Health policy and health services research in the Netherlands

HEALTH POLICY AND HEALTH SERVICES RESEARCH IN THE NETHERLANDS

GEEKT VAN ETTEN' and FRANS RUTTEN'

‘Staffbureau for Policy Development. Ministry of Health and Environmental Protection, P.O. Box 439. 2260 AK Leidschendam and ‘Department of Health Economics, Rijksuniversiteit Limburg, P.O. Box

616. 6200 MD Maastricht. The Netherlands

Abstract This paper describes the development of health services research in The Netherlands in the last decade. For that purpose. an outline of the organisational structure of health research in general is presented first. It is shown that an increasing share of total resources for health research is allocated to health services research, now amounting to almost lo”,,. Emphasis is on the development of gov’ernment health policy. which has given a strong stimulus to the volume of research projects in this area. Preparatory to the introduction of the new Health Care Services Act, which introduces the concept of planning of all health services at decentralised level. a large research program is being developed by the Ministry of Health and Environmental Protection. This program includes activities such as the development of regional health information systems, studies on the coherence of health care facilities, studies on efficient resource allocation and studies related to quahty assessment and effectiveness of health care provision. Furthermore. a number of governmental policies to support the development of health services research are considered. Most important in this respect is the development of a Council for Health Research. which advises the government on all issues of research policy and which constitutes of scientists, government representatives and representatives of organisattons using research work. Finally, an attempt is made to describe the Dutch situation within the international context.

INTRODL!CTION

Since Blanpain and Delesie reviewed the position of the health services research in The Netherlands among other Western European countries during the early 1970s [l]. no further publications on this subject have appeared in the international literature [2]. This paper will meet this gap and aims at document- ing the developments which have taken place in the last decade. This paper. however, does not attempt to give a detailed account of all institutions and all projects related to health services research in The Netherlands. Its intention is rather to present a general outline of this research within the context of the overall health policy of the Ministry of Health and Environmental Protection. Moreover, it will also touch on policies relevant to health services research of other Ministries. Special emphasis is on the role of government in health services research.

Health services research can be defined in a way the Special Working Group on Health Services Research of the EEC-Committee on Medical Research put it:

“Health servtces research is concerned with how health services work. are managed. financed and planned, with a view to deciding priorities in health care. It is thus the basic tool for the development of methods, of formulating objectives and of evjaluating results. Health services research is concerned with the structure, economics. organ- i7ation and outcome of health services and their relation- ship to social and environmental circumstances”.

THE ORGAYKATION AND FINANCING OF

HEALTH SERVICES RESEARCH

For a better understanding of the organisation of health services research it is useful to describe its position against the background of health research in

general. For this purpose a brief account of the organisational structure of health research will be presented first. Subsequently, a more detailed account will be given of the situation of the health services research.

When considering the organisational setting of health research in The Netherlands, one can usefully distinguish between four major administrative structures in which health research takes place. First, research activities are performed within the universities, in particular in the medical faculties and university hospitals. The main part of it is financed directly by the Ministry of Education and Sciences. This Ministry also provtdes funds- though at a relatively small scale-to university institutes through the Netherlands Organisation for the Advancement of Pure Scientific Research ZWO. This is a national grant-aiding body for fundamental research and it also has a separate organisation for the allocation of resources into medical research called FUNGO.

A second category of health research institutes is financed by the Ministry of Health and Environmen- tal Protection, in three different ways. First. there are a number of institutes run by the government itself such as the National Institute of Public Health (the Public Health Laboratory), the National Institute of Drinking Water Supply Services and the National Institute of Drugs Research. Another type of institutes belongs to the large semi-governmental Central Organisation for Applied Scientific Research (TNO), which also has a special organisation with various institutes for health research. Finally. there exists a number of research institutes which are run by voluntary agencies but at the same time are strongly dependent on subsidies from the Ministry of Health and Environmental Protection, generally amounting to more than 75”,, of their total budget. This category also includes the National Cancer Institute.

II9

120 Gt-EKT VAN ETTEU and FKANS RI’TTEN

A third category consists of health research carried out and;or financed within the framework of the health insurance scheme of the Sick-Funds. In the 1950s a special foundation for research into health prevention has been created rccciving its funds from the public health insurance scheme. Occasionally resources for research are allocated from both public and private insurance premiums. This is the case with the National Hospital Institute, which is run by the National Hospital Board, the organisation of hospitals and financed out of hospital cash flows.

