Context

As the Netherlands is facing many issues related to the sustainability of healthcare, the Dutch government introduced a long-term transition program, which includes the Cross-Sectoral Care Agreement (IZA) and other healthcare agreements such as the Healthy and Active Living Agreement (GALA) and Housing, Support and Care for Older People (WOZO) in an effort to tackle some of these challenges. In this policy analysis we further elaborate on the WOZO agreement.

In 2022, the Dutch government introduced the WOZO program together with 40 stakeholders in long-term care (including umbrella organizations of patients, health insurers, municipalities, home care providers and healthcare professionals). The WOZO is a policy program on housing, support and care for older people lasting five years in total (Programma Wonen, Ondersteuning en Zorg voor Ouderen). This program focuses on the long-term perspective of long-term care, consisting of a set of measures, initiatives and projects aimed at making it future-proof. The Dutch cabinet has allocated approximately 1.5 billion euro to support this plan. The first evaluation of this program was published in December 2024.

Impetus

Due to an aging population with more chronic conditions and increasing life span, the demand for healthcare is increasing. However, the number of people working in healthcare and the number of informal caregivers is not growing at the same pace. Without appropriate changes to how long-term care is organized, a shortage is anticipated in the near future. Therefore, reorganization to optimize the use of available resources while ensuring high quality of care is essential.

Main purpose of the reform

The aim of the WOZO is to reform care for older people with a strong focus on self-reliance. The norm will be to “take care of yourself if possible, at home if possible and digitally if possible”. 

Content

In more detail, the WOZO is centred on enabling older people to be as self-reliant as possible by (re)learning skills if necessary, staying fit, using assistive devices and receiving support from their environment. The program prioritizes delivering care digitally whenever possible and encouraging people to live at home unless no longer feasible.

The WOZO program is structured around five action points, each divided into multiple subthemes:

1. Growing old together vitally in a suitable environment. This point focuses on stimulating people to think about their future, promoting cohabitation of younger and older people and knowledge development on and increasing reablement.
2. Strong basic care for older people entails improving the collaboration between healthcare and the social domain and strengthening primary care.
3. Appropriate long-term care for individuals who require continuous and intensive care. This care needs to fit their needs by for example developing a personal healthcare plan with a cross-sectoral approach.
4. Housing and care for older people focuses on creating sufficient housing in an environment that fits their needs. For each municipality, it is calculated how many houses need to be built.
5. Labour market and innovation directed towards keeping healthcare workers in the sector. With the help of technological and social innovations, healthcare workers will be deployed in the most efficient way to take care of older people.

Implementation steps taken/outcomes to date 

Within WOZO, there have been initiatives for housing of older people, an awareness program for older people to assess their wishes for future housing and a study to gain insight into the decision to relocate by older people. Furthermore, incentive programmes have been set up to subsidize housing initiatives for older people. Assessing the effect of WOZO is challenging for several reasons. First, its changes align with a broader societal shift, making it difficult to isolate WOZO’s effects only. Secondly, many projects have not been fully implemented yet as they require collaboration between various stakeholders, such as healthcare providers and municipalities, which is a complex process. The involvement of the social domain could also be improved.

Additionally, the current healthcare structure does not fully support the optimal use of WOZO. The Dutch Healthcare Authority (NZa) has noted the following: To be able to finance initiatives structurally, the Long-term Care Act (Wlz) needs to be restructured: the core aims of WOZO “by yourself if possible, at home if possible and digitally if possible” need to be specified further. The old budget regime – nursing homes received a budget per client - needs to be changed. The newly introduced financial separation of housing and care is a challenge for institutions that have long-lasting commitments for their buildings. Future actions foreseen by the Ministry of Health are broadening the movement, integrating it into the Sectoral Care Agreement, collecting challenges and options for improvement and focusing on reablement and options to strengthen people living at home. 

In 2023, the Cross-sectoral Care Agreement was signed by a broad representation of stakeholders in healthcare. The Agreement outlined that healthcare should become sustainable, and that the current system must therefore change dramatically to meet future care demand. The vision of the Agreement is that health not healthcare should be the focus, guided by the principle of “personalized care at the right place”.

To initiate programs to achieve these objectives, the Ministry of Health has allocated 2.8 billion EUR for 2023–2026. The idea is to provide budget and a stepwise approach to implement overarching innovative projects that contribute to “the right care at the right place”, without involving more personnel in healthcare.

The impetus of this new funding is that new healthcare initiatives, especially when related to care under the jurisdiction of several Acts or sectors, and where the burdens and the benefits are felt differently among different stakeholders, often face financing challenges. There was thus a felt need by stakeholders for a different financing structure to bring these overarching projects to fruition, and also to facilitate additional experiments in programs targeting care innovation.

A process has also been outlined to come to meaningful initiatives that have a broad support. This starts with a regional approach. In the Netherlands, a region usually comprises several municipalities and is an already existing entity. Within a region, healthcare providers, insurers, municipalities, and patient organizations work together under the direction of the dominant health insurer and one of the municipalities.

