Persistent problems in the Dutch health care system: learning from novel practices for a transition in health care with the UPP framework

T.J. Schuitmaker-Warnaar

Research output: PhD ThesisPhD-Thesis – Research and graduation external


The current Dutch health care system, as many Western health care systems, is considered to be unsustainable. In other words, it is questionable whether the health care provisions that exist now will be available for future generations. This concern is usually talked about in terms of maintaining and improving availability, accessibility, acceptability and quality of care. From a government perspective, this problem of sustainability is related to the wider problem of tenability of the welfare state. Over the last 60 years, the costs of health care provisions kept on growing every year without exceptions. Not only in absolute terms, but as a percentage of the gross domestic product. From a health care practitioners and care consumers perspective, this growth in costs did not lead to an equal growth in quality of care. In general, there is a problem of diminishing returns.

This dissertation explores why it appears so difficult to solve these problems in the Dutch health care system. By applying the UPP framework developed in chapter two, it is revealed how enduring problems of rising costs and problems of quality of care are reproduced. It appears that the model of disease, called biomedicine, in cooperation with the state-supported care arrangements, has led to great successes, but that its dominance, in the way it institutionalised, also has negative side effects. The systemically embedded artificial dichotomy between mind and body, further formalised by the dominant research methodology, also internalised by patients, leads to agents overlooking possibilities, interestingly enough including the change agents themselves. Consequently, the enduring problems of disputed quality of care and high communal costs are reproduced, contributing to problems of sustainability of the Dutch health care system.

The process of unravelling of the identified persistent problems through the UPP framework can provide support for a transition in health care on multiple levels. First, because the analysis stays close to the daily practice of the change agent (it deconstructs the daily practice so to say) the structural factors that are unravelled can be directly used to help the practice function on the niche level it is at now. For instance, the notion of protoprofessionalisation and its mechanism of self-objectifying can inform practices on how to better deal with this phenomenon. As the initiators of the new clinic for unexplained diseases figured, the medical discourse itself can be used to draw patients away from it. Second, the outcome of an analysis through the UPP framework can inform policy makers to change factors at the regime level. New policies can create room for practices that address the features and mechanisms of reproduction. For instance the managerial quality assurance mechanisms based on evidence-based medicine can be redesigned to leave more room for practices that support the patient as co-producer of care. Furthermore, new evaluation methodologies can be developed to support practices that have interventions that are difficult to prove effective with a standard RCT. The third level is the landscape level. In medical schools, and this transition is already taking place, the training of the medical professionals can change to become more sensitive to delivery of care, instead of evidence-based specialised cure.
Original languageEnglish
Awarding Institution
  • UVA Universiteit van Amsterdam
  • Grin, J., Supervisor, -
  • M'Charek, A., Co-supervisor, -
Award date23 Jan 2013
Publication statusPublished - 23 Jan 2013
Externally publishedYes


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