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.
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 .
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:
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:
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 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.
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.
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.
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.
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.
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.
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.
In due course, improvements in health, education and labour productivity will jointly foster greater affluence, an important outcome in the Healthy Prosperity perspective.
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.
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.
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.
If effort is made to enhance participation in vulnerable social groups on the basis of the Everyone Participates perspective, their participation will improve.
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.
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.
Many policy papers advocate a stronger role for individual citizens. And a large part of the Dutch population agrees.
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.
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.
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: