J.K. Helderman

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.

An open letter to The BMJ editors on qualitative research

Seventy six senior academics from 11 countries invite The BMJ ’s editors to reconsider their policy of rejecting qualitative research on the grounds of low priority. They challenge the journal to develop a proactive, scholarly, and pluralist approach to research that aligns with its stated mission

The institutional space of community initiatives for renewable energy: a comparative case study of the Netherlands, Germany and Denmark

BackgroundCommunity initiatives for renewable energy are emerging across Europe but with varying numbers, success rates and strategies. A literature overview identifies structural, strategic and biophysical conditions for community success. Our analysis focuses on institutional structure, as we describe the variety between the Netherlands, Germany and Denmark, and place this within the institutional context of the policies, power structures and energy discourses of each country.MethodsWe conducted a policy arrangements analysis with a series of semi-structured interviews, extensive content analysis of policy documents, media analysis and use of existing research, in a qualitative comparative analysis between the Netherlands, Germany and Denmark.ResultsWe demonstrate that the (evolving) institutional configuration of the energy sector strongly influences the available space for community initiative development. Denmark has a traditionally civil society-friendly energy sector, although opportunities for communities have decreased following the scaling up of production facilities. The Netherlands knows a predominantly market-oriented institutional arrangement that leaves little space for communities, but the potential for community based energy is increasingly recognized. In Germany, the typically state-dominant Energiewende strategy creates a window of opportunity for community initiatives that fit within the state policy.ConclusionsWe conclude that the institutional arrangement of the energy policy subsystem can both constrain or enable community energy projects. Decentralization appears to be one of the most important characteristics of the general institutional development and generally increases the institutional space for local (community) players. The alignment of discourses across government levels and actors is one of the important enabling features of an energy system, as it provides the stability and predictability of the system that enables communities to engage in renewable energy projects.

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 global financial crisis, health and health care.

From the early outward signs of a collapse in the US sub-prime mortgage market in the spring of 2007, the global banking crisis unfolded. Financial institutions thought too big to fail, failed. In the summer of 2007 the French bank BNP Paribas ceased activity in three hedge funds that specialized in USmortgage debt.Meanwhile, in Britain, on 14th September investors in the bank, Northern Rock, withdrew over £1 billion in the biggest run on a bank in the United Kingdom for more than a century. The bank was nationalized in February of 2008 after two private bids to take it over failed. In the autumn of 2007 more and more banks started to announce losses. Across the Atlantic, in the spring of 2008 the US investment bank Bear Sterns was merged with JP Morgan Chase as part of the Federal Reserve Bank’s rescue package. By the autumn of 2008 the seizure in bank lending and the scale of the financial problem started to accelerate with the decision of the US government not to support Lehman Brothers investment bank. On 15th September, Lehman’s filed for bankruptcy. At the April meeting of the G20 group of countries in 2009 a commitment was made to co-ordinate further financial support for the banking industry globally as well as fiscal stimulus through quantitative easing and other measures to try and dampen recessions in many countries. By 2009, the cost of the financial support to banks and the world economy in general reached a total of around £7.1 trillion, a fifth of the total annual global economy (Daily Telegraph, 2009). In the United Kingdom, the cost of support by the government was estimated at around £1.23 trillion – over 80%of the country’s annual gross domestic product (GDP). Interest rates were cut severely – UK central bank interest rates hit their lowest level since 1694 at just 0.5% (Bank of England, 2009).

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.

Reflecting on ‘The evaluation of lifestyle interventions in the Netherlands’

In their 2012 HEPL article, ‘The evaluation of lifestyle interventions in the Netherlands’, Rappange and Brouwer problematized the structural underinvestment in preventive lifestyle interventions in the Netherlands (Rappange and Brouwer, 2012). They sought the explanation for this in the decision-making framework used in the Netherlands to delineate the basic benefits package of the National Health Insurance, a framework that seems ill-suited to include investments in lifestyle interventions in the basic benefits package. In their article, Rappange and Brouwer examined how the two most important criteria in the framework (‘necessity’ and ‘cost-effectiveness’) could or should be operationalized and applied in such a way that preventive lifestyle interventions will be included in the basic benefits package. In this short essay, I will argue that it is true that the decision framework that they focused upon does not facilitate a social optimal choice for investments in the most effective health-promoting interventions, but that this has not so much to do with the decision framework as such, but with a more fundamental problem of social insurance schemes in the welfare state. Let us start with textbook knowledge. There are two problems with respect to health-related risks that actuarial (private) insurance schemes cannot handle and that therefore require either public regulation or direct state provision. The first problem is that of adverse selection, meaning that it is always in the interest of private insurers to eliminate ‘bad risks’. As premiums are set to reflect expected loss, the strategy of adverse selection may lead to a spiral of escalating premiums, whereby more and more low-risk individuals drop out of the market until the principle of pooling is completely lost (Schut, 1995; Barr, 1998). The second problem is moral hazard, which is the difficulty that insurance companies would have in gathering the correct information when an involuntary injury, giving right to benefits, has occurred. As high-risk individuals have better

Making Sense of Complexity. The contribution of Rudolf Klein to our understanding of The New Politics of the NHS

Bespreking van: R. Klein,The New Politics of the NHS: From Creation to Reinvention London:Radcliffe Publishing , 978-1846194092