The Public Health Status and Foresight report 2014: Four normative perspectives on a healthier Netherlands in 2040

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Tilburg University

The Public Health Status and Foresight report 2014

Schoemaker, Casper G.; Van Loon, Jeanne; Achterberg, Peter W.; Van Den Berg, Matthijs;

Harbers, Maartje M.; Den Hertog, Frank R.J.; Hilderink, Henk; Kommer, Geertjan; Melse,

Johan; Van Oers, Hans; Plasmans, Marjanne H.D.; Vonk, Robert A.A.; Hoeymans, Nancy

Published in:

Health Policy

DOI:

10.1016/j.healthpol.2018.10.014

Publication date:

2019

Document Version

Publisher's PDF, also known as Version of record

Link to publication in Tilburg University Research Portal

Citation for published version (APA):

Schoemaker, C. G., Van Loon, J., Achterberg, P. W., Van Den Berg, M., Harbers, M. M., Den Hertog, F. R. J.,

Hilderink, H., Kommer, G., Melse, J., Van Oers, H., Plasmans, M. H. D., Vonk, R. A. A., & Hoeymans, N. (2019).

The Public Health Status and Foresight report 2014: Four normative perspectives on a healthier Netherlands in

2040. Health Policy, 123(3), 252-259. https://doi.org/10.1016/j.healthpol.2018.10.014

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ContentslistsavailableatScienceDirect

Health

Policy

jo u rn al h om ep a ge :w w w . e l s e v i e r . c o m / l o c a t e / h e a l t h p o l

The

Public

Health

Status

and

Foresight

report

2014:

Four

normative

perspectives

on

a

healthier

Netherlands

in

2040

Casper

G. Schoemaker

a,∗

_,

_Jeanne

_van

_Loon

a,b

_,

_Peter

_W.

_Achterberg

a

_,

Matthijs

van

den

Berg

a

_,

_Maartje

_M.

_Harbers

a

_,

_Frank

_R.J.

_den

_Hertog

a

_,

_Henk

_Hilderink

a

_,

Geertjan

Kommer

a

_,

_Johan

_Melse

a

_,

_Hans

_van

_Oers

a

_,

_Marjanne

_H.D.

_Plasmans

a

_,

Robert

A.A.

Vonk

a

_,

_Nancy

_Hoeymans

a,c

a_National_Institute_for_Public_Health_and_the_Environment_(RIVM),_PO_Box_1,₃₇₂₀_BA_Bilthoven,_The_Netherlands b_Ministry_of_Education,_Culture_and_Science,_Rijnstraat_50,₂₅₁₅_XP_Den_Haag,_The_Netherlands

c_Department_of_Public_Health,_City_of_Utrecht,_Stadsplateau_1,_3521AZ_Utrecht,_The_Netherlands

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received6June2018

Receivedinrevisedform4October2018 Accepted22October2018 Keywords: Publichealth Populationhealth Foresight Publicinvolvement TheNetherlands Normativescenarios

a

b

s

t

r

a

c

t

Policy-orientedforesightreportsaimtoinformandadvisedecision-makers.Invalue-ladenareassuchas

publichealthandhealthcare,deliberativescenariomethodsareclearlyneeded.ForthesixthDutchPublic

HealthStatusandForecasts-report(PHSF-2014),anewapproachofco-creationwasdevelopedaiming

toincorporatedifferentsocietalnormsandvaluesinthedescriptionofpossiblefuturedevelopments.

ThemajorfuturetrendsintheNetherlandswereusedasastartingpointforadeliberativedialogue

withstakeholderstoidentifythemostimportantsocietalchallengesforpublichealthandhealthcare.