1. The process starts with writing a region review (the challenges) and plan (the targets) by the stakeholders in the region. Based on this, transformation initiatives can be submitted by healthcare providers, patient organizations, health insurers and or municipalities.
2. Initiatives receive a quick assessment from health insurers based on whether the initiative contributes to changes in either care provided under the Healthcare Act; deployment of staff; regional/national redistribution of care; or real estate in the care sector. 
3. Once approved, a detailed plan should be written, containing SMART-formulated targets that can be reached within five years, an impact analysis, an implementation plan and commitment of all stakeholders involved and impact of sustainability.
4. This plan will be assessed by two dominant health insurers of the region(s) involved. When a plan is approved, all health insurers in the region follow this plan. Notably, an initiative does not necessarily coincides with a region, but may cover a larger or smaller scale.
5. Lastly, the Dutch Healthcare Authority (NZa) makes it administratively possible for each initiative to declare costs that cannot be financed via existing channels.

All regional reviews and plans are published at a common website (Regiobeelden en regioplannen: https://www.dejuistezorgopdejuisteplek.nl/programmas/integraal-zorgakkoord/regionale-samenwerking/regiobeelden-en-plannen). In April 2024, 102 transformation initiatives had already been positively assessed and 12 had received a green light (Goedgekeurde voorstellen en plannen: https://www.dejuistezorgopdejuisteplek.nl/programmas/integraal-zorgakkoord/transformatieplannen/goedgekeurde-voorstellen-en-plannen/?soort=transformatieplan,transformatievoorstel&weergave=lijst).

Reasons for a negative evaluation are diverse, including poor writing, not adhering to the regional plan or lacking commitment of relevant stakeholders. To assess their impact and adjust where needed in the process, results of these initiatives will be monitored, and sustainability will be assessed during the implementation process. 

Introduction

To stop growth in healthcare expenditure, sectoral agreements in the Kingdom of the Netherlands were introduced in 2012, targeting financial and care related matters in hospital care, primary care, mental care, home nursing and paramedical care. These agreements have evolved from reducing growth and cost containment towards improvements in care provision, including providing the right care in the right place. The group of stakeholders expanded from only providers, insurers and the MoH to patients, nurses and integrated care organisations. Evaluations by the National Audit Office (Algemene Rekenkamer) and the Council for Healthcare and Society (Raad voor de Volksgezondheid en Samenleving) show the agreements have been successful in reducing expenditure but less so in reforming care provision.

Based on this and persistent challenges in healthcare, including rising health expenditure as percentage of GDP, personnel shortages and climate change, a new cross-sectoral agreement, the Cross-sectoral Care Agreement (Integraal ZorgAkkoord, IZA), has been reached involving stakeholders from the care and social sectors to keep health and social care accessible, affordable and of high quality in the future.

Approach and content of IZA 

The IZA shifts the focus from disease to health, emphasizing more prevention and support for vulnerable people and an intersectoral response to care requests, for example, evaluating when a medical response or other care (for example, social) is more appropriate. It envisions reduced personnel outflow through better personnel deployment, for example, planning, better work-life balance, more career options and larger role in strategic and procedural decisions; reduced administrative burden and less workload; and increased work satisfaction and trust in professional competences, especially among government and insurers. For these efforts, technological innovation and enhanced data collection and exchange are essential – the latter also for evaluating interventions.

Moreover, the IZA states that the healthcare system should provide “appropriate care (Passende zorg)”, covering the following elements: 

• value-driven (effective, of added value to the patient)
• corresponds to the state of science 
• makes efficient use of resources
• patient-centred and participative
• addresses health instead of disease
• less labour intensive and provided in a pleasant working environment

In a departure from previous agreements, the IZA acknowledges a role for municipalities in realising health and preventing illness through their legal responsibility to support people in being independent and to promote active and healthy lifestyles.

Operationally, the IZA contains detailed agreements (around 400) on:

• appropriate care
• regional cooperation
• strengthening primary care, with more time for the patient
• cooperation with social care, GP and mental care
• healthy life and prevention
• labour market
• concluding contracts between health insurers and providers
• digitalisation and data exchange
• financial agreements

And it will align with other Ministry of Health programmes targeting healthy lifestyle (Gezond en Actief Leven Akkoord – GALA), housing, support and care for the elderly (Wonen, Ondersteuning en Zorg voor Ouderen – WOZO), labour market (Toekomstbestendige arbeidsmarkt Zorg – TAZ), the Green Deal Sustainable Healthcare and the Reform Agenda Youth Care.

Challenges

First, initially, GPs refused to sign the agreement in September 2022 based on reservations that more time for patients would not translate into more reimbursement. When health insurers explicitly agreed with their concerns, GPs ultimately signed in January 2023. Second, monitoring change will be challenge as no central data collection system working across sectors yet exists.

Third, the Dutch healthcare system is legally underpinned by provider-insurer competition, which may hamper cooperation. Different legal and financial arrangements among sectors may also constrain cooperation, possibly frustrating innovative integrated care pathways. Fourth, important stakeholders seem absent to IZA, including from the education and public health sectors. 

Finally, “appropriate care” has been on the Dutch health agenda for decades, which has led to incremental changes, for example, shifting care from the hospital to primary care. However, an explicit design of this concept needs to be developed for operationalization now that it is central to the healthcare system.