A fourth category of health research takes place within industry which also finances the research. Par- ticular reference can be made to the pharmaceutical industry and the manufacturers of medical equipment.

Apart from the four administrative structures for research described above a fifth category can be mentioned consisting of research carried out within so- called national planning bureaus run by the government. These can be seen pro\#iding a link between research and government policy by providing scienti- fically based advice to the government.

When considering the total expenditure for health research, it should be mentioned that in The Nether- lands private foundations such as for cancer and heart disease make substantial contributions to the funding of health research. Their resources come from fund raising among the Dutch public. According to recent estimates [3] the total expenditure for health research amounts to over 750 million Dutch guilders (one guilder is about 0.38 U.S. Dollar). In Table 1 a break- down of this expenditure is presented (see also Fig. 1).

It can be seen that most funds for health research come from the government and in particular from the Ministry of Education and Sciences spending about 25”,, of its research budget on health research and to a less extent from the Ministry of Health and Environ- mental Protection. It is also apparent that when compared to other countries in Western Europe a relatively small part of the budget of the Dutch Ministry

Fig. I. An estimate of the total current annual expenditure for health research III The Netherlands. I- Minislrq of Education and Sciences: (a) direct to universities: (b) indirect to universities through FUNGO. 2 -Ministry of Health and Environmental Protection: (a) Government institutes: (b) subsidies to TNO: (cl subsidies to voluntary agencies: (d) subsidies for contract research. 3~ Insurance

schemes. 4 Private foundations. 5 -Industry.

of Education and Sciences goes indirectl~~ to universities. In fact, this part represents only 4’Yi of this Ministry’s total budget for health which underlines the different position of the FUNGO organisation on the one hand and that of the Medical Research Coun- cil in England and Scotland and of the Deutsche Forschungsgemeinschaft in Germany on the other hand. In the latter countries the share of these organ- isations into the total health research budget is about 25”

T’;lrning to the description of the health services

Table I. An estimate of the total current annual expenditure fol- health rcscarch In general and health scr\icc\ research in particular in The Netherlands (in millions of Dutch guilders)

Enpendlture Expenditure for health

for health services Source of finance research ” I, research “,)

I. MinIstry of Fducation and Sciences

(a) direct to uni\craitioa 3x5 49 20 29 (b) indirect to uni\cl-sitics through FL’NGO 15 2

7. Ministry of Health and Ln~lronmental ProtectIon

(a) Go\ernmcnt institutes” 30 4 (h) Sukidics to TN0 65 8 8 12 (cl Sutxidics to voluntary agencies 25 3 10 15 (d) Subs~d~cs fol- contl-act research 10 I IO 15

3. Inaurancc xhernes+ 40 5 20 29 4. Pri\ate foundations 40 5 S. Indurtg 180 22 6. National planning bureaus 0.5 0.5 Total 790.5 100 6X.5 100

*Research actlwties cstimatcd at one-third of total activity. tlncluding cxpcntliturc h! the Foundation for Prebcntion and the National Hospital Insti-

tutc.

Health policy and health services research in The Netherlands 121

research it is worth mentioning that the interest for this type of research both from the policy-makers and the scientific community is of a rather recent date. Also the share of health services research in the total health research activities was and still is, quite small leaving the biomedical research in a dominant position. On the other hand, health services research is getting more attention as will be explained later on.

Following the outline of the administrative structure for research activities as presented above. the present organisation of health services research can be described as follows. First. health services research is carried out within the eight existing medical faculties, in particular by the Institutes of Social Medicine, and the Institutes of General Practitioners and the Insti- tutes of Social Psychiatry, though the input of the various institutes differs considerably. In recent years also other university institutes, often belonging to other faculties, have made contributions to this field. in particular the Institutes of Medical Sociology and the Institutes of Public (or Health) Economics. It is estimated that expenditure for health services research through their regular budgets amounts to a maximum of 20 million Dutch guilders. or 5”,, of the total university budget for health research. So far no funds for health services research have been made available from the FUNGO budget.

