- Email: [email protected]
Political decision-making in health care: the Dutch case
Health Policy, 11 (1989) 243-255 Elsevier HPE 00268
Political decision-making the Dutch case
in health care:
E. Elsinga Office for Health Cultural
Affairs,
Accepted
12 February
Policy Development, Rijswijk,
Ministry
of Welfare,
Health and
The Netherlands
7989
Summary In many western countries health care is a subject of increasing importance on the political agenda. Issues such as aging, development of medical technologies, equity and efficiency of care, increasing costs, market elements, etc. are leading to a review of existing health care systems. In The Netherlands the government has proposed fundamental changes in the structure and financing of care, based on a report by the so-called Dekker Committee. The final result of a step-wise process of change should be the introduction of a new insurance scheme and the strengthening of market elements. After a short description of the government proposals, this article gives an analysis of the process of decision-making for a restructuring of health care in the Netherlands. The analysis is based on a bureaupolitical model, as originally described by Allison.
Health care policy; Structure, organization in health care; Insurance system
and financing of care; Decision-making
1. Introduction In August 1986, the Dutch government (the Cabinet) appointed an external committee that was instructed to find ways to improve the structure and financing of the health care system. This Committee on the Structure and Financing of Health Care (the Dekker Committee) had 6 months in which to formulate its recommendations. In March, 1987, the Dekker Committee published a report entitled ‘Willingness to Change’ [l] which contained their proposals for fundamental changes in Address
fare,
for
Health
correspondence:
and Cultural
0168.8510/89/$03.50
0
Dr. E. Elsinga, Office for Health Policy Development, Ministry Affairs, P.O. Box 5406, 2280 HK Rijswijk, The Netherlands.
1989 Elsevier
Science
Publishers
B.V. (Biomedical
Division)
of Wel-
244
the present health care system that would result in a new system of financing and insurance (basic insurance) and enhancement of market-oriented activities. After a prolonged and difficult decision-making process, the Cabinet presented its final reaction to the Dekker report in the policy paper ‘Change Assured’ in March 1988; Parliamentary debates followed in June 1988. The first steps toward the new health care system were taken on January lst, 1989. Full implementation will take at least 4 years and should be finalized in 1992. In this article, the process of political decision-making in the health care system in the Netherlands, as recommended by the Dekker Committee, is analysed. The aim of this analysis is to provide insight into the complex and highly diverse fields of interest that play a role in decisions about health care. At the same time, the analysis may help elucidate the Cabinet’s proposals and also yield some predictions about the further course of the process of restructuring health care in the Netherlands. Such an analysis is especially relevant at this time in view of the fact that similar discussions on (radical) changes in existing systems and/or enhancement of market elements in health care are now taking place in other countries (U.K., W. Germany). The analysis of the decision-making process in Section 3 is preceded by a short discussion of the government’s proposals for changing the Dutch health care system, as presented in the policy paper ‘Change Assured’ [2]. The article ends with some concluding remarks.
2. Changing health care in the Netherlands
[3]
On March 7th 1988, the Dutch Cabinet presented its definitive reaction to the report of the Dekker Committee. The principal aim of the Cabinet’s proposals, as set out in the policy paper ‘Change Assured’ [4], is the creation of a health care system which combines the essentially social character of a health care system with effective mechanisms that guarantee cost effectiveness and efficiency (regulated competition) [5]. The main elements of the cabinet’s proposals are a restructuring of the insurance system and a greater role for market elements in the health care system. Insurance
system
According to the Cabinet’s proposals, some important changes in the insurance systems will become operative between 1988 and 1992, resulting ultimately in a system of basic plus supplementary insurance. The basic insurance package will cover most provisions in the field of health care (hospitalisation, the GP, specialists, etc.) as well as social care services (homes for the elderly, family care, certain forms of home care, etc.). The supplementary insurance package, which will account for nearly 15% of the total cost of health care and social care services, will include medicines, physiotherapy and dental care for persons over the age of 18. The structure and some
features of the new insurance system are shown in Fig. la. Comparison with the present systems for insurance and funding (Fig. lb) clearly reveals the simplification that will be achieved. The basic insurance plan will be financed partly by an income-dependent premium and partly by a flat rate (nominal) premium. The income-dependent pre-. mium will be collected by the Department of Finance and paid into a Central Fund which will then be distributed among the insurers on a predetermined basis. The nominal premium will be paid directly by the insured to the insurer. In 1992 there will no longer be any distinction between health insurance funds and private insurance companies. There will be only one type of insurance, and the insured will be free to choose his insurer. In principle insurers will be obliged to accept all applicants and charge all persons insured by that company the same hxed premium. Market
elements
The Cabinet’s aim is to reduce the volume of legislation in the health care sector and enhance the role of market elements and self-regulation, thereby promoting flexibility, efficiency, the consumer’s freedom of choice. individual responsibility and substitution. The insurers and the providers of health care in particular will have to become increasingly aware of their joint responsibility with regard to the volume, price and quality of the care provided. Some illustrations of market elements in the new system are the freedom of insurance companies to contract health providers (competition between providers) and competition between insurance companies with regard to the level of the nominal premium charged to the insured. Evidently, the market-oriented approach cannot provide solutions to all the problems facing the health care sector. Government regulations will still be needed in important areas, such as the quality of health care and the provisions of the basic insurance plan. The market-oriented approach will also be subject to certain limitations as far as large-scale intramural provisions, such as hospitals and homes for the elderly, are concerned. The construction of new institutions of this type can only be initiated after completion of the licensing procedures applicable in the relevant province. The central government will define the financial framework for each province. Implementation In June 1988, the full Parliamentary debate on the Cabinet’s policy paper took place. Since then, the implementation process has started. The guideline will be the time schedule given in the policy paper ‘Change Assured’, which defines the steps to be taken each year until the new system is fully operational in 1992. In accordance with this time schedule, the first two steps have been taken: incorporation of a nominal premium in the Health Insurance Act and extension of
246 1 a The
new
insurance
and
financing
Basic insurance - compulsory - covers health care and social care services (85%) - mainly an income-dependent premium plus a small flat
1.
2.
Supplementary insurance - optional - cwers all provisions - flat rate (nominal)
1.b The
present
insurance
insurance/financing
not included premium
and
- compulsory - income-dependent
premiums
-
I , I ;
I I 1 I 1 _ i
compulsory below a specific income, level ’
3.
