insurance reforms.

This article adds to recent theorizing on gradual institutional change by focusing on how institutional displacement occurs through sequential patterns of change. It argues that under certain conditions, reformist political actors may achieve systemic reform through sequences of incremental reforms. We illustrate our argument through a comparative analysis of systemic health care reforms in two Bismarckian health insurance systems, the Netherlands and Germany. These reforms involved further universalization of health care insurance combined with regulated competition to enhance efficiency. The analyses show that reformist actors anticipated institutional drift and that they employed layering and conversion over time to pave the way for institutional displacement. In the Netherlands, successive sequences complemented each other so that over time the former bifurcated insurance system could be replaced by a universal system. In Germany, successive sequences did not complement each other, and bifurcation is still in place.

Negotiating authority: a comparative study of reform in medical training regimes.

Recently the medical profession has faced increased outside pressure to reform postgraduate medical training programs to better equip young doctors for changing health care needs and public expectations. In this article we explore the impact of reform on professional self-governance by conducting a comparative historical-institutional analysis of postgraduate medical training reform in the United Kingdom and the Netherlands. In both countries the medical training regime has shifted from professional self-regulation to coregulation. Yet there are notable differences in each country that cannot be explained solely by diverging institutional contexts. They also result from the strategic actions by the actors involved. Based on an assessment of the recent literature on institutional transformation, this article shows how strategic actions set negotiating authority processes into motion, producing new and sometimes surprising institutional arrangements that can have profound effects on the distribution and allocation of authority in the medical training regime. It stresses the need to study the interactions among political context, the properties of institutions, and negotiating authority processes, as they are crucially important to understanding institutional transformation.

The rise of the regulatory state in health care: a comparative analysis of The Netherlands, England and Italy.

In a relatively short time, regulation has become a significant and distinct feature of how modern states wish to govern and steer their economy and society. Whereas the former 'dirigiste' state used to be closely related to public ownership (e.g. hospitals), planning (volume and capacity planning) and centralised administration (e.g. fixed prices and budgets), the new regulatory state relies mainly on the instrument of regulation to achieve its objectives. In this paper, we wish to relate the rise of the 'regulatory state' to the path-dependent trajectories and institutional legacies of discrete European health-care systems. For this purpose, we compared the Dutch corporatist social health insurance system, the strongly centralised National Health Service (NHS) of England and federal regionalised NHS system of Italy. Comparing these three different health-care systems suggests that it is indeed possible to identify a general trend towards the rise of the regulatory state in health care in the last two decades. However, although the three countries examined in this paper face similar problems of multilevel governance of networks of third-party payers and providers, each system also gives rise to its own distinct regulatory challenges.

Changing choices in health care: implications for equity, efficiency and cost.

Although choice may be seen as an end in itself, the papers included in this special issue of Health Economics, Policy and Law, examine choice policies in European systems of health care, which aim to be effective instruments for ameliorating the systemic pressures from the iron triangle of equity, efficiency, and cost. Three papers consider the nature of differences between and within countries following the Beveridge and Bismarck models of financing and organising the delivery of care, and how choices are changing within different systems. Within countries following the Beveridge model, current policies in England, Denmark and Sweden emphasise increasing patient choice of provider. Within countries following the Bismarck model, current policies in France and Germany seek to restrict choice of specialists by introducing 'soft' gatekeeping; and in the Netherlands there is a system of managed competition with choice of insurer that, in principle, allows insurers to contract selectively with providers. A fourth paper considers how government policies that seek to restrict choice within systems of universal coverage have been subject to challenges in the courts. A commentary explores the implications of the fraught and complex nature of choices between insurers and providers of health care for designing effective choice policies.

Market-oriented health care reforms and policy learning in the Netherlands.

In this article we analyze the evolution of market-oriented health care reforms in the Netherlands. We argue that these reforms can be characterized as policy learning within and between competing policy programs. Policy learning denotes the process by which policy makers and stakeholders deliberately adjust the goals, rules, and techniques of a given policy in response to past experiences and new information. We discern three distinctive periods. During the first period (1988-1994), the prevailing corporatist and etatist policy programs were seriously challenged by the proponents of a new market-oriented program. But when it came to political decision making and implementation, the market-oriented program soon lost its impetus because it was technically too complex and could not provide short-term solutions to meet the urgent need for cost containment. During the second period (1994-2000), the etatist program regained its previously dominant position. In parallel to a strengthening of supply and price controls, however, the government also persevered in creating the technical and institutional preconditions for regulated competition. Moreover, public discontent over waiting lists and the call for more autonomy by individual providers and insurers strengthened the alliance in favor of regulated competition. This led to the revival of the market-oriented program in a 2001 reform plan. We conclude that the odds of these new post-2001 reforms succeeding are substantially higher than in the first period due to the technical and institutional adjustments that have taken place in the past decade.