Academic journal article Review of Social Economy

The Dynamics of the Dutch Health Care System-A Discourse Analysis (1)

Academic journal article Review of Social Economy

The Dynamics of the Dutch Health Care System-A Discourse Analysis (1)

Article excerpt

Kor Grit (2)

Wilfred Dolfsma (3)

Abstract In this article, we analyze recent dynamics of the Dutch health care sector, a hybrid system of public, private and professional elements, in terms of clashing discourses. Although these elements are intricately interwoven, this does not mean that the system is stable. Most notably, since the eighties the introduction of more market elements in the health care system has been widely debated. Hospitals introduced different methods commonly used in businesses, for instance. The position of managers in the institutions of health care has become more central. A discourse analysis shows the concomitant patterns of institutional change in the health care sector. We distinguish four different discourses concerning health care: economic, political, medical-professional and caring discourses. These different discourses give rise to, for example, different views of good care, the character and position of the patient, and leadership in health care organizations--views that sometimes clash intensely.

Keywords: Health care system, the Netherlands, discourse analysis, institutional change, modernization, 'economization', health care management

INTRODUCTION

The Dutch health care system is a hybrid system of public, private and professional elements. Constitutionally, the Dutch State is responsible for the accessibility, the quality and the efficiency of health care. Nevertheless, the government has just a minor role in the realization of these aspects of health care and therefore depends crucially on the cooperation of private parties such as insurance companies, private institutions of health care and professional provision as well as a number of other organizations. The parties are mutually dependent on each other. As a result, the Dutch health care sector does not have one power center that can interfere unilaterally in the organization of health care. Decisions may simply seem to "happen." The fact that different actors contribute to the provision of health care causes confusion about the responsibility for providing good care. When many parties are involved, the contribution of separate actors is difficult to determine.

The problem of the distribution of responsibilities is aggravated by the unstable configuration between the different actors. Since the eighties, for instance, different committees commissioned by the government have argued in favor of using more market elements in the health care system. Many organizations of health care, without a profit motive, became more interested in the methods of private enterprise. Institutional changes have ensued. The management of these organizations acquired a stronger position. These developments can be labeled as "economization". In this paper we analyze the recent dynamics of the Dutch health care sector in terms of clashing discourses. We distinguish patterns in the changes arising from the clashing discourses; with consequences for the distribution of responsibilities and the way health care is provided.

We need to realize that reverence for the market, business methods and management is not unique to any health care system. (4) Like other countries, Dutch society at large has experienced a process of economization in the last decades. Discourse theory helps to discover and to analyze the patterns of institutional change in modern society in general and for the health care sector in particular. Discourse theory is not generally accepted in economics, however, but has been invoked more often with the influential publication of Klamer et al. (1988), and Dudley-Evans and Henderson (1993). Rather than indicating the quantitative significance of "talk" in this part of the economy (cf. Klamer and McCloskey 1995), we analyze the effects of different discourses on economic and social structures and institutions. Any use of this approach to understand developments in health care in a way that is relevant for economics is not available as far as we are aware of. …

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