Perspectives on the future

What do we mean by A Healthier Netherlands?

Which trend in public health is most important?

The PHSF reviews the most important trends in Dutch public health. Two clear challenges are the rising health expenditures and the rising numbers of people with long-term illnesses. On the basis of trend data alone, we cannot determine whether to attach more importance to cost reduction or to disease management. That will depend on societal values and norms: everyone sees it differently. And the issue is further complicated by the fact that measures designed to reverse one trend may have positive or negative effects on others.

A drawing of a group of people who are holding a banner with text: Better health. The people are saying: Long and healthy life, Quality of life, Vulnerable participate, No health expenditures

A long and healthy life, isn’t that what everybody wants?

Everyone wants to live a long and healthy life – until you ask what they actually mean by that. Does health primarily mean living without disease? Or is it about social participation, even if you have activity limitations? And does matter that some groups have a higher risk of disease than others? Does a healthy life imply not using health care? Or is the meaning of health different for each person? We tend to disagree on the answers.

And is good health care the kind that cures you? Or does it imply better care for vulnerable people? Or is it health care that has been proven effective? There is no consensus about what good health care means. A lively debate has arisen about the most desirable future in the fields of public health and health care. That prompted the Netherlands Scientific Council for Government Policy (WRR) to recommend a futures study devoting explicit attention to normative issues like these. That is what we have done in the Public Health Status and Foresight Study 2014 .


Four societal challenges for public health

We organized a participatory process in which stakeholders were involved from a broad range of sectors (health professional, insurance companies, patient organizations, national and local policy makers). The major trends in public health were used as a starting point to identify and formulate the most four societal challenges for public health:

  1. To keep people healthy as long as possible and cure illness promptly
  2. To support vulnerable people and enable social participation
  3. To promote individual autonomy and freedom of choice
  4. To keep health care affordable.


Four perspectives on public health

Scenarios based on perspectives

Working with stakeholders, we formulated these societal challenges into four perspectives on public health. These are entitled In the Best of Health, Everyone Participates, Taking Personal Control and Healthy Prosperity. Each perspective centres on one of the four challenges, with the other challenges subordinated. Notions such as ‘health’, ‘prevention’, ‘health care’ and ‘quality of care’ have different meanings in each perspective.

Watch our videos on the four different perspectives:

Strategic discussions

The scenarios should be seen as ideal-typical visions of the future. They are hypothetical in the sense that none of the scenarios will become reality in isolation from the other challenges. The four perspectives make explicit the diversity in visions that exists on the notions of health and care. The perspectives could aid politicians, policymakers, local authority portfolio holders, health professionals and patient organisations in forging links between various stakeholders. We expressly have not formulated a preference for any one perspective. The perspectives have helped us discover strategic opportunities and options for the future. Our ultimate goal is to see our analyses being put to use in a wide range of strategic discussions and determinations.

In the Best of Health

Concerns and motivations

  • Long, healthy lives
  • Healthy lifestyles
  • Protection from health hazards
  • Effective prevention and care

Health and health care in this perspective

In this perspective you’re healthy if you do not have a disease. A healthy lifestyle is a healthy diet, sufficient exercise and not smoking. Care consists of prevention and curative treatment. Quality care means curing the ill and preventing premature death.

Everyone Participates

Concerns and motivations

  • Protection and support for vulnerable people
  • No person excluded
  • Social participation by people with health problems
  • Prevention and care targeted at vulnerable groups

Health and health care in this perspective

In this perspective you’re well if you participate. Care extends beyond medical care and includes services for welfare, occupational health, mental health and rehabilitation. Quality care enables social participation, with a particular focus on vulnerable people.

Taking Personal Control

Concerns and motivations

  • We know best what is good for us.
  • The quality of our own lives is the prime concern.
  • Government enables individual initiatives.
  • Health care providers listen to us.

Health and health care in this perspective

In this perspective, health primarily means quality of life; individuals determine for themselves what that involves. Prevention and care are broad notions that may include alternative medicine and life coaching. Quality care ensures well-being, as determined by each individual.