Second, the dominant position of biomedical research is also reflected in the pattern of expenditure for research by the Ministry of Health and Environ- mental Protection. This applies both to its funding of the government institutes described earlier and to the Organisation for Health Research TN0 and also to the voluntary agencies. In fact, within the government institutes and the TN0 organisation relatively little is being done in the area of health services research. An exception can be made for the Netherlands Institute of Preventive Medicine of TNO-it changed its name recently into Preventive Health Care-which has gradually developed itself into undertaking research on health care delivery systems in general and for special groups of the population such as youth and industrial workers in particular. Total expenditure for health services research within TN0 is estimated to amount to 8 million of Dutch guilders. which is 15”,, of the total TNO-budget for health research.

Apart from this. government-aided health services research is carried out by various other institutes whose common characteristics are their social sciences base for research and their establishment in the late 1960s when the social sciences began to enter the field of health research. Moreover, they are unlike the previous ones not governmental or semi-governmental institutes, though heavily subsidised by the Ministry of Health and Environmental Protection, and rather small in terms of manpower and budget. To these institutes belong the National Institute of General Practitioners. the National Center for Mental Health and institutes involved in research on the use of alcohol and drugs. child psychiatry. social sexuo- logy, gerontology and the mentally handicapped. The contribution to these voluntary agencies is about IO million Dutch guilders. Subsidies for health services research on a contract base amount to another 10 million Dutch guilders; this research is mainly done by universities and voluntary agencies.

Third. health services research is carried out andjor financed within the framework of the health insurance schemes. Various developments can be held responsible for this. One is that the Sick-Funds, with a tra- ditional charity background, became more interested in the efficiency of providing health care when adopt- ing the role of consumer representatives in the sense that they felt responsible for the increase in social insurance premiums. This led in 1973 to the development of a national data-system of medical consumption of publicly insured people (about 70”,, of the population). Together with the hospital data base of the Foundation of Medical Records this system provides ample opportunities for research. There are, however. few research activities within Sick-Funds. Another development was the establishment in the late 1960s of the National Hospital Institute by the national organisation of hospitals. As mentioned earlier. this institute receives its funds from hospital cash flows. In all, it is estimated that about half of the funds available within this category of insurance- aided research goes into health services research. The remaining part is allocated to biomedical research in particular through the Foundation for Prevention.

Fourth, the involvement of national planning bureaus in health services research is growing. The Social and Cultural Planning Bureau has studied problems of health manpower, the personal distribution of benefits of public insurance and the supply of health and welfare facilities for the aged. Furthermore. both the Central Planning Bureau and the Scientific Coun- cil for Government Policy give regular advice to the government on matters of health policy, which is based on their own research projects. Their share in total health services research is still very small and of limited importance.

Finally. within the domain of the private foundations and the industry the contribution to health services research appears to be relatively small. There is. however, no general registration system for research in this area and activities might be insufficiently reported.

Summarising. it can be concluded that presently a maximum of about 70 million guilders per year is spent on health services research, which amounts to less than lo”,, of the total budget for health research. Most funds for health services research come from central government and the insurance schemes.

THE HEALTH POLICY COSTEXT

The needs of policy-makers for information and research are strongly dependent on developments in health policy. Therefore, in this section an attempt is made to describe trends in health policy development. which bear importance in this context. For this reason, a brief historical account of health policy and health services research over the past two decades will be presented.

Private persons and institutions, which often had organised themselves along the lines of religious denominations, stood at the cradle of health services development in The Netherlands. At the same time the government’s commitment was for a long period

ot time limited to the field of higher medical edu- the paramount pattern of health policy development cation. the aualitv-control of health care and. finallv. the financing. in particular bv administering the social

until recently.

insurance system. Character&tic of this development Both the changing role of government in the health

sector and the changing pattern of health policy de- until recently was the lack of health planning etforts velopment created needs for information. in which by the government. However, towards the end of the research should play an important role. In a sense, 1960s government involvement in the health care this pattern of policy development presupposes a sector increased substantially. Among the serious more scientific attitude. In fact, these developments problems confronting the government at that period taking place in the second half of the 1970s led to a were the imbalance between hospital and ambulatory change from a rather passive to an active health care, the predominance of curative over preventive research policy, which has three main characteristics. medicine. the control of health care costs and the lack First, research areas will be defined by the policy- of planning resulting in a health system without making institutions rather than by the research coherence and in ineflicient use of available resources. workers. Second, the various research areas will be

