| At present, Dutch and other western health care systems are facing several challenges: I. Cost control versus quality&accesibility improvement There is a growing tension between the felt need amongst policy to control and reduce costs, and the need felt by different parties to improve health care in terms of quality and accessibility. This challenge occurs against a backdrop of globalisation of the economy, which raises questions on how to improve the tenability of the welfare state, and serious difficulties for governments and even the EU for controlling the strongly transnational industry. II. Shifting responsilities amongst actors and domains The pressure on the welfare state also leads to adaptations in other domains in the welfare state, such as changes in sickness leave and labour-incapability (WAO) insurances. Simultaneously, many of the diseases frequently encountered in the labour domain appear to be caused by a combination of factors: genetic factors, physical labour conditions, stress on the shop-floor, private lifestyles (sport, food, smoking, drinking), family circumstances, etc. This leads to problems in the relation between health care, labour and private domains: unclear competence divisions between family doctors and general health care provisions vs. labour-related doctors and provisions; unclear responsibilities of the different insurance companies involved; questions concerning the possibility and legitimacy of asking patients / employees to adapt lifestyles etc. III. Taking diversity factors into account General practitioners and some medical specialists (e.g. paediatrics; psychiatrists) are increasingly confronted by the need to take into account in diagnosis and treatment the diversity in terms of the nature of diseases and the backgrounds of patients. The recent reform of the Dutch health care system is unlikely to adequately deal with all these challenges. Like many earlier attempts at reform, in the Netherlands and elsewhere, it ignores several persistent problems that bother attempts to adequately deal with these challenges. The existing governance system, which has many problems already (Van Heffen & Kerkhof, 1999; Rotmans, 2003; Grin et al., 2004; Medawar & Hardon, 2005) is mainly transformed in the sense that the dominance shifts from doctors towards insurance companies, thus increasing a longer standing problem (Van der Grinten & Klashost, 1999); patients that are supposed to take more responsibility still constitute a very weak party, and there is hardly any attention to provisions to support them (M charek & Willems, 2005). |