Healthy Prosperity

Concerns and motivations

  • Prosperity for both current and future generations
  • Government retains the wherewithal for education and other public services.
  • Insurance premiums stay affordable for individuals and employers.
  • Cost-effective care for those who really need it

Health and health care in this perspective

In this perspective you’re healthy if you generate no costs for curative or long-term care. Publicly funded care is narrowed to essential services. Quality care is relevant and cost-effective, as determined by the health ministry and insurance companies.



Health, participation and prosperity

Experts evaluate scenarios based on perspectives

To identify potential interrelationships between the four public health perspectives, we organised four expert meetings to explore how engagement based on each particular perspective would affect the other three societal challenges.

This approach was designed to clarify areas in which positive spin-offs could occur and productive links between perspectives could be created. It was also to identify areas in which negative side-effects could arise and where political and other choices or more intensive efforts would be necessary. We summarise the most important results below.


Health …

When health and longevity are promoted from the Best of Health perspective, that results in fewer activity limitations for people with long-term illnesses. That could improve their participation – one of the concerns in the Everyone Participates perspective.

Book: In the best of health > Learn, work, participate


… and participation …

Conversely, when from the Everyone Participates perspective more effort goes into boosting educational and labour participation in vulnerable social groups, that could help lighten the overall burden of disease – one concern in the Best of Health perspective.

Book: Everyone Participates > Live long, without diseases


… will boost prosperity …

In due course, improvements in health, education and labour productivity will jointly foster greater affluence, an important outcome in the Healthy Prosperity perspective.

Live long, without diseases + Learn, work, participatie > Welfare


… but will also necessitate more health care spending, ...

However, if more effort is put into improving health and participation, that may lead to higher health care expenditure. That could be at odds with another important goal in the Healthy Prosperity perspective – controlling health care spending.

Book: In the best of Health + Everyone Participates > Welfare/Health expenditures


... which could have contrary effects on prosperity.

More participation and more health care spending could have adverse effects on societal prosperity. Social cost-benefit analysis is a method for estimating the net outcome of any changes.

Book: In the best of health + Learn, work, participate > Welfare


Vulnerable groups: health and self-direction

Self-direction is not always feasible for everyone.

If more room is created for diversity and freedom of choice – concerns under the Taking Personal Control perspective – there will be some vulnerable groups that are insufficiently equipped to cope with it. That makes them unable to fully participate in society, a concern in the Everyone Participates perspective.

Book: Taking Personal Control > Vulnerable people stay behind

Support for vulnerable groups …

If effort is made to enhance participation in vulnerable social groups on the basis of the Everyone Participates perspective, their participation will improve.

Book: Everyone participates > Vulnerable people participate

… fosters autonomy  …

If participation in vulnerable social groups is promoted from the Everyone Participates perspective, then that could enhance well-being, autonomy and shared decision-making – concerns in the Taking Personal Control perspective.

Book: Everyone Participates > More autonomy

… and improves population health.

If support and assistance were provided to vulnerable groups, that could lighten the disease burden for the entire population, which is one concern in the Best of Health perspective.

Book: Everyone Participates > Lower disease burden

Individual health autonomy does not just arise by itself

Greater individual freedom of choice is desired ...

Many policy papers advocate a stronger role for individual citizens. And a large part of the Dutch population agrees.

Two people on a bench

... but is difficult to achieve if health and longevity …

Efforts from the Best of Health perspective to improve health and longevity could increase pressure on people to practise healthy living, thereby potentially placing limits on their autonomy and on shared health decision-making – concerns in the Taking Personal Control perspective.

Book: In the best of Health and two people on a bench

... or health care costs are the primary focus.

Similar consequences could arise if freedom of choice in health care were to be constrained on the basis of the Healthy Prosperity perspective, in an attempt to curb rising expenditures. Autonomy and freedom of choice could be in jeopardy if priority is given to other concerns.

 Book: In the best of health, two people on a bench an the book: Healthy Prosperity

More information on strategic opportunities and options

Our booklet A Healthier Netherlands, which has announced the key findings of the PHSF, explores strategic opportunities and options for the future in more detail:

  • Promoting health and promoting participation are mutually reinforcing.
  • Health and participation boost prosperity.
  • Better health, more participation, higher expenditures.
  • Improving population health by supporting vulnerable groups.
  • Self-direction not always feasible for everyone.
  • Support for vulnerable groups fosters autonomy.
  • Room for autonomy does not materialise by itself.


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