The growth of the state intervention into the health integrated into a comprehensive research program sector is best demonstrated by its extensive legislative which would meet the policy requirements of the activities over the past decade. First. there is the Hos- Ministry. Third, in view of the government’s involve- piral Facilitie.s Act. which regulates the supply of hos- ment in developing the health care delivery system, pital services. Though this legislation was introduced priority will be given to health services research. in the early 1970s. it is only effective from 1979. Moreover. within the Ministry a unit for health policy Second, in 1981 the Hedth Cure Tar(flk Act has been development was established which, in 1979, was also introduced which gives the central government regu- given the responsibility of developing and co-ordinat- latory power to control the prices of all health care ing the health research policy. facilities. At the same time, this act is complementary to other pieces of legislation related to health care financing, i.e. the Sicli Funds Act of 1964 and the Gw-

THE DEVEI.OP\lENT OF HEALTH SERVIC‘ES

~a/ Act on Spdd .Sickne.xv E.~pen.sc~.s of 1967. Fourth. RESEARCH

there is the new Health Cure SWIGS Act which intro- As a result of developments in health policy health duces the concept of planning for all health services services research has been given considerable atten- and also for health workers. Moreover. it provides for tion in recent years. First of all. central government a considerable increase in responsibilities in the and also voluntary agencies have increasingly taken health sector by the provincial and municipal authori- initiatives to undertake health services research. In ties. At the same time this act calls for a major res- The Netherlands the development of this type of tructuring of health services by emphasising the research started in the second half of the 1960s when coherence of the health system. particularly at the re- in most universities Institutes of Social Medicine were gional level. and by providing the instruments for de- established. In the same period the National Hospital veloping regional budgets and regional health infor- Institute was created and the Ministry of Health and mation systems. It is expected that this act will pass Environmental Protection began to subsidise social parliament by mid-1982 and will extend the govern- sciences based institutes established by voluntary ment’s possibilities to control developments in the agencies. However, no major studies. perhaps with a health sector substantially. Finally. a proposal has few exceptions, were carried out. This situation been made in 1981 for a bill regulating the perform- slightly changed after the publication of the Memor- ance of individual health workers. andum on the Structure of Health Services in the

Apart from these legislative efforts. major polic) middle of the 1970s. which introduced major pro- documents have been presented such as the Memor- posals for the reorganisation of the health services andum on the Structure of Health Services of 1974 and which also paid some attention to health services and more recently a Memorandum on the Cost Con- tainment of 1979. a Memorandum on primary health

research requirements. Subscquentl~ the government, in collaboration with health orgamsations and advi-

care. a Memorandum on public health services. both sory bodies. initiated various research projects. some published in 1980 and another- one on consumer of which have drawn the attention from the inter- policy in health care of 1981. In the 1974 Memoran- national research community. dum the riced for health services research as a tool for One effort concerns the development of a quantitat- health policy development was mentioned explicitly. ive model of the Dutch health care sector and was Moreover. in all the policy documents published since undertaken by a team of econometricians at the Uni- 19X0 new areas for research to be undertaken on kersity of Leyden [4-S], The aim of this project was behalf of the government have been mentioned, to analyst the determinants of health services’ use in a

The changing role of the government in the health global way concentrating on possibilities of substitu- sector also created the need for innovation in the pat- tion between different facilities and on economic tern of health policy development and consequently mechanisms underlying supply and demand for health in health research policy. Moreover. it also led to care. The results of the project were used in defending adaptations in the organisutional structure of the before parliament measures to reduce hospital bed Ministry of Health and Environmental Protection. capacity in the mid seventies. Another project aimed This new approach in health policy dcvclopment can at explaining the cost-structure of hospitals in terms be characterised by its orientation towards an inte- of sile. functions. star and other hospital character- grated and a comprehensive health system rather than istics 171. It is now debated whether or not results of by its fragmentary and (I(/ hoc orientation which was this project may he LISC~ in setting guidelines for the


operation of hospitals and in establishing hospital budgets. A third effort to be mentioned here is the variety of studies on the determinants of health care consumption and related subjects as absenteeism among workers. Both economists and medical sociologists have contributed in this field.