Social
# 1’ I I I L
insurance
package
premiwn
(15%)
system
I I 1 c I Insurance I
f I I optional for the self-employed earning more than the specific income
’
I I 1
I ’ ’
I
mainly incomedependent premiums
basic
(nominal)
Nursing homes. prolonged hospitalization etc.
B private insurance
’ I I
-
the
rate
Areas covered:
Exuenses - AWBZ
A Health insurance funds
financing
in
system
1. Fxceotional Medical (Comuensation) Act
2.
system
nominal
premiums
for Del-SO= in D”blic service
Hospitals, specialists, medicines,
GP’s
etc.
- statutory requirement for civil servants employed by provincial ? and ?unicfpal governments
I 0 ’ [ I I
incomedependent premiums
care - Government
budget
Fig. 1 New and present systems for health
and direct
insurance
payments
and funding
Family care, homes for elderly, etc.
in the Netherlands.
the Exceptional Medical Expenses (Compensation) Act (AWBZ) were submitted to Parliament. After prolonged discussion, Parliament finally accepted both steps. which went into effect on January lst, 1989. In the years to come, many other measures have to be adopted if the new system of insurance and financing is to become effective in 1992. These measures include: (1) Freedom of choice as far as the contract between insurer and provider is concerned; (2) More freedom and flexibility in the establishment of the tariffs for health care: (3) Introduction of a budgeting system for the Health Insurance Funds; (4) Development of quality regulation via both self-regulation (e.g. certification:1 and government regulation; (5) Anti-cartel legislation; (6) Definition of the functions of the various health and social care services.
3. Analysis of the decision-making
process
Introduction
Although the preceding description of the proposed changes in the structure of the Dutch health care system is necessarily brief, it should be clear that the changes involved are drastic in nature. It is therefore not surprising that numerous groups participated or wanted to participate in the decision-making process. This, together with the wide range of opinions, explains the relatively slow and difficult process of decision-making. The diverse ideological views of those involved (including the political parties represented in the present Cabinet) also hampered the process. As a result, a number of important decisions have not yet been made and the proposals made are clearly compromises. In this section the decision-making process for health care in the Netherlands will be further analysed. The purpose of this analysis is to elucidate the decisionmaking process, on the one hand, and to formulate expectations for the process of implementation on the other. Such an analysis is also useful in an international context since similar processes of change could also take place in other countries. The following analysis of the process of decision-making is based on the so-called bureaupolitica/ model, described originally by Allison [6]. A main characteristic of this model is that it proceeds from the standpoint that competition and rivalry exist between the parties involved in the decision-making. The bureaupolitical model is therefore an example of the so-called modern approach to political decisionmaking and the implementation of policy. Whereas the accent in the classical approach was placed on strong, mechanistic and rational management [7], the modern approach is based on dynamic, interactive processes. Political decision-making and the implementation of policies are no longer presumed to be the results of a purely rational process; there is now recognition of the existence of conflicting interests, the need for adaptation, etc. The modern approaches - including the bureaupolitical model used here - are therefore much more empirical in nature than
248
the classical approaches, which can be characterized as being predominantly normative [8]. The bureaupolitical model was chosen here because it appears to provide an adequate explanation of the decision-making process with regard to Dutch health care in the future. Application
of the bureaupolitical
model
For application of the bureaupolitical model to political decision-making with regard to the Dekker proposals, use will be made of the 4 characteristics of this model described by Rosenthal [9]: (a) many groups with highly diversified interests (b) none of the groups has a preponderant influence (c) differences settled by compromise (d) interval between decision-making and implementation of the decisions. a. Many participants
with highly diversified interests. Changes in the health care system will affect the interest of many people. In the first place, there will be alterations in the positions of those who are active in the health care sector: the providers, the insurers and the consumers. In addition, however, there are also important socio-economic and administrative aspects of the revision of the health care system as proposed by the Dekker Committee. This explains the considerable involvement of, for example, other Departments as well as trade and industry. The various groups participating - directly or indirectly - in the discussions on revision of the health care system are shown schematically in Fig. 2. Fig. 2 provides a highly simplified diagram of the actual network in the health care sector. Obviously, further subdivisions can be made within each cell and a multitude of relationships exists between the various cells.
Fig. 2
Policy network
in Dutch
health
care
It is impossible to provide a complete overview here of the opinions/interests of all of these groups with respect to the proposals for restructuring health care in the Netherlands. Therefore only the major characteristics of their views will be given. Ministry of Welfare, Health and Cultural Affairs. This department has the primary responsibility for health care policy. Its activities are directed toward the achievement of an effective, low-cost, high-quality system of health care. Other ministries. Various other departments are also involved in the revision of the health care system. They must ensure, for example, that the measures taken are in accordance with genera1 financial and socio-economic policies. This will be discussed in more detail below. Insurers. Here one must differentiate between the Health Insurance Funds and the private insurance companies. The Health Insurance Funds emphasized the social character and accessibility of the health care system. The private insurance companies stressed in particular the principle of free enterprise and the significance of competition in health care. Care providers. In genera1 the providers of health care have their doubts about the distinction between a basic and a supplementary insurance package. Patients/consumers. The representative organizations pointed out the effects on the financial and social position of people in the lower income brackets and the chronically ill. Industry. The employers’ organizations expressed their fear that the new system would mean an increase in labour costs. The labour unions, on the other hand, argued in favour of a national health scheme instead of a basic insurance package. Advisory councils. The advisory councils (composed mainly of representatives of the most important organizations in health care) were in genera1 sceptical to negative in their reactions. For a number of the present advisory councils, the proposals of the Dekker committee would lead to a decrease in responsibilities or even dissolution of the council. Local authorities: The municipalities and provinces pointed out their responsibilities in the present health care system and questioned the proposed decrease in these responsibilities (especially the municipalities). To reach decisions about radical structural changes in a field comprising such a. wide diversity of interests is very difficult. That which is acceptable to or even necessary for one party is undesirable or even unacceptable for another. Policy-making in such a field therefore is a question of balancing winners and losers. In fact the complex, partially corporate, character of the Dutch health care system is one of the most important causes of previous failures to restructure the system. The lack of a clear-cut centre of power or a (voluntary) consensus impedes and may even thwart change [lo]. For these and other reasons, it was decided that an independent committee, con sisting predominantly of individuals from outside the health care sector, should be formed. This committee, the Dekker Committee, dissociated itself completely from the arena of health care organizations. They had at their disposal a Secretariat provided by the Department of Health, but otherwise carried out their activities independently of the various groups [ll].
250
The Cabinet faced the same problem with respect to the political decisions to be made about the Dekker report: how should it operate? The two extremes were (a) to remain totally independent of those involved (like the Dekker Committee) or (b) to form their opinions in a dialogue with all those involved. Several obvious considerations affected their choice: the manner in which these important decisions were reached could influence the chances of realization of the plans and the intended changes would be both structural and fundamental in character. In view of the latter, in particular, an approach to decision-making was chosen that accentuated the role of the government. All organizations involved were given the opportunity to present their views and opinions to the Cabinet at specially organized public hearings in May 1987. Using the information from these oral presentations and the many written reactions, the Cabinet then prepared their policy paper in relative isolation. In this manner the decision-making arena was reduced to the so-called Dekker hexagon, which consisted of ministers or government officials from the 6 most immediately concerned departments. A logical consequence of the departmental organization of the government is, however, that even in this smaller arena there are obvious conflicts of interests, which ultimately function as a system of checks and balances. In brief, the various roles in the decision-making process with regard to the Dekker proposal were as follows: - Ministry of Welfare, Health and Cultural Affairs (WVC): the ministry with the primary responsibility for health care. - Ministry of Finances: its main concern was macro-economics in the field of health care, especially cost projections and the subsequently developed policies for cost containment. - Ministry of Social Affairs and Employment: its main concern was the influence of changes in the system on personal income and, in a more general sense, the social character of the new system. - Ministry of Economic Affairs: its major concern was how the changes would affect the position of trade and industry in general and the private insurance companies in particular (costs of labour, position in the international market). - Ministry of Internal Affairs: they focussed mainly on the consequences of the new system for the present insurance scheme for civil servants. - Ministry of General Affairs: this ministry plays a coordinating role and therefore had the task of arriving at a combination/integration of the various interests involved in the light of the Cabinet’s general policy. b. None of the groups has a preponderant influence. Decision-making in both the governmental and political Dekker hexagons was characterized by (changing) balances of power. The essential balance of power was that between WVC, on the one hand, and the socio-economic departments on the other. WVC had a position of power on the grounds of its primary responsibility for health care policy. Restructuring of the health care system and the interrelated social care facilities belongs of course in the portfolio of the Minister/State Secretary of WVC. On the other hand, politically speaking, the three socio-economic departments (Finances,
Economic Affairs and Social Affairs) have impressive influence. Without the cooperation/agreement of these departments, it would be impossible to reach any fundamental decision in the field of health care. In addition to this balance of powers at the Ministerial level, a second balance of power could be identified at the level of the political parties. The existing Cabinet in the Netherlands is formed by a coalition between the Christian Democratic Alliance (CDA) and the Liberal Party (VVD). Both parties support a change in the health care system, although the emphasis differs (CDA: stresses the importance of the basic insurance package; VVD: stresses market-oriented activities). This contrast was apparent during preparation of the Cabinet’s standpoint on ‘Change Assured’ and explains why it took so long for a definitive standpoint to be reached. A crucial factor in this respect was the assurance that in both the final system and in the step-by-step realization of that system the two approaches (revision of the insurance system and enhancement of the market-oriented approach) would be sufficiently and - as far as possible - equally represented. Finally, in this respect, the position of the Dutch Prime Minister should be considered. In contrast to for example England, the Prime Minister here does not have a preponderant influence in the formal sense of the word. However, it was clear that the present Prime Minister (R. Lubbers) was and is deeply concerned about developments in the field of health care. This was clear at various times in the course of the political decision-making. In fact the strong support of the Prime Minister for the Dekker proposals was decisive in the political decision-making process. c. Differences settled by compromise. From the above it follows almost automatically that decision-making could not be achieved without compromises. There were after all numerous, often conflicting interests and none of the groups in the arena could claim preponderant influence. Theoretically, the only alternative then is no decision, which means the avoidance/postponement of decisions. In the beginning, this also applied to the Cabinet as it attempted to reach a standpoint on the restructuring of the health care sys tern. In an early letter to Parliament (June, 1987). the Cabinet reported that with-. out a doubt revision of the insurance system had its advantages (e.g. with regard to substitution, accessibility of care, equity) but that on the other hand there were also important ‘disadvantages and uncertainties’ (e.g. with regard to the devel.opment of expenditures and the resulting influence on personal incomes). In this way a definitive decision about the Dekker proposals was postponed. Via a motion to reach a fun.passed by Parliament in June, 1987. the Cabinet was petitioned damental decision soon. The Cabinet’s definitive standpoint, as described in Section 2, is in fact a COMpromise. Several illustrations can be given. The first and most crucial element of compromise is the combination of a revision of the insurance system with the enhancement of market elements (competition in health care, decreased legislation. freedom of choice for the insured, etc.). This compromise - in the form of a package deal - was also a basic tenet of the report of the Dekker Committee itself. As
2.52
mentioned before, it forms the basis for political acceptation of the plans. Previous attempts in The Netherlands had shown that a fundamental restructuring of the insurance system immediately encountered ideological objections (national health plan). The only way, therefore, to realize a basic insurance plan (‘new style national health plan’) was to emphasize the significance of market-oriented activities in the execution of such a plan. A second illustration of the compromises inherent in the Cabinet decisions is the step-wise approach to the process of change. The arguments for a step-wise approach are based in the first place, of course, on the size and complexity of the process of change and the need for painstaking care. However, another factor also played a role in this respect: implementation in phases would make it possible to introduce interim adjustments and to postpone difficult and politically controversial decisions. A third and last illustration of compromises in decision-making is the role of planning in the new health care system. Although the insurers play a very important part in determining the volume of the costs of health care in a market-oriented system, there will remain an important guiding role for the (provincial) governments as far as the intramural provisions (e.g. hospitals) are concerned. It appears that in this respect the competitive system is not fully trustworthy
[121. d. Interval between decision-making and implementation of the deciDifficult processes of decision-making are indeed not seldom solved by sions.
