Abstract
Healthcare is a highly complex force field: on the one hand, the actors involved see it as their shared responsibility to keep it accessible to patients and citizens. On the other hand, the interests of these actors do not always align. This has become highly visible in the ‘regulated healthcare
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market’ instituted in 2006 in The Netherlands. This is a system in which both unprecedented health solidarity is codified, while at the same time the system relies on competition between parties in health care (such as insurers and health care providers). All of this under the auspices of the state, which has an interest in maintaining solidarity but also in pushing down costs and keeping healthcare delivery as efficient as possible.
However, the mixture of specific political, financial and medical interests and goals now evident in this system has a far longer pedigree. These relationships therefore call for an understanding of how they developed historically, and what role the state had in expanding access to healthcare (through legislation and financing) but also in ‘governing’ healthcare as a sector which expanded rapidly in the past century, to become one of the biggest areas of government spending at the moment. In my dissertation, I studied these relationships during the period between 1848 (when healthcare first came to be seen as a concern for the state) and 2015 (the most recent transitions in the Dutch healthcare system). I did so using Foucault’s concept of ‘governmentality’, which encompasses both concrete instruments for the governance of institutions and systems, but also the deeper political-ideological and cultural mentalities underlying how the state seeks to govern these institutions.
This analysis has resulted in a longue durée history of Dutch health care, which shows us that healthcare governance in The Netherlands can be divided into four ‘governmentalities’ succeeding each other: a ‘Liberal’, ‘hybrid’, ‘planning’, and finally ‘regulated market’ governmentality. These four governmentalities ultimately show a great and recurring paradox. While the dominant political and cultural rhetoric during this long period focused on keeping state interventions in healthcare small while stimulating ‘private initiative’, government through the back door increasingly became involved in guaranteeing that Dutch citizens could get access to affordable healthcare. The history of Dutch healthcare governance is the history of this great and recurring mismatch between the ‘rhetoric’ of a small state in healthcare, and the ‘reality’ of healthcare as something which increasingly came to be seen as a social necessity and right, and for which the state should bear responsibility.
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