However, the major impetus into health services research by the Ministry of Health and Environmen- tal Protection has been given in the past 334 years. In this period, the government formulated its health research policy, developed a research program with an emphasis on health services research and at the same time doubled its budget for grants to research institutes for carrying out this program. Since the Ministry had committed itself to an active research policy, it also felt responsible for developing a research program which would meet its policy requirements. To highlight the major subjects of the current program, the following details can be presented.

The bulk of projects in this research program can be considered to be preparatory to the extension of the Hospital Fuci/itie.\ Act and, in particular, to the introduction of the Health Care Serzkes Act. The last act provides a framework for the planning of all health care facilities in contrast with the former act, which only regards the planning of hospitals. Further- more. an important principle of the Health Care Ser- kw Act is the decentralisation of resource allocating power. Within this framework. the provinces and municipalities are responsible for the planning of health care services in their territories and are therefore obliged to prepare health plans describing health services developments to be initiated in a 4-year period. Central government will provide guidelines and budget-restrictions for global steering of decentralised planning. Much research is needed to implement this intricate planning system.

First, the regionalisation process which ac- companies the decentralisation of planning responsibility calls for the development of a regional health information system. The objective of such a system is the provision of relevant information to local authorities for formulating and implementing their health policies and for monitoring the health sector’s per- formance in their area. The system will contain information on both mortality and morbidity figures and data on the production and consumption of health services as well as on their costs and finances. Insti- tutes involved in this research are the Netherlands Institute of Preventive Health Care, the Department of Health Economics of the Rijksuniversiteit Limburg at Maastricht and the Institute of Health Care Studies at Tilburg.

Secondly, in formulating their health plans local authorities need information on the regional needs for health care on the one hand and on the regional distribution of health services and health manpower on the other. Furthermore, insight is needed into the coherence between the various services including social welfare services at the regional level. Finally, a health plan should be translated into financial terms, c.q. the money and manpower resources to be allocated to health care facilities should be estimated, Research is considered to be one of the useful instruments in supporting the preparation of health plans

by local authorities. Presently, emphasis in the various studies is being paid to problems of substitu- tion of inpatient care by outpatient care, the introduction of day-care services within hospitals and to problems related to manpower planning. Furthermore, a number of studies concern the improvement of coherence in the field of mental health care. Finally, the Health Economics Department of the Rijksuniversit- eit Limburg is developing a scenario for producing a regional budget in relation to a regional health plan and has experimented with a regional budget for the region South-Limburg.

The third research need relates to the provision of a basis for the formulation of central guidelines. In the framework of the Heulth Care Services Ad (and to a less extent, the Hospital Facilities Act) (I priori budgets are provided to provincial authorities stating the financial restrictions within which health plans should be developed. Research will have to contribute to the development of a dividing principle for allocating resources to provinces. The Netherlands Institute of Preventive Health Care at Leyden is studying the use of similar dividing mechanisms abroad (cf. the for- mula of the Resource Allocation Working Party in the United Kingdom) and is developing and testing a number of alternative dividing keys, involving regional morbidity data and regional data with respect to health services use.

A fourth research subject. which is not directly linked to the introduction of the new planning system, concerns studies related to quality assessment and to the effectiveness of health care services. Until recently, this area of research has been almost neglected in The Netherlands, though the recent formulation of policy documents on quality control as well as on cost con- tainment have brought about some changes. First of all, since the introduction of some kind of pro- fessional standard review organisation various research projects are carried out within this context covering both medical and economic aspects of quality assessment. Secondly. a comprehensive research program is being developed to satisfy the need for evaluation research, both in the field of diag- nostic and therapeutic procedures and of health services. Meanwhile, a number of studies have been started such as on the evaluation of psychotherapy and on the effectiveness of non-conventional cancer therapies.

OTHER GOVERNMENT POLICIES REL.ATED

TO HEALTH SERVICES RESEARCH

In the foregoing section a brief review has been given of the research policy of the Ministry of Health and Environmental Protection within the framework of this Ministry’s overall health policy. In this section attention will be paid to government policies relevant to health services research as far as recently formulated by/or together with other Ministries. Among the topics to be discussed here are the proposed changes in the funding of university research. the recent policy document of the FUNGO organisation towards applied medical research. the funding of epidemiological research by the Minister for Science Policy and, finally, the policy proposals concerning the so-called sector council for health research.

124 GI:ERT VAN ETTFU and FKANS Rr ITL~

In 1979 the Ministry of Education and Sciences submitted to parliament a Memorandum on the func- tioning. the funding and the public accountability of university research. which was accepted by parliament in 1980. The major objectives of this Memorandum are to improve the efficient use of resources by for- ward planning and the division of tasks between the various universities, to make the provisions for stat- istical information about university research and to increase its public accountability. Within the context of this paper particular attention must be drawn to the proposals regarding the future structure of financing research. Following these proposals university research will be directly financed by means of a lump- sum to each university for ensuring the quality of university teaching. In addition. universities will be given a budget which will be allocated only if certain conditions are met. In particular, they are requested to develop research programs which are of special social and scientific importance and which are based on medium-term agreements among both universities and the government. Within the framework of this policy it is expected that the relevant university institutes will attempt to develop a health services research plan on a national level.

A second development concerns the recent policy proposals aiming at the strengthening of the position of ZWO. the Netherlands Organisation for the Ad- vancement of Pure Research. Not only will this organisation be given an increase in its budget. it will also be allowed to make provisions for research of an applied nature. These measures will aFfect the medical research which sector presently is receiving about 15 million guilders per year. or IS”,, of the ZWO-budget. In fact. in its recent policy document for the period 1982--19X6, the special organisation for medical research. FUNGO, proposes that it will in principle favour requests for grants in such areas as social medicine. family medicine, epidemiology. gerontology. social psychiatry and hospital sciences. Thus. these arrangements will ailow the FUNGO organisation- for the first time in history -to allocate resources to health services research. particularly as far as carried out within the universities.

Another important policy measure is the one taken by the former Ministry for Science Policy with regard to the training of epidemiological research workers. It originated from the public debate in parliament on the government policy regarding cancer control and research towards the end of the seventies. As a result. the government prepared a document which also paid much attention to cancer research. In particular. the need of a national cancer register and epidemiological research was stressed. though it was at the same time observed that the country lacked the adequate potential of qualified epidemiologists. To this end. representatives of both the Ministry for Science Policy and the Ministrv of Health and Environmental Protection worked-out a plan for the training of epidemiological research workers which the Ministrv for Science Policy decided to fund as from 19Si. Within the framework of this scheme. professors with an exper- tise in epidemiology arc invited to apply for a grant. which allow,s for the payment of the training of a candidate during these years. The scheme also allows for the training abroad. at least for some part of it.

One of the conditions for entering the scheme is that the training will be directed. among other things, to the epidemiology of cancer. At the same time. the scheme aims at strengthening the position of psychi- atric epidemiology. The scheme will run for a period of 4 years with an annual intake of 4 candidates. The policy measure described here aims at stimulating the epidemiological research on a temporary base. after which the universities are expected to have prepared their own arrangements.

Finally. in considering the future position of health services research in The Netherlands it is worth spending a few words on the development of the proposed Council for Health Research, which seems not to have its parallel in other countries of Western Europe. This Council will be part of a framework of so-called sector councils for science policy which main aims are to advise the government on all research in a particular policy domain and to formu- late multi-annual research plans relevant to this domain. Moreover. these councils consists not only of research workers. but also of representatives of relevant government departments as well as of organis- ations using research work. However, they will have no budget except for the council’s office. The government policy towards these sector councils originates from the Ministry for Science Policy and dates back to the middle of the 1970s. Meanwhile provisional councils for research into development corporation. energy and environmental protection have been established. It is expected that the Council for Health Research will be operating as from the beginning of 1983. It will also replace two existing advisory bodies in this field. One is the Council for Health Research set up in the early seventies under the Central Organ- isation of TN0 to advise the government on applied health research; the other is the Council for Bio- medical Research set up in the same period by the Royal Academy of Sciences.