means of the formulation of compromises. The conflicts - and problems that may result from such conflicts - are in this way often passed on from the present to the future, from the phase of decision-making to the phase of implementation (conflict postponement). This characteristic of the bureaupolitical model is also applicable to the decisions that had to be made about restructuring health care in The Netherlands. The Cabinet plans, as described in the policy paper ‘Change Assured’. are general in a large number of respects. This is, in the first place, the result of the nature of the policy paper. The purpose of the memorandum was not to describe the new system of health care in detail but to sketch perspectives for such a new system. In a certain sense, the paper was meant to produce a ‘paradigmatic change’: the introduction of a more political-economic approach to the operation of the health care system. From the viewpoint of this paradigm, the most important relationships in health care are described. Inevitably such a description will occasionally be rather general or even model-like in character. Irrespective of whether the purpose was to evade conflicts now, this general approach means of course that many questions still need to be worked out in detail - not only the ‘technical specifications’ but also (and of considerably more importance) essential aspects, such as the precise definition of the future basic package, the relation between the income-dependent and the nominal premiums for the future basic insurance package, the design of the system of contracts, etc. The pertinent question of course is, what are the consequences of postponing such important problems until the phase of implementation - the phase in which
the participation of the numerous other (non-governmental) parties involved in decision-making can no longer be ignored. The near future will reveal the extent to which the ‘willingness to change’ - as urged by the Dekker Committee - actually exists on a broad scale or whether such factors as self-interest and inertia will dominate the implementation process. Especially because revision of the system cannot be completed during this Cabinet period (the time schedule is based on completion in 1992, the present Cabinet period ends in 1990), the final form of the future system of health care will alsc depend to a large extent on the formation and composition of the next Cabinet. Numerous forms and gradations of ‘policy drifting’ are still possible and feasible.
4. Concluding
remarks
1. The report of the Dekker Committee, presented on March 2&h, 1987. caused an upheaval in the Dutch health care sector. In fact, the Committee has made a blueprint for a completely new system of care. Despite criticism - in addition to appreciation - of the Dekker plan, many felt that it was in any event a comprehensive, integral plan characterized by a consistent structure based on a (predominantly) political-economic analysis of health care. The Dekker reporr can therefore be characterized as highly rational in design. 2. The definitive Cabinet standpoint with regard to the Dekker report, as defined in the policy paper ‘Change Assured’ and presented on March 7th, 1988, is to a large extent based on the ‘rational model’ of the Dekker report. However, an extensive plan for implementation has been added. The memorandum there,fore provides on the one hand a final objective (to be reached in 1992) and on the other hand a schedule of the year-by-year measures required to achieve that objective. The bureaupolitical process has therefore ensured that the final ob.jective is defined, but also that a markedly incremental approach to implemen.tation has been chosen. 3. The indecision and contrasts within the Dutch health care sector gave the government. as it were, a mandate to present drastic proposals. In the course of time it had in fact become clear that the various interest groups in the health care sector were not able to reach agreement on far-reaching proposals. 4. For political acceptation of the proposals for restructuring the Dutch health care system, (political) coupling of revision of the insurance system and enhancement of the role of market elements in health care now appears to be essential. In this manner, social and economic aspects will be integrated in the new system. In view of the existing political relationships, the combination of these two elements provides a political basis for change. Overemphasis of one or the other element could endanger political realization of the restructuring of the Dutch health care system. 5. It will become clear in the course of time whether the incremental approach to implementation will lead to adaptation of the final aim (policy drifting) or even a smothering of the entire operation. Especially because the circle of partici-
254
pants will increase markedly in the implementation phase and decision-making can no longer be a non-committal process, tension and conflicts could become enhanced. Clear-cut unequivocal political support for revision of the health care system will then be essential - as well as the ability to negotiate strategically on implementation with both winners and losers. 6. In some sectors (e.g. hospitals and specialists), the risk of tension is even greater because the short-term policy is to reach significant cost reductions in these sectors. The short-term cost containment policy in health care (as established by the Cabinet) could lead to conflicts with those sectors with which cooperation is so necessary for the long-term policy for restructuring. The major routes to radical changes in the health care system in the Netherlands have been established. In 1992 the present disjointed insurance and financing system must be replaced by a uniform basic insurance plan which leaves sufficient space for market elements such as freedom of choice and competition. The first important step in this direction was taken on January lst, 1989, in the form of a shift within the existing insurance packages and a reduction in existing differences in premium payments. In a variety of other aspects, many organizations (insurers and care providers) are actively involved in preparation for the changes. Dutch health care is therefore ‘in motion’, due to the shock effects of the Dekker Committee. Where it will ultimately end (in the long-term view) is still uncertain. In any event this shock effect has been an important impulse (the catalyst) for short-term innovations. Compared with the pre-Dekker period, the steps that may now perhaps be characterized as ‘incremental’ are in fact quite revolutionary in the history of Dutch health care.
Acknowledgement I am indebted to Prof. R.M. Lapre, Prof. J.A.M. Maarse and some of my colleagues for their useful comments on and suggestions for this article.
References In Dutch: Bereidheid tot verandering: rapport van de Commissie Structuur en Financiering Gezondheidszorg, March 1987. An extensive English summary of the debate in The Netherlands on restructuring health care (including a summary of the Dekker report and the Cabinet policy paper ‘Change Assured’) is available from the author. This section is a follow-up of an article by Lapre in this journal, which gave a description of the proposals of the Dekker Committee. See Lapre, R.M., A change of direction in the Dutch health care system? Health Policy, 10 (1988) 21-32. In Dutch: Nota ‘Verandering Verzekerd’, Tweede Kamer, 1987-1988, 19945, nos. 27-28. In many respects the Dekker and Dutch Cabinet proposals resemble the ideas of Alain Enthoven. See e.g. Enthoven, A.C., Managed competition: an agenda for action. Health Affairs (summer 1988) 25-46. Allison, G., Essence of Decision: Explaining the Cuban Missile Crisis, Boston, 1971, esp. p. 144-184. See for example the synoptic-rational policy as described by Lindblom or Allison’s (1971) model of the rational actor.
8 Cf. Maarse. J.A.M., Uitvoering en effecten van beleid, Enschede, 1983. 36-60. 9 Rosenthal. U.. Bureaupolitiek en bureaupolitisme. Alphen aid Rijn, 1988. 10 Van der Grinten, T.E.D., Ordening van gezondheidszorg. Tijdschrift voor Sociale Gezondheidszorg, 65 (1987) 678-681. 11 The only contact took place at the end of the process. Shortly before publication of the Committee report, the organizations involved were informed about the contents of the report. 12 See for a discussion on health planning in The Netherlands: Kirckman-Liff, B.L., Lapre. R. and Kirckman-Liff. T.L.. The metamorphosis of health planning in The Netherlands and the USA. Journal of Health Planning and Management. 3 (1988) 89-109.