Foursocietalchallengeswereidentiﬁed:1)Tokeeppeoplehealthyaslongaspossibleandcureillness

promptly,2)Tosupportvulnerablepeopleandenablesocialparticipation,3)Topromoteindividual

autonomyandfreedomofchoice,and4)Tokeephealthcareaffordable.Workingwithstakeholders,we

expandedthesesocietalchallengesintofourcorrespondingnormativescenarios.Inasurveythe

norma-tivescenarioswerefoundtoberecognizableandsufﬁcientlydistinctive.Weorganizedmeetingswith

expertstoexplorehowengagementandpolicystrategiesineachscenariowouldaffecttheotherthree

societalchallenges.Possiblesynergiesandtrade-offsbetweenthefourscenarioswereidentiﬁed.Public

healthforesightbasedonabusiness-as-usualscenarioandnormativescenariosisclearlypracticable.The

processandtheoutcomessupportandelucidateawiderangeofstrategicdiscussionsinpublichealth.

license(http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction

Itiswellestablishedthatpoliticaldecision-makingprocesses inpublichealthandhealthcareinvolvetrade-offsbetween com-petinginterestsandvalues[1–3].Duetothefactthatthereisno consensusaboutasinglemostimportantgoal,policydecisionsin publichealthandhealthcarecanbecontestedinnumerousways [4,5].Eventhecommonlyrecognizedmajorpublichealthgoalsof improvinghealthandreducinghealthinequalitiescanbeintension withoneotheranddecidingwhichtoprioritiseisanormative deci-sion[6,7].Alldecisionswillhaveimplicationsforsectoralbudgets andprioritiesandwillimplycertainopportunitycosts[8]. More-over,healthpolicyissuesarelikelytoinvolvesocialconsiderations

∗ Correspondingauthor.

E-mailaddress:casper.schoemaker@rivm.nl(C.G.Schoemaker).

beyondhealthoutcomesalone-suchasquestionsofequity, jus-tice,ormorality[9,10].Forinstance,adecisiontoincreasetaxeson tobaccoinvolvesanormativedecisionaboutwhetherpolicymakers shouldinterveneinthismatter[11,12].Ontheonehand, incom-patiblegoalsmayleadtodilemmasin policymakingthatseem resistanttosolution.Ontheotherhand,apolicydecisionaimedat onegoalmayhavepositiveeffectsonothergoalsaswell:awin-win strategy[13].

Policy-orientedhealthforesightreportsaimtoinform decision-makingprocesses[14,15].Intheirscopingreviewontheuseofthe scenario-methodinthecontextofhealthandhealthcare,Vollmar etal.concludedthatthescenariomethodiswellsuitedforthis purpose[16].Awidespectrumofstrategicaimsiscoveredby het-erogeneousvariantsofthescenariomethod[17–19].Despitetheir largepotentialthusfar,scenariomethodsarerarelyusedinpublic health[20].

https://doi.org/10.1016/j.healthpol.2018.10.014

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Ingeneral,threeclassesoffuturescenarioscanbedistinguished [19,21],answeringthequestions:whatwillhappen(descriptive scenarios,trendextrapolations,business-as-usualscenarios);what couldhappen(foresighting,strategicscenarios)andwhatshould happen(normativescenarios,desirable futures,critical futures). From the emerging literature on scenario methods, it is well establishedthatforvalue-ladenareassuchaspublichealthand healthcare,descriptivescenariosmaynotsufﬁceanddeliberative scenariomethodsareneeded[15,22,23].Inthesemethods, fore-sightisconsideredless asproblemsolvingthanasa processof argumentordebate[24].ThisviewsitswellwiththeworkofWeiss [25],whoholdsthataprincipaluseofresearchforpolicymakingis conceptual:asourceofenlightenmentandawayofthinkingabout anissue[26].