With Iregard to health services research. this Coun-

cil will be important for three main reasons. First. the council will cover health research in the broadest sense including health services research and social science research. Moreover. representatives of the health services research sector will also bc appointed into this council. In fact, this development will mark a historical event since it will be the first time in The Netherlands that representatives of both biomedical and health services research will join their clthrts in developing a masterplan for health research. Another advantage of the council is that it will be a mechan- ism for integrating the research activities and advisory bodies of both the Ministry of Education and Sciences and of Health and Environmental Protec- tion. It is also expected that one of the first tasks to be taken up by the council will be to advise on the first viable organisation for the co-ordination of health services research on a national Icvcl, which has been less dckeloped ax compared to the biomedical sector of health research.

In concluding this paper we will introduce a com- parative component providing an international context for examming developments in Dutch research


policies. For this purpose we will consider The Federal Republic of Germany. the United Kingdom and the United States.

A common feature of these countries has been the increase in the needs for research within government policy sectors. This certainly applies to the health sector. though this development has taken place much earlier in both the U.S. and the U.K. than in Ger- many and The Netherlands. For example, already in the late sixties the U.S. government recognised the field of health services research as of special relevance for policy and established the National Center for Health Services Research, apart from the National Institutes of Health. Also an administrative organisation was created within the Health Department deal- ing with the development and coordination of policy- related health services research. In the U.K. a health research policy was initiated in 1972.-1973 following the publication of Lord Rothschild’s Report on the organisation and management of research. According to his recommendations applied research was best funded through government departments and con- trolled by the customer-contractor principle, whereas basic research would be funded through universities and research councils. At the same time, a special research organisation. known as the Chief Scientist Office was established in both England and Scotland to carry out this policy. On the other hand, the health services research pohctes of both the German and the Dutch governments date from the late seventies. Also in these countries special. though small. research units with administrative responsibilities were created within the health departments.

Developments in more recent years show a variety of government involvement. both in terms of planning and funding as well as organizing health services research. For example. both the German and the Dutch gov’ernment havje taken a stronger position in favour of planning research by government agencies and appear to bc more optimistic about the government department’s capacity to devclc,p and monitor research programmes. Also, in both Germany and The Netherlands the research is much more orientated to the health care delivery system as a whole rather than to single health care problems as has for a number of years been the case in the U.K. In the latter county this development has been strongly influenced by the Research Liaison Groups (RLG’s) us an important feature of the department’s research organisation which system has apparently led to a compartmentalisation rather than to an integration of research planning.

There are also ditferent appraoches in the way governments have formulated institutional arrangements for commissioning health services research. For example, in the U.S. the main agency for channelling grants from the Department of Health and Human Services is the National Center for Health Services Research which institute also has a task in carrying out research.

In the U.K. following the Rothschild report the responsibility for commissioning health services research was given to the Department of Health and Social Services and this was materialised through the transfer of one quarter of the Medical Research Council’s budget to the Department. Meanwhile it

has been decided that with effect from I April 1981 the transferred funds would return to the Medical Research Council, thus shifting the initiative in the commissioning of policy-related research from the Department to the Medical Research Council [g]. On the other hand, both the German and the Dutch governments are developing their own health services research programme and also commission this research directly to research institutes. though in Ger- many through the intermediary of the Ploic~l\ftrrr(lcr.~- chqfien (bureaus for project-promotion. sclcction and management).

With respect to the intrastructure for carrying out the research the following differences can be observed. In the U.S. the National Center for Health Services Research and the National Center for Health Care Technology are part of the Departments organisation. The Dutch government’s health services research capacity rests with the Netherlands Institute for Preven- tive Health Care of the semi-gov,ernmental TNO- research organisation and also with a number of smaller institutes run by voluntary agencies, as described earlier. However, the health departments in both Germany and the U.K. have no in house research institution. though in the case of the U.K. the creation of an Institute for Health Services Research was strongly recommended in 1979 by the Royal Commission into the National Health Service. It can also be observed that in Germany and The Netherlands the greater part of health services research is carried out within (semi)-governmental institutions and much less within university institutes, perhaps with the exception of research in health economics.

Finally, a common feature of the European countries is that, traditionally, medical research foundations are largely orientated to biomedical research and are paying little or no attention to health services research. This applies to the Medical Research Coun- cil in the U.K.. the Deutsche Forschungsgemeinschaft and the Max Planckgesellschaft in Germany and to the FUNGO organisation of ZWO in The Nether- lands, It should be added. however, that the Medical Research Council funds a number of special health services research units for longer periods. and that in The Netherlands the FUNGO organisation has recently developed a new policy of also funding applied research, including health services research.

