International Journal of Technology Assessment in Health Care, 20:1 (2004), 35���43. Copyright c 2004 Cambridge University Press. Printed in the U.S.A. Technology assessment, priority setting, and appropriate care in Dutch health care Marc Berg Tom van der Grinten Erasmus University, Rotterdam Niek Klazinga University of Amsterdam This article provides a critical analysis of the impact of health technology assessment (HTA) on priority setting in The Netherlands. It describes the limited steering powers of the Dutch government its complex interactions with insurers, health-care providers, and patients and the role of HTA in this context as an attempt to rationalize the debate about cost-effectiveness issues. HTA has been drawn upon for decision making on the health insurance package. Also, HTA findings have been linked to the national guideline development programs of the medical community. However, these impacts by no means have been straightforward. We argue that the political nature of the priority-setting debate asks for a broader approach to what constitutes HTA, and how it should be drawn upon in priority setting. Suggestions are made on how to do justice to the social dynamics of decision making and the behavior of stakeholders in health-care systems. Keywords: Health technology assessment, The Netherlands Over the past few decades, health technology assessment (HTA) has received much interest from the research commu- nity and policy makers. In this article, we provide a critical analysis of its impact on one of the major health policy chal- lenges: priority-setting. We will describe how HTA has been used as an input from the scientific community to rationalize the debate about cost-effectiveness issues. After describing the role of government and the development of HTA, we will discuss the use of HTA for decision making on the Dutch health insurance package and the attempts to link HTA find- ings to the national guideline development programs of the medical community. We argue that the political nature of the priority-setting debate asks for a broader approach to what constitutes HTA. Several suggestions are made on how to This paper is partly based on Berg M, van der Grinten TED. Priority Setting in Dutch Health Care. In: Ham C, Robert G, eds: Reasonable rationing: International experience of priority setting in health care. Open University Press, Buckingham-Philadelphia, 2003. complement the economic and epidemiological assumptions in HTA with the social dynamics of decision making and the behavior of stakeholders in health-care systems. POLICY ENVIRONMENT The Dutch state has a major constitutional responsibility for the accessibility, efficiency, and quality of health care. But the Dutch government is not the power center from which social processes are organized or corrected. In fact, an important feature of the Dutch health-care policy-making system is the government���s powerlessness. It does not directly control the main financial flows driving the health-care system nor are there clearly legitimated and fully equipped governing insti- tutions for implementing decisions on the arrangements for health care. The historical basis of this bounded power can be found in a strong preference for a plurality of values and the in- volvement of actors outside the government in health-care 35

Berg et al. policy making (representative bodies of physicians, service organizations, insurers, and social partners). One key concept is ���self governance���: that what can be handled in the private sphere should not be undertaken by government. Thus, the implementation of welfare state arrangements has histori- cally been kept as far as possible outside the political and governmental sphere. This combination of strong government responsibilities, limited government power and heavy reliance on private (not-for-profit) initiatives has been reflected specifically in health care, not only in the way in which care is financed (insurance-based) and delivered (by free-standing profes- sionals and private service organizations), but also in the way in which health care is administered. As a consequence of their marked mutual dependencies, the three key stakehold- ers in the system���government, providers, and insurers��� are all fully dependent on one another for achieving their own objectives. These interdependencies are at the root of the most notable feature of the Dutch health-care policy-making system: the participation of the associations of hospitals, doc- tors, and insurance companies in public policy-making and, more recently, the contribution of individual hospitals, for- profit home-care organizations, and other private institutions to the production of public goods like health care. The roles of private organizations in the public domain are embedded in the broader public-private cooperative traditions of the Dutch welfare state (31 32). Examining in more detail the way that Dutch policy on health-care choices has been conducted and decisions reached in recent years brings us to a significant paradox. The rhetoric and deployment of this policy is permeated with the need to be as rational and explicit as possible in decision making concerning medical treatment at the various levels. Evidence-based and explicit knowledge���that is what is at is- sue. But this strict approach is applied in a real-life situation that is heavily dependent on professional involvement at the lowest level of care, on the barely enforceable cooperation of institutions and care-insurers at the meso level, and on a consensus-building type of policy-making at the macro-level. In practice, priority-setting becomes a joint affair of public, private, and professional stakeholders, who have to act within the complex intermingling of responsibilities and decisional power. Although the positions in this system are changing, these strong dependencies and the associated policy practices of consensus and cooperation still characterize most of the decision-making processes in Dutch health care. Over the past few decades, patients and their organiza- tions have increasingly become a fourth stakeholder involved in health-care policy processes. They have become part and parcel of the consensus-based policy processes, especially at the macro-level of the health-care system. This finding has further increased the complexity of the interdependencies the questions of who should speak for ���the patient,��� and how far the influence of patients ought to reach, remain controversial issues. In light of this, it is striking that formal policy documents emphasize the rational underpinning of decisions. Science (in the form of ���evidence��� and ���technology assessment������ see below) is given a large role in determining the health- care choices to be made. Fields such as ���medical decision making,��� ���evidence-based medicine,��� and ���technology as- sessment��� have had, from the beginning, a great appeal to policy makers. The apparent promise of such fields, that a rational grasp of, and thereby ���control��� over, health-care de- cision making is possible, is hard to resist (3 28). However, contrary to the evidence-based culture of policy making and policy debates, the collaborative and political nature of actual decision making and implementation is hardly emphasized. This is unfortunate, we will argue, because this quest for a rational means of making decisions on health-care choices will always remain an illusion. In addition, by downplaying the actual way choices are made within the current system, policy makers cannot learn from what currently goes right or wrong. Thus, they neglect the potentialities within the com- plex of interdependencies that has evolved over time, and the implicit or tacit knowledge within this system, especially at the meso- and micro-level. Formal policy fails to draw upon the repertoire of personal skills of those concerned in health care, and their experience, imagination, and intuition. There is a preoccupation with erasing these ���subjective��� fac- tors so that it becomes possible to manage on the basis of explicit knowledge laid down in rules, procedures, protocols and manuals (35). Thus, these two worlds coexist, and their potential interrelations are not adequately drawn upon. The formal policy process fed by (scientific) evidence threatens to remain locked up in streams of government reports and policy discourses. On the other hand, the political world of on-going debates between stakeholders with different inter- ests threatens to remain unaffected by the lessons that these scientific tools could bring. DEVELOPMENT OF TECHNOLOGY ASSESSMENT IN DUTCH HEALTH CARE The active role of technology assessment in Dutch health care dates from the early 1980s. Its emergence was closely connected with the development of priority setting as a de- liberate policy. Especially important were the delineation of the basic health-care package covered by social insurance at the national level and the stimulation of appropriate use of health care at the decentralized levels. Inspired by the activities of the Office of Technology As- sessment in the United States, ���technology assessment��� was initially introduced as part of national endeavors in health- care forecasting. It stood for a broad assessment of the ���im- pacts��� of a technology, including economic, organizational, social, and ethical considerations. Yet it rapidly became syn- onymous with the performance of economic evaluations in health care, notably cost-effectiveness analyses (and this is what we mean by HTA here). In The Netherlands, these 36 INTL. J. OF TECHNOLOGY ASSESSMENT IN HEALTH CARE 20:1, 2004