2. TheDutchPublicHealthStatusandForecastsreport (PHSF)

TheDutchNationalInstituteforPublicHealthandthe Environ-ment(RIVM)haspublishedaPublicHealthStatusandForecasts report(PHSF) everyfouryears since 1993.ThePHSF integrates researchdataonpublichealthandidentiﬁesfuturetrendsinpublic healthintheNetherlands.Thereporthasgrowninto‘an authori-tativeandstructurallyusedsourceofinformationforgovernment agenciesandthepublichealthsector’[27].In2002,theDutch Pub-licHealth Actgave thereportanofﬁcialstatusinpublichealth policymaking[28]:everyfouryears,thePHSFprovidesthe pol-icythemesforthepublicationofa‘NationalHealthMemorandum’ bytheMinistryofHealth[29].

The format and focus of the PHSF have changed, reﬂecting developmentsinpublichealthandpolicymaking[28].The percent-ageofpeoplelivingwithchronicillnesseshasrisen.Inresponse to rising health care expenditures, a number of health system reformshavebeenimplementedintheNetherlands.Asaresult, manypublichealthfunctionsandresponsibilitiesweretransferred fromnationaltolocalauthorities.Consequently,localCommunity HealthServicesstartedtotranslatethenationalPHSFsintotheir ownlocalPHSFs.DeGoedeetal.studiedtheusefulnessofthese localreportsforthedevelopmentoflocalpublichealthpolicy[30]. TheyconcludedthatlocalPHSFsdidnotfullyconnecttothe exist-ingbeliefsystemsofpolicymakers:“Wenoticedaconstanttension betweenamedical,epidemiologicalapproach(publichealthframe) guidedbythenationalPHSFreport,andamoresocietalframe.”[30]. LocalPHSFsfocusedonprioritiessuchasalcohol,overweightand depression,andneglectedwelfareissuessuchassocialcohesionin neighborhoods,informalcareandsocialparticipationofdisabled people.

DeGoedeetal.pointedatamoregeneralproblemin evidence-informedpublichealthpolicymaking:thepersistentdisconnection betweenacademicepidemiologicalresearchandthesocietal real-ityofnationalandlocalpolicymakers[2,31–35].Onthebasisof acomprehensivereview,Oliveretal.recommendedpublichealth researcherstoinvolvestakeholderswithdiverseperspectivesand livedexperiencesintheirresearch[36].Society’s“diverse perspec-tives arecrucial forinclusive framing of ‘wicked’ publichealth issuesthatseemincomprehensibleandresistanttosolution”[5]. These newdirections in evidence-informed policy researchare clearlyinlinewiththeaforementionedliteratureonforesightand scenariomethods[15,22].

In this article, we describe the sixth PHSF ‘A Healthier Netherlands’[37], forwhich wedeveloped a novelapproach of co-creation tobring epidemiological researchand societal per-spectivestogether.Themajorfuturetrendsinpopulationhealth and itsdeterminants wereusedas astarting point for a delib-erativedialoguewithstakeholderstoidentifyandformulatethe

mostimportantsocietalchallengesfortheDutchhealthsystem. Workingwiththesestakeholders,weexpandedthesesocietal chal-lengesintofourperspectives.Theseperspectivesare“frames”that highlightcertainaspectsofaproblematicsituation,while obscur-ingothersinordertodeﬁneissues,diagnosecauses,makemoral judgments and suggest remedies [38,39]. To identify potential interrelationshipsbetweentheperspectives,weorganised meet-ings with experts to explore how engagement based on each particular perspective would affect all societalchallenges. This approachwasdesignedtoclarifyareasinwhichpositivespin-offs couldoccurandwin-winstrategiescouldbecreated (opportuni-ties).It wouldalsoidentifyareasinwhich negativeside-effects couldariseandwherepoliticalandotherchoiceswouldbe nec-essary(optionsordilemmas).

3. Materialsandmethods

Generally,TheNetherlandsisconsideredapioneerandoneof themostactivecountriesintheﬁeldofforesight,ingeneral,and policy-oriented foresight,inparticular[15]. InTheNetherlands, policy-orientedforesightishighlyinstitutionalised[14,16,40].In 2010,theDutchScientiﬁcCouncilforGovernmentPolicy(WRR) exploredthepracticesoffuturesstudiesconnectedtopolicymaking intheDutchnationalgovernment.Theyofferedacomprehensive conceptualframeworkthatfacilitatesandstructuresthinkingand communicatingaboutthefuture[15].

