The Dutch model

Page 44 

Drawing by Ruairi O Brien (

With medical professionals and institutions responsible for devising their own separate quality systems, achieving a coherent quality framework for the Netherlands is proving a harder job than many had bargained for.

A report by the World Health Organisation in 2000 ranked the Netherlands 17th in the world for the quality of its health services. The OECD too has scrutinised the Dutch healthcare system and several reports comparing the Dutch situation with other countries have been produced in the Netherlands. All of them have sparked much debate in the Dutch press and among academic circles.

There is no doubt that benchmarking has put the question of performance indicators for health systems on the Dutch political agenda. But the indicators these studies have used, like disability-adjusted life expectancy or fairness in financial contribution, do not really address the acutely felt problems in the Dutch healthcare system, such as waiting times and labour shortages. So while interesting, these international indicators lack a strong link with national policy and decision-making frameworks in the Netherlands.

More energy should be channelled into filling these gaps, for when it comes to developing such indicators, the Netherlands is lagging behind countries like the US, Canada and Australia. One reason is the different approaches the Netherlands has chosen for monitoring its healthcare system, which can be characterised as a self-regulating system within which public and private elements are intertwined.

After a decade of planning regulations, like health manpower and budgets, healthcare policy shifted towards a regulated market in the second half of the 1980s. A nationwide emphasis was placed on the quality of care.

Over a decade ago, in 1989, the first national broad-based conference on quality in healthcare was held. Participants agreed that healthcare professionals - doctors, nurses and other personnel - and institutions such as hospitals and nursing homes, should each develop "quality systems" of their own. They agreed these systems would be used to achieve improvements in quality as well as external accountability; that patient organisations and financiers (municipalities, public and private insurers) would be involved in devising the quality system; and that the government would enforce these policies, with the inspectorate of health exerting control.

Legislation followed in 1991 and in the last decade many initiatives were taken to enforce already existing quality assurance mechanisms, or to introduce new ones. The drive to develop quality systems among professionals comes from both internal and external pressures. Work includes formalised training programmes, accreditation of courses, and the introduction of obligatory re-licensing for the medical professions (since 1989). It also includes plans to introduce national practice guideline programmes for medical specialists, general practitioners and nursing professions; peer review and audit programmes for these groups and others, like nursing home physicians and specialists in social medicine; and to develop clinical registries by scientific societies.

Healthcare institutions, on the other hand, have been more active in applying new systems, like the European Foundation for Quality Management (EFQM) model, the International Organization for Standardization (ISO) model and the North American Accreditation model. In 2000, two-thirds of the institutional healthcare providers were involved in project-based quality improvement. A third were preparing for the implementation of a comprehensive, coherent quality system.

A conference on quality in 2000 endorsed the principle of self-regulation, but saw the danger of a divide emerging between professionals and institutions instead of more integrated care arrangements. Present legislation and financing structures reinforce this divide, treating prevention, cure and social care as separate entities. Yet the need for integrated care is recognised. For instance, Dutch healthcare is financed through a mix of private and public insurance schemes. The public schemes are regulated through the Sick Fund Law (ZWF), covering most of the treatment (or curative) sector (e.g. hospitals, physicians) and prescription drugs, and the Catastrophic Illness Act (AWBZ), covering most of the care (e.g. nursing homes, homes for the elderly, home care). Now there are proposals to merge the AWBZ and ZWF under one basic insurance package for treatment and care.

In terms of monitoring by means of performance indicators, one of the major challenges ahead will be to link public health data with the performance data of individual services in a meaningful way. A prerequisite is that health services and professionals become more community oriented. But this will be difficult to achieve under the self-regulation model where financial and legislative incentives work in opposite directions. Governments must therefore provide guidance towards the overall goals of healthcare, take initiatives to safeguard coherence in the system and assure that it is population-based, instead of service-based.

Linking public health data with performance data on health services and professions begs several questions: for instance, do we provide the optimal mix of services to our population and are these services provided effectively, efficiently, in a client-oriented manner?

We have to develop performance indicators for healthcare institutes and professions that are community-based. These national performance indicators have to be placed in a quality system framework. In other words, for national indicators to be meaningful for policy and management, they will have to be part and parcel of a quality system for healthcare as a whole. The WHO 2000 report helped to reorient the focus of the Dutch healthcare system. It is now time to take the next step and develop an integrated, policy-friendly, national performance framework.


 Casparie, A.F., Sluijs, E.M., Wagner, C., de Bakker, D.H., "Quality systems in Dutch Health Care Institutions", Health Policy, December 1997.

 Kramers, G.N., Achterberg, P.W., van der Wilk, E.A., "De prestaties van de Nederlandse Gezondheidszorg in internationaal perspectief: achtergronden en implicaties voor beleid", Nederlands Tijdschrift voor Geneeskunde (145), 36, 2001.

 Klazinga, N., Stronks, K., Delnoij, D., Verhoeff, A., "Indicators Without a Cause. Reflections on the development and use of indicators in health care from a public health perspective", The International Journal for Quality in Health Care.

 Klazinga, N., Lombarts, K., Van Everdingen, J., "Quality Management in Medical Specialties: the use of channels and dikes in improving health care in The Netherlands", Jt Comm J Qual Improv, May 1998.

 Sluijs, E.M., Wagner, C., "Kwaliteitssystemen in zorginstellingen", Stand van zaken in 2000, Utrecht: Nivel, 2000.

 "Health Systems: Improving Performance", World Health Report 2000, Geneva, WHO, 2000.

©OECD Observer No 229, November 2001 

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