From our brief survey of the development of health services research in The Netherlands it is obvious that

the gradually increasing involvement of government in health care policy has been of decisive influence. Not only has the percentage of total resources for health research, which is allocated to health services research. increased rapidly in recent years. but also the planning of health services research, especially through governmental agencies. has become predomi- nant. Government policies instituted to deal with the problems of planning, financing and distributing health services have created several layers of policy- making. to be developed by different government agencies. These agencies need information for their complex tasks in developing health policy and health

I26 GFFRT VAN ETWK and FRANS RUTTEN

services research can partly fill this need. From this it follows quite logically that the government got strongly involved in the planning of precisely this type of research by formulating a research program and by increasing the number of contract--research projects in this field.

As has been rightfully suggested by Bite [9] there is an important role for social scientists in the development of research policy. In fact, his suggestion to create groups in which social scientists, policy-makers and those who implement policy programs, is just what the new development of sector councils for science policy, described above. is all about. Because health services research is still in its early days sys- tematic review of research projects by fellow social scientists and careful handling of research results by policy makers is especially important. To institute a platform for communication between all parties involved seems to be a good guarantee for implementing a successful and balanced research policy.

Finally. it seems important to further develop health services research as a scientific approach, which has its own body of knowledge. Epidemiolo- gists. sociologists and economists all face theoretical problems, which are characteristic for the health care sector. Many scientists enter this fascinating new field nowadays: new scientific journals are being set up (for instance, the Journul o#’ HP&/~ Ec~non~ics). It is a great challenge. indeed, for all parties involved to use this potential to the best interest of the health care sector. Also in The Netherlands. signs are present showing that both scientists and policy-makers at government levels are busy in creating better conditions to enable them to take up this challenge.

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REFERENCES

Blanpain J. and Delesle L. C‘ontnnrnit~ Heulth Inw\t- nwnf. Health Swf,icc,s Rrsearch in B~Igium. Frunw. Fedrrul Gwrnan Republic trnd The Netherlantl,~. Oxford University Press. Oxford. 1976. References on this subject in the Dutch language are: van Etten G. M. De relatie onderzoek en beleid in de gezondheidsrorg in Nederland. Gezo&wid en Sumen- leriny 1, 74-82, 1980; van Etten G. M. Gezondheids- zorgonderzoek en Overheidsbeleid. In Vukenningrw irr de So&/r Genrrskunde (Edited by Sturmans F.. Per- soon .I., Morshuis J. and Windhausen R.). Dekker van de Vegt, Nijmegen, 1981. Raad van Advies voor het Wetenschapsbeleid. Err1 kovteninl,enttrri\trtie run bet ,nc,tlivch-,~~,tc,n\clzclpprli;k ondrrzoek in N&r/and, Staatsuitgeverij, ‘s-Gravcn- hage, 1919; Wrtcnschapsh~lrlg~t i 98-7. van der Gaag J.. Rutten F. F. H. and van Praag B. M. S. Determinants of hospital utilization in The Nether- lands. Hlth Serc. Rrs. 10, 264277, 1975. Rutten F. F. H. and van der Gaag J. Referrals and the demand for specialist care in The Netherlands. Hlth Serv. Res. 12. 233-250, 1977. Hooymans E. M. and van de Ven W. P. M. M. Imple- menting a health status index in a structural health care model. In Economic\ of Hrulth Care (Edited by van der Gaag J.. Neenan W. B. and Tsukuhara Th.). Praeger Grants Economics Series. New York, 1982. Aert .I. H., van Groot L. M. J.. van Montfort A. P. W. P. and Verheyen. P. A. Kostenstruktuur van algemene zlekenhuizen in Nederland. Ac,tcl Ho.@. X\‘II. 221 247. 1977. Leading article. Health services research. Br. Med. J. 282, 845 846. 1981. Bite Th. W. Social science and health services research: Contributions to public policy. Milhunk nwml Fund Q. Hlth SM. 58, 173 -200. 1980.

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Health policy and health services research in the Netherlands