AccordingtotheWRR,thefutureisnotdetermined,norisit anemptyspaceinwhichwecanmoveunhindered.Thechallenge forfuturesstudiesistoappropriatelyaddressbothitsopenandits non-emptycharacter.Inpolicyﬁeldsforwhichitisnotsensibleto assumecontinuityorstability,ornormativeconsensus,normative futuresstudiescanprovideaddedvaluebyexplicitlytakingsocial andnormativeuncertaintiesintoaccount.Imagesofthefutureare presentedintermsofdesirability/undesirability,relatedtovalues orpoliticalstandpoints[15].Thismethodemphasisesthatimages ofpossiblefuturesarenotneutralbutrepresentparticulardesires, values,culturalassumptionsandworldviews[41].

InspiredbytheWRR-report[15],wechoseanormativescenario approachforthesixthPHSF.Thereportconsistsofthree compo-nents:(a)atrendscenarioforpopulationhealthintheNetherlands upto2030;(b)futurescenariosbasedonfournormative perspec-tives;and(c)opportunitiesandoptionsforhealthpolicymaking. 3.1. AtrendscenarioforhealthintheNetherlandsuntil2030

A trendscenarioassumesa continuationof historical trends withnoneworadditionalpoliciesbeingimplemented (‘business-as-usual’)[15].ThistrendscenarioofthePHSF-2014wasbasedon analysisofhistoricaltrendsandonacombinationofdemographic and epidemiologicalprojections.If therewerenoadequate his-toricaltrenddataavailable,ademographicprojectionwasmade, supplementedbyﬁndingsfromliteraturestudiesandassessments byexperts.Thefuturetrendsextendedto2030,wheneverpossible thetimehorizonwasexpandedto2040[42].

3.2. Futurescenariosbasedonfournormativeperspectives

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sustainableuseofnaturalre-sources,andtheutilityofnature.A comparisonoftheproblemsandthemotivesprovidedfour chal-lengesfornaturepolicy.Thesewereinturnusedtodeﬁnefour normative scenarios, describing alternative desirable futures of nature.Bydoing this,thescenarioteaminspiredthediscussion aboutthedirectionofnaturepolicy[40].

Todevelop normativescenarios for Dutchpopulationhealth and healthcare,we organised a similarparticipatoryprocess in whichmorethan 100stakeholderswereinvolvedfroma broad rangeofsectors(healthprofessional,patientorganisations,unions, students,insurance companies,nationaland localhealth policy makers).Themajortrendsin populationhealthand healthcare servedasastartingpointforadeliberativedialoguewith stakehold-erstoidentifyandformulatethemostimportantsocietalchallenges forpublichealth.Thesechallengeswereexpendedintonormative perspectivesonpublichealth.Eachperspectivecentersononeof thesocietalchallenges, withtheother challengessubordinated. Foreachperspective,anideal-typicalvisionofthefuturewas con-structed,includingastrategytogetthere(anormativescenario). Thesescenariosarearchetypicaldescriptionsofalternativeimages ofthefuture,createdfromdifferentperspectivesonpast,present andfuturedevelopmentsinDutchhealth[18].Theyhelpto imag-inearangeofpossiblefuturesifwefollowakeysetofassumptions andnormativeconsiderations[20,44].Theyarehypotheticalinthe sensethatnoneofthemwillbecomerealityinisolationfromthe otherchallenges.