Political decision-making the Dutch case
in health care:
E. Elsinga Office for Health Cultural
Affairs,
Accepted
12 February
Policy Development, Rijswijk,
Ministry
of Welfare,
Health and
The Netherlands
7989
Summary In many western countries health care is a subject of increasing importance on the political agenda. Issues such as aging, development of medical technologies, equity and efficiency of care, increasing costs, market elements, etc. are leading to a review of existing health care systems. In The Netherlands the government has proposed fundamental changes in the structure and financing of care, based on a report by the so-called Dekker Committee. The final result of a step-wise process of change should be the introduction of a new insurance scheme and the strengthening of market elements. After a short description of the government proposals, this article gives an analysis of the process of decision-making for a restructuring of health care in the Netherlands. The analysis is based on a bureaupolitical model, as originally described by Allison.
Health care policy; Structure, organization in health care; Insurance system
and financing of care; Decision-making
1. Introduction In August 1986, the Dutch government (the Cabinet) appointed an external committee that was instructed to find ways to improve the structure and financing of the health care system. This Committee on the Structure and Financing of Health Care (the Dekker Committee) had 6 months in which to formulate its recommendations. In March, 1987, the Dekker Committee published a report entitled ‘Willingness to Change’ [l] which contained their proposals for fundamental changes in Address
fare,
for
Health
correspondence:
and Cultural
0168.8510/89/$03.50
0
Dr. E. Elsinga, Office for Health Policy Development, Ministry Affairs, P.O. Box 5406, 2280 HK Rijswijk, The Netherlands.
1989 Elsevier
Science
Publishers
B.V. (Biomedical
Division)
of Wel-
244
the present health care system that would result in a new system of financing and insurance (basic insurance) and enhancement of market-oriented activities. After a prolonged and difficult decision-making process, the Cabinet presented its final reaction to the Dekker report in the policy paper ‘Change Assured’ in March 1988; Parliamentary debates followed in June 1988. The first steps toward the new health care system were taken on January lst, 1989. Full implementation will take at least 4 years and should be finalized in 1992. In this article, the process of political decision-making in the health care system in the Netherlands, as recommended by the Dekker Committee, is analysed. The aim of this analysis is to provide insight into the complex and highly diverse fields of interest that play a role in decisions about health care. At the same time, the analysis may help elucidate the Cabinet’s proposals and also yield some predictions about the further course of the process of restructuring health care in the Netherlands. Such an analysis is especially relevant at this time in view of the fact that similar discussions on (radical) changes in existing systems and/or enhancement of market elements in health care are now taking place in other countries (U.K., W. Germany). The analysis of the decision-making process in Section 3 is preceded by a short discussion of the government’s proposals for changing the Dutch health care system, as presented in the policy paper ‘Change Assured’ [2]. The article ends with some concluding remarks.
2. Changing health care in the Netherlands
[3]
On March 7th 1988, the Dutch Cabinet presented its definitive reaction to the report of the Dekker Committee. The principal aim of the Cabinet’s proposals, as set out in the policy paper ‘Change Assured’ [4], is the creation of a health care system which combines the essentially social character of a health care system with effective mechanisms that guarantee cost effectiveness and efficiency (regulated competition) [5]. The main elements of the cabinet’s proposals are a restructuring of the insurance system and a greater role for market elements in the health care system. Insurance
system
According to the Cabinet’s proposals, some important changes in the insurance systems will become operative between 1988 and 1992, resulting ultimately in a system of basic plus supplementary insurance. The basic insurance package will cover most provisions in the field of health care (hospitalisation, the GP, specialists, etc.) as well as social care services (homes for the elderly, family care, certain forms of home care, etc.). The supplementary insurance package, which will account for nearly 15% of the total cost of health care and social care services, will include medicines, physiotherapy and dental care for persons over the age of 18. The structure and some
features of the new insurance system are shown in Fig. la. Comparison with the present systems for insurance and funding (Fig. lb) clearly reveals the simplification that will be achieved. The basic insurance plan will be financed partly by an income-dependent premium and partly by a flat rate (nominal) premium. The income-dependent pre-. mium will be collected by the Department of Finance and paid into a Central Fund which will then be distributed among the insurers on a predetermined basis. The nominal premium will be paid directly by the insured to the insurer. In 1992 there will no longer be any distinction between health insurance funds and private insurance companies. There will be only one type of insurance, and the insured will be free to choose his insurer. In principle insurers will be obliged to accept all applicants and charge all persons insured by that company the same hxed premium. Market
elements
The Cabinet’s aim is to reduce the volume of legislation in the health care sector and enhance the role of market elements and self-regulation, thereby promoting flexibility, efficiency, the consumer’s freedom of choice. individual responsibility and substitution. The insurers and the providers of health care in particular will have to become increasingly aware of their joint responsibility with regard to the volume, price and quality of the care provided. Some illustrations of market elements in the new system are the freedom of insurance companies to contract health providers (competition between providers) and competition between insurance companies with regard to the level of the nominal premium charged to the insured. Evidently, the market-oriented approach cannot provide solutions to all the problems facing the health care sector. Government regulations will still be needed in important areas, such as the quality of health care and the provisions of the basic insurance plan. The market-oriented approach will also be subject to certain limitations as far as large-scale intramural provisions, such as hospitals and homes for the elderly, are concerned. The construction of new institutions of this type can only be initiated after completion of the licensing procedures applicable in the relevant province. The central government will define the financial framework for each province. Implementation In June 1988, the full Parliamentary debate on the Cabinet’s policy paper took place. Since then, the implementation process has started. The guideline will be the time schedule given in the policy paper ‘Change Assured’, which defines the steps to be taken each year until the new system is fully operational in 1992. In accordance with this time schedule, the first two steps have been taken: incorporation of a nominal premium in the Health Insurance Act and extension of
246 1 a The
new
insurance
and
financing
Basic insurance - compulsory - covers health care and social care services (85%) - mainly an income-dependent premium plus a small flat
1.
2.
Supplementary insurance - optional - cwers all provisions - flat rate (nominal)
1.b The
present
insurance
insurance/financing
not included premium
and
- compulsory - income-dependent
premiums
-
I , I ;
I I 1 I 1 _ i
compulsory below a specific income, level ’
3.
Social
# 1’ I I I L
insurance
package
premiwn
(15%)
system
I I 1 c I Insurance I
f I I optional for the self-employed earning more than the specific income
’
I I 1
I ’ ’
I
mainly incomedependent premiums
basic
(nominal)
Nursing homes. prolonged hospitalization etc.
B private insurance
’ I I
-
the
rate
Areas covered:
Exuenses - AWBZ
A Health insurance funds
financing
in
system
1. Fxceotional Medical (Comuensation) Act
2.
system
nominal
premiums
for Del-SO= in D”blic service
Hospitals, specialists, medicines,
GP’s
etc.
- statutory requirement for civil servants employed by provincial ? and ?unicfpal governments
I 0 ’ [ I I
incomedependent premiums
care - Government
budget
Fig. 1 New and present systems for health
and direct
insurance
payments
and funding
Family care, homes for elderly, etc.
in the Netherlands.
the Exceptional Medical Expenses (Compensation) Act (AWBZ) were submitted to Parliament. After prolonged discussion, Parliament finally accepted both steps. which went into effect on January lst, 1989. In the years to come, many other measures have to be adopted if the new system of insurance and financing is to become effective in 1992. These measures include: (1) Freedom of choice as far as the contract between insurer and provider is concerned; (2) More freedom and flexibility in the establishment of the tariffs for health care: (3) Introduction of a budgeting system for the Health Insurance Funds; (4) Development of quality regulation via both self-regulation (e.g. certification:1 and government regulation; (5) Anti-cartel legislation; (6) Definition of the functions of the various health and social care services.
3. Analysis of the decision-making
process
Introduction
Although the preceding description of the proposed changes in the structure of the Dutch health care system is necessarily brief, it should be clear that the changes involved are drastic in nature. It is therefore not surprising that numerous groups participated or wanted to participate in the decision-making process. This, together with the wide range of opinions, explains the relatively slow and difficult process of decision-making. The diverse ideological views of those involved (including the political parties represented in the present Cabinet) also hampered the process. As a result, a number of important decisions have not yet been made and the proposals made are clearly compromises. In this section the decision-making process for health care in the Netherlands will be further analysed. The purpose of this analysis is to elucidate the decisionmaking process, on the one hand, and to formulate expectations for the process of implementation on the other. Such an analysis is also useful in an international context since similar processes of change could also take place in other countries. The following analysis of the process of decision-making is based on the so-called bureaupolitica/ model, described originally by Allison [6]. A main characteristic of this model is that it proceeds from the standpoint that competition and rivalry exist between the parties involved in the decision-making. The bureaupolitical model is therefore an example of the so-called modern approach to political decisionmaking and the implementation of policy. Whereas the accent in the classical approach was placed on strong, mechanistic and rational management [7], the modern approach is based on dynamic, interactive processes. Political decision-making and the implementation of policies are no longer presumed to be the results of a purely rational process; there is now recognition of the existence of conflicting interests, the need for adaptation, etc. The modern approaches - including the bureaupolitical model used here - are therefore much more empirical in nature than
248
the classical approaches, which can be characterized as being predominantly normative [8]. The bureaupolitical model was chosen here because it appears to provide an adequate explanation of the decision-making process with regard to Dutch health care in the future. Application
of the bureaupolitical
model
For application of the bureaupolitical model to political decision-making with regard to the Dekker proposals, use will be made of the 4 characteristics of this model described by Rosenthal [9]: (a) many groups with highly diversified interests (b) none of the groups has a preponderant influence (c) differences settled by compromise (d) interval between decision-making and implementation of the decisions. a. Many participants
with highly diversified interests. Changes in the health care system will affect the interest of many people. In the first place, there will be alterations in the positions of those who are active in the health care sector: the providers, the insurers and the consumers. In addition, however, there are also important socio-economic and administrative aspects of the revision of the health care system as proposed by the Dekker Committee. This explains the considerable involvement of, for example, other Departments as well as trade and industry. The various groups participating - directly or indirectly - in the discussions on revision of the health care system are shown schematically in Fig. 2. Fig. 2 provides a highly simplified diagram of the actual network in the health care sector. Obviously, further subdivisions can be made within each cell and a multitude of relationships exists between the various cells.
Fig. 2
Policy network
in Dutch
health
care
It is impossible to provide a complete overview here of the opinions/interests of all of these groups with respect to the proposals for restructuring health care in the Netherlands. Therefore only the major characteristics of their views will be given. Ministry of Welfare, Health and Cultural Affairs. This department has the primary responsibility for health care policy. Its activities are directed toward the achievement of an effective, low-cost, high-quality system of health care. Other ministries. Various other departments are also involved in the revision of the health care system. They must ensure, for example, that the measures taken are in accordance with genera1 financial and socio-economic policies. This will be discussed in more detail below. Insurers. Here one must differentiate between the Health Insurance Funds and the private insurance companies. The Health Insurance Funds emphasized the social character and accessibility of the health care system. The private insurance companies stressed in particular the principle of free enterprise and the significance of competition in health care. Care providers. In genera1 the providers of health care have their doubts about the distinction between a basic and a supplementary insurance package. Patients/consumers. The representative organizations pointed out the effects on the financial and social position of people in the lower income brackets and the chronically ill. Industry. The employers’ organizations expressed their fear that the new system would mean an increase in labour costs. The labour unions, on the other hand, argued in favour of a national health scheme instead of a basic insurance package. Advisory councils. The advisory councils (composed mainly of representatives of the most important organizations in health care) were in genera1 sceptical to negative in their reactions. For a number of the present advisory councils, the proposals of the Dekker committee would lead to a decrease in responsibilities or even dissolution of the council. Local authorities: The municipalities and provinces pointed out their responsibilities in the present health care system and questioned the proposed decrease in these responsibilities (especially the municipalities). To reach decisions about radical structural changes in a field comprising such a. wide diversity of interests is very difficult. That which is acceptable to or even necessary for one party is undesirable or even unacceptable for another. Policy-making in such a field therefore is a question of balancing winners and losers. In fact the complex, partially corporate, character of the Dutch health care system is one of the most important causes of previous failures to restructure the system. The lack of a clear-cut centre of power or a (voluntary) consensus impedes and may even thwart change [lo]. For these and other reasons, it was decided that an independent committee, con sisting predominantly of individuals from outside the health care sector, should be formed. This committee, the Dekker Committee, dissociated itself completely from the arena of health care organizations. They had at their disposal a Secretariat provided by the Department of Health, but otherwise carried out their activities independently of the various groups [ll].