Threestakeholdermeetingswere organised.During thefirst meetinginDecember2012wepresentedtheprovisionaltrend sce-nario.Weenquiredthestakeholder’sexpectations,motivesand ideasonthefutureofpublichealthandhealthcare.Whatwould betheirrolesandresponsibilities?Whatwerethemajorvisionsof thefutureofpublichealth?Afterthefirstmeeting,theresearch groupframedthevisionsand societalchallengesinto four per-spectivesonpublichealth.Foreachoftheperspectives,afuture scenariowasdescribedinwhichtheenvisagedoutcomecouldbe achieved,withpossiblesocietaldevelopmentstakeninto consid-eration.DuringthesecondmeetinginApril2013wediscussedthe draftperspectivesandscenarioswiththestakeholders.Theywere askedwhethertheyrecognisedthem andtoaddcontenttothe descriptionofthescenarios.InafinalsessioninJune2013we dis-cussedpossiblesynergies(opportunities),dilemmasandtrade-offs (options)betweenthefourperspectives.Duringthewhole partici-patoryprocessalldocumentsandworkshopreportswerepublicly availablethroughawebsite.

In November and December 2013, anindependent research agency(TNSNIPO)carriedoutasurveyinarepresentativesample oftheDutchadultpopulationtotestwhetherthefourperspectives andtheiraccompanyingfuture scenarioswererecognisableand sufﬁcientlydistinctive[45].Atotalof1176membersofanonline panelwereinvitedtoparticipate,876(75%)ﬁlledinanonline ques-tionnaire.Theirresponseswerereweightedfor sex,age,region, educationandsocialclasstorepresenttheDutchadultpopulation [45].

3.3. Opportunitiesandoptionsforhealthpolicymaking

Toidentifypotentialinterrelationshipsbetweenthe perspec-tives,weorganisedfourmeetingswithexperts:Lifeexpectancy andburdenofdisease(Feb262014),Participationandexclusion (March72014),Autonomyofciviliansandpatients(February20 2014)andHealthbudgetandeconomy(March62014).Beforehand theexpertsreceivedinformationonthetrendscenario,thetrends inthreeindicators(seeTable3),andonthefourperspectives.

TheexpertsessionswereheldinaGroupDecisionRoom(GDR), an‘electronicmeetingroom’thatenablesfastandefﬁcient stake-holderdialoguewithreal-timeexchangeofopinions,feedbackof

results,brainstorminganddiscussions[46,47].Severalstudieshave demonstratedtheusefulnessofGDRs[48].

Theparticipantswereaskedtoratetheeffectsofthe perspec-tivesandtheirstrategiesonthetrendsinthreeindicatorsupto 2040,comparedtothetrend scenario.Weuseda 5point scale rangingfrom−2(substantiallydeterioratedcomparedtothetrend scenario)to+2(substantiallyimprovedcomparedtothetrend sce-nario).Theexpertsweretheneachgiventheopportunitytoexplain theirratingsanonymously.Theseratingsandexplanationswere displayedonthescreen,anddiscussed.Afterthediscussion par-ticipantswereaskedtoentertheirﬁnalscores.Eventually,each expertsessionresultedin12meanscores,rangingfrom−2to+2 (seetherowsinTable4).Thesescoresshowhowengagementbased oneachparticularperspectivewouldaffecttheotherthreesocietal challengesandmakeitpossibletoidentifysynergies (opportuni-ties)anddilemma’sandtrade-offs(options).Thedurationofthe workshop,includingabreak,wasaboutthreehours.

4. Results

4.1. Atrendscenarioforpopulationhealthandhealthcareinthe Netherlandsupto2030

Thetrend scenario ofthe PHSF-2014was basedonanalysis of historical trends and on a combination of demographic and epidemiologicalprojections(assuming‘business-as-usual’). Popu-lationageingwasakeyfactorinthetrendscenario.Asaresultof theincreasednumberofelderlypeople,thepercentageofpeople livingwithchronicillnesses,includingdementia,willkeeprising. Thenumberofpeoplewithmulti-morbiditywillriseaswell.These trendsareinlinewithrecentforecastsinseveralotherEuropean countries[49,50].By2030,Dutchlifeexpectancywouldincreaseby afurther2–3yearsandthepercentageofpeoplelivingwithchronic illnesseswillriseto40%.Thedifferenceinlifeexpectancybetween peoplewithlowandhighlevelsofeducationwouldremain6years, orgrowslightly.Somenegativetrendsinlifestylefactors–smoking andoverweight–havebeenmitigated,butitremainstobeseen whetherthatwillbesustained.Themostuncertainofalltrendswas thefutureevolutionandimpactsofhealthcareexpenditures.Itwas notyetknownwhatthelonger-termeffectswouldbeofmanyof theplannedorrecentlyimplementedpolicymeasures[42].

4.2. Futurescenariosbasedonfournormativeperspectivesin publichealth

Theaforementionedmajortrendsinpublichealthservedasa startingpointforadeliberativedialoguewithstakeholders.Four societalchallenges forpublichealth wereidentiﬁed and formu-lated:

1To keep people healthy as long as possible and cure illness promptly

2Tosupportvulnerablepeopleandenablesocialparticipation 3Topromoteindividualautonomyandfreedomofchoice 4Tokeephealthcareaffordable.

Workingwithstakeholders,weframedthesesocietalchallenges intofourperspectivesonpublichealth.Theseareentitled‘Inthe BestofHealth’,‘EveryoneParticipates’,‘TakingPersonalControl’ and‘HealthyProsperity’(seeTable1).Eachperspectivecenterson oneofthefoursocietalchallenges;theothersaresubordinate.For eachoftheperspectives,wehavedrawnupanideal-typicalvision ofthefuturein2040(seeTable2).

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Table1

Fournormativeperspectivesonpublichealth:societalchallenges,concernsandmotivations.*

Perspective IntheBestofHealth EveryoneParticipates TakingPersonalControl HealthyProsperity

Societalchallenge Tokeeppeoplehealthyas

longaspossibleandcure illnesspromptly.

Tosupportvulnerable

peopleandenablesocial

participation.

Topromoteindividual

autonomyandfreedomof

choice.

Tokeephealthcare affordable.

Concernsandmotivations -Long,healthylives

-Healthylifestyles

-Protectionfromhealth

hazards

-Effectivepreventionand care

-Protectionandsupport

forvulnerablepeople

-Nopersonexcluded

-Socialparticipationby

peoplewithhealth

problems

-Preventionandcare targetedatvulnerable groups

-Weknowbestwhatis

goodforus

-Thequalityofourown livesistheprimeconcern.

-Governmentenables

individualinitiatives. -Healthcareproviders listentous.

-Prosperityforboth

currentandfuture

generations

-Governmentretains

wherewithalforeducation

andotherpublicservices.

-Insurancepremiumsstay

affordableforindividuals

andemployers.

-Cost-effectivecarefor thosewhoreallyneedit

*_More_information_about_the_PHSF_can_be_found_at:_{https://rivm.archiefweb.eu/?subsite=eengezondernederland#archive}_(see_English_version).

Table2

Fournormativeperspectivesonpublichealth:ideal-typicalvisionsofthefuture.

Ideal-typicalvision ofthefuture

In2040theDutchareinthe bestofhealth.Welivelonger andenjoythebesthealthin

Europe.Becausewelive

healthylives,therewillbe fewerchronicallyillpeople.

Thegovernmentprotectsus

againstallrisks,relatedtothe

environment,nutritionand

care.Butifwefallillwegetthe besthealthcaretoquicklyget

healthyagain.Treatmentsare

continuouslyimprovingthanks

tothelatesttechnology.We don’tsmoke,eatvarieddiets andhavesufﬁcientexercise,all tostayhealthy.This

perspectiveaimsatprevention

andcarethatfocusesoncure. Curingdiseasesandthe

preventionofprematuredeath,

That’swhatit’sallaboutinIn thebestofhealth!