250
The Cabinet faced the same problem with respect to the political decisions to be made about the Dekker report: how should it operate? The two extremes were (a) to remain totally independent of those involved (like the Dekker Committee) or (b) to form their opinions in a dialogue with all those involved. Several obvious considerations affected their choice: the manner in which these important decisions were reached could influence the chances of realization of the plans and the intended changes would be both structural and fundamental in character. In view of the latter, in particular, an approach to decision-making was chosen that accentuated the role of the government. All organizations involved were given the opportunity to present their views and opinions to the Cabinet at specially organized public hearings in May 1987. Using the information from these oral presentations and the many written reactions, the Cabinet then prepared their policy paper in relative isolation. In this manner the decision-making arena was reduced to the so-called Dekker hexagon, which consisted of ministers or government officials from the 6 most immediately concerned departments. A logical consequence of the departmental organization of the government is, however, that even in this smaller arena there are obvious conflicts of interests, which ultimately function as a system of checks and balances. In brief, the various roles in the decision-making process with regard to the Dekker proposal were as follows: - Ministry of Welfare, Health and Cultural Affairs (WVC): the ministry with the primary responsibility for health care. - Ministry of Finances: its main concern was macro-economics in the field of health care, especially cost projections and the subsequently developed policies for cost containment. - Ministry of Social Affairs and Employment: its main concern was the influence of changes in the system on personal income and, in a more general sense, the social character of the new system. - Ministry of Economic Affairs: its major concern was how the changes would affect the position of trade and industry in general and the private insurance companies in particular (costs of labour, position in the international market). - Ministry of Internal Affairs: they focussed mainly on the consequences of the new system for the present insurance scheme for civil servants. - Ministry of General Affairs: this ministry plays a coordinating role and therefore had the task of arriving at a combination/integration of the various interests involved in the light of the Cabinet’s general policy. b. None of the groups has a preponderant influence. Decision-making in both the governmental and political Dekker hexagons was characterized by (changing) balances of power. The essential balance of power was that between WVC, on the one hand, and the socio-economic departments on the other. WVC had a position of power on the grounds of its primary responsibility for health care policy. Restructuring of the health care system and the interrelated social care facilities belongs of course in the portfolio of the Minister/State Secretary of WVC. On the other hand, politically speaking, the three socio-economic departments (Finances,
Economic Affairs and Social Affairs) have impressive influence. Without the cooperation/agreement of these departments, it would be impossible to reach any fundamental decision in the field of health care. In addition to this balance of powers at the Ministerial level, a second balance of power could be identified at the level of the political parties. The existing Cabinet in the Netherlands is formed by a coalition between the Christian Democratic Alliance (CDA) and the Liberal Party (VVD). Both parties support a change in the health care system, although the emphasis differs (CDA: stresses the importance of the basic insurance package; VVD: stresses market-oriented activities). This contrast was apparent during preparation of the Cabinet’s standpoint on ‘Change Assured’ and explains why it took so long for a definitive standpoint to be reached. A crucial factor in this respect was the assurance that in both the final system and in the step-by-step realization of that system the two approaches (revision of the insurance system and enhancement of the market-oriented approach) would be sufficiently and - as far as possible - equally represented. Finally, in this respect, the position of the Dutch Prime Minister should be considered. In contrast to for example England, the Prime Minister here does not have a preponderant influence in the formal sense of the word. However, it was clear that the present Prime Minister (R. Lubbers) was and is deeply concerned about developments in the field of health care. This was clear at various times in the course of the political decision-making. In fact the strong support of the Prime Minister for the Dekker proposals was decisive in the political decision-making process. c. Differences settled by compromise. From the above it follows almost automatically that decision-making could not be achieved without compromises. There were after all numerous, often conflicting interests and none of the groups in the arena could claim preponderant influence. Theoretically, the only alternative then is no decision, which means the avoidance/postponement of decisions. In the beginning, this also applied to the Cabinet as it attempted to reach a standpoint on the restructuring of the health care sys tern. In an early letter to Parliament (June, 1987). the Cabinet reported that with-. out a doubt revision of the insurance system had its advantages (e.g. with regard to substitution, accessibility of care, equity) but that on the other hand there were also important ‘disadvantages and uncertainties’ (e.g. with regard to the devel.opment of expenditures and the resulting influence on personal incomes). In this way a definitive decision about the Dekker proposals was postponed. Via a motion to reach a fun.passed by Parliament in June, 1987. the Cabinet was petitioned damental decision soon. The Cabinet’s definitive standpoint, as described in Section 2, is in fact a COMpromise. Several illustrations can be given. The first and most crucial element of compromise is the combination of a revision of the insurance system with the enhancement of market elements (competition in health care, decreased legislation. freedom of choice for the insured, etc.). This compromise - in the form of a package deal - was also a basic tenet of the report of the Dekker Committee itself. As
2.52
mentioned before, it forms the basis for political acceptation of the plans. Previous attempts in The Netherlands had shown that a fundamental restructuring of the insurance system immediately encountered ideological objections (national health plan). The only way, therefore, to realize a basic insurance plan (‘new style national health plan’) was to emphasize the significance of market-oriented activities in the execution of such a plan. A second illustration of the compromises inherent in the Cabinet decisions is the step-wise approach to the process of change. The arguments for a step-wise approach are based in the first place, of course, on the size and complexity of the process of change and the need for painstaking care. However, another factor also played a role in this respect: implementation in phases would make it possible to introduce interim adjustments and to postpone difficult and politically controversial decisions. A third and last illustration of compromises in decision-making is the role of planning in the new health care system. Although the insurers play a very important part in determining the volume of the costs of health care in a market-oriented system, there will remain an important guiding role for the (provincial) governments as far as the intramural provisions (e.g. hospitals) are concerned. It appears that in this respect the competitive system is not fully trustworthy
[121. d. Interval between decision-making and implementation of the deciDifficult processes of decision-making are indeed not seldom solved by sions.
means of the formulation of compromises. The conflicts - and problems that may result from such conflicts - are in this way often passed on from the present to the future, from the phase of decision-making to the phase of implementation (conflict postponement). This characteristic of the bureaupolitical model is also applicable to the decisions that had to be made about restructuring health care in The Netherlands. The Cabinet plans, as described in the policy paper ‘Change Assured’. are general in a large number of respects. This is, in the first place, the result of the nature of the policy paper. The purpose of the memorandum was not to describe the new system of health care in detail but to sketch perspectives for such a new system. In a certain sense, the paper was meant to produce a ‘paradigmatic change’: the introduction of a more political-economic approach to the operation of the health care system. From the viewpoint of this paradigm, the most important relationships in health care are described. Inevitably such a description will occasionally be rather general or even model-like in character. Irrespective of whether the purpose was to evade conflicts now, this general approach means of course that many questions still need to be worked out in detail - not only the ‘technical specifications’ but also (and of considerably more importance) essential aspects, such as the precise definition of the future basic package, the relation between the income-dependent and the nominal premiums for the future basic insurance package, the design of the system of contracts, etc. The pertinent question of course is, what are the consequences of postponing such important problems until the phase of implementation - the phase in which
the participation of the numerous other (non-governmental) parties involved in decision-making can no longer be ignored. The near future will reveal the extent to which the ‘willingness to change’ - as urged by the Dekker Committee - actually exists on a broad scale or whether such factors as self-interest and inertia will dominate the implementation process. Especially because revision of the system cannot be completed during this Cabinet period (the time schedule is based on completion in 1992, the present Cabinet period ends in 1990), the final form of the future system of health care will alsc depend to a large extent on the formation and composition of the next Cabinet. Numerous forms and gradations of ‘policy drifting’ are still possible and feasible.
4. Concluding
remarks
1. The report of the Dekker Committee, presented on March 2&h, 1987. caused an upheaval in the Dutch health care sector. In fact, the Committee has made a blueprint for a completely new system of care. Despite criticism - in addition to appreciation - of the Dekker plan, many felt that it was in any event a comprehensive, integral plan characterized by a consistent structure based on a (predominantly) political-economic analysis of health care. The Dekker reporr can therefore be characterized as highly rational in design. 2. The definitive Cabinet standpoint with regard to the Dekker report, as defined in the policy paper ‘Change Assured’ and presented on March 7th, 1988, is to a large extent based on the ‘rational model’ of the Dekker report. However, an extensive plan for implementation has been added. The memorandum there,fore provides on the one hand a final objective (to be reached in 1992) and on the other hand a schedule of the year-by-year measures required to achieve that objective. The bureaupolitical process has therefore ensured that the final ob.jective is defined, but also that a markedly incremental approach to implemen.tation has been chosen. 3. The indecision and contrasts within the Dutch health care sector gave the government. as it were, a mandate to present drastic proposals. In the course of time it had in fact become clear that the various interest groups in the health care sector were not able to reach agreement on far-reaching proposals. 4. For political acceptation of the proposals for restructuring the Dutch health care system, (political) coupling of revision of the insurance system and enhancement of the role of market elements in health care now appears to be essential. In this manner, social and economic aspects will be integrated in the new system. In view of the existing political relationships, the combination of these two elements provides a political basis for change. Overemphasis of one or the other element could endanger political realization of the restructuring of the Dutch health care system. 5. It will become clear in the course of time whether the incremental approach to implementation will lead to adaptation of the final aim (policy drifting) or even a smothering of the entire operation. Especially because the circle of partici-
254
pants will increase markedly in the implementation phase and decision-making can no longer be a non-committal process, tension and conflicts could become enhanced. Clear-cut unequivocal political support for revision of the health care system will then be essential - as well as the ability to negotiate strategically on implementation with both winners and losers. 6. In some sectors (e.g. hospitals and specialists), the risk of tension is even greater because the short-term policy is to reach significant cost reductions in these sectors. The short-term cost containment policy in health care (as established by the Cabinet) could lead to conflicts with those sectors with which cooperation is so necessary for the long-term policy for restructuring. The major routes to radical changes in the health care system in the Netherlands have been established. In 1992 the present disjointed insurance and financing system must be replaced by a uniform basic insurance plan which leaves sufficient space for market elements such as freedom of choice and competition. The first important step in this direction was taken on January lst, 1989, in the form of a shift within the existing insurance packages and a reduction in existing differences in premium payments. In a variety of other aspects, many organizations (insurers and care providers) are actively involved in preparation for the changes. Dutch health care is therefore ‘in motion’, due to the shock effects of the Dekker Committee. Where it will ultimately end (in the long-term view) is still uncertain. In any event this shock effect has been an important impulse (the catalyst) for short-term innovations. Compared with the pre-Dekker period, the steps that may now perhaps be characterized as ‘incremental’ are in fact quite revolutionary in the history of Dutch health care.
Acknowledgement I am indebted to Prof. R.M. Lapre, Prof. J.A.M. Maarse and some of my colleagues for their useful comments on and suggestions for this article.
References In Dutch: Bereidheid tot verandering: rapport van de Commissie Structuur en Financiering Gezondheidszorg, March 1987. An extensive English summary of the debate in The Netherlands on restructuring health care (including a summary of the Dekker report and the Cabinet policy paper ‘Change Assured’) is available from the author. This section is a follow-up of an article by Lapre in this journal, which gave a description of the proposals of the Dekker Committee. See Lapre, R.M., A change of direction in the Dutch health care system? Health Policy, 10 (1988) 21-32. In Dutch: Nota ‘Verandering Verzekerd’, Tweede Kamer, 1987-1988, 19945, nos. 27-28. In many respects the Dekker and Dutch Cabinet proposals resemble the ideas of Alain Enthoven. See e.g. Enthoven, A.C., Managed competition: an agenda for action. Health Affairs (summer 1988) 25-46. Allison, G., Essence of Decision: Explaining the Cuban Missile Crisis, Boston, 1971, esp. p. 144-184. See for example the synoptic-rational policy as described by Lindblom or Allison’s (1971) model of the rational actor.
8 Cf. Maarse. J.A.M., Uitvoering en effecten van beleid, Enschede, 1983. 36-60. 9 Rosenthal. U.. Bureaupolitiek en bureaupolitisme. Alphen aid Rijn, 1988. 10 Van der Grinten, T.E.D., Ordening van gezondheidszorg. Tijdschrift voor Sociale Gezondheidszorg, 65 (1987) 678-681. 11 The only contact took place at the end of the process. Shortly before publication of the Committee report, the organizations involved were informed about the contents of the report. 12 See for a discussion on health planning in The Netherlands: Kirckman-Liff, B.L., Lapre. R. and Kirckman-Liff. T.L.. The metamorphosis of health planning in The Netherlands and the USA. Journal of Health Planning and Management. 3 (1988) 89-109.