In2040nooneisexcluded:

everybodyparticipates.We

helpeachother:weensure

thatthevulnerablecan contributetosocietyas

well,andtechnologies

enableustodoso.Inthis perspectiveitisallabout participating,byeither working,learningorcaring. Notonlyarehealthand

medicalcareimportant,

butwell-beingandworkas

well.Rehabilitationand mentalhealthcareplayan importantroleinthis perspective.Thankstoour

careanyonecan

participate,includingthe weak.That’swhatit’sall aboutinEveryone participates!

In2040wedecidefor ourselveswhatisgoodforus!

Wetakecontroltoensureour

ownqualityoflife.Oursocial

networksareoursupport.Only

ifweourselvesask,willweget

helpandwedetermine

ourselvesfromwhomweget

help.Wetakemattersintoour ownhands.Inthisperspective itisallaboutqualityoflife,and

whatthatmeans,wewill

deﬁneourselves.We

determinewhatistobe

includedincare:alternative medicine,lifecoaches,the choicewillbeours.Peoplecan

decideforthemselveswhat

theydoordon’tdoandchoose whentobecontentorsatisﬁed.

Wetakepersonalcontrol!

In2040healthcarespendingwill beundercontrolandwewill

ensureourprosperity.Wewilltake

actionagainstwasteandfraud.We

willbelookingtoensuresensible andefﬁcientcare.Technologywill

reduceourcosts.Weneedtomake

sureourcarestaysaffordable.

Therearesomanyotherthingswe

wanttospendourmoneyon:

education,pensionsortaxcuts. Prosperitywillincreaseandthe

Netherlandswillalsoremain

ﬁnanciallyhealthy.Inthis perspective,youarehealthyifyou don’tgeneratecoststhatmustbe

reimbursedbyyourhealth

insurance.Ensuringwepayonly

forthosewhoreallyneedit.No more,noless.Prudentand

economical,withthegovernment

andhealthinsurancecompaniesas

referees.That’showwecan

achievehealthyprosperity!

don’tsmoke,eatvarieddietsandhavesufﬁcientexercise,alltostay healthy.Inthe‘EveryoneParticipates’perspectivenoonewillbe excluded:everybodyparticipates.Peoplehelpeachother,toensure thatthe vulnerablecancontributetosociety aswell.The third perspective,‘TakingPersonalControl’,peoplewilldecidefor them-selveswhatisgoodforthem!Peoplewilltakecontroltoensure theirownqualityoflife.Inthefourthperspective,‘Healthy Pros-perity’,in2040healthcarespendingwillbeundercontroltoensure prosperity.Actionswillbetakenagainstwasteandfraud.

AscanbeseeninTable3,notionssuchas‘health’,‘prevention’, ‘healthcare’and‘qualityofcare’havedifferentmeaningsineach perspective.Accordingtothe‘IntheBestofHealth’perspective, ‘health’isunderstoodmainlyastheabsenceofdisease.By con-trast,in ‘EveryoneParticipates’clinicaldiagnosesareirrelevant, sincesocialparticipationisthevitalconcern.Thethirdperspective, ‘TakingPersonalControl’,containsnouniversallyvalidconception ofhealth.Individualpeopledeterminethatforthemselves.Inthe

fourthperspective,‘HealthyProsperity’,‘health’standsmainlyfor aslittlehealthcarespendingaspossible.

Furthermore,theinterpretationsgiventothenotionof ‘qual-ityofcare’aredifferentineachperspective(seeTable3).Under ‘In theBest of Health’,health care qualitymeansthat illnesses arecuredandprematuredeathisavoided.Under‘Everyone Par-ticipates’theemphasisis ontheeffectsofhealth careonsocial participation.In‘TakingPersonalControl’,eachindividual deter-mineswhatgood-qualitycareis,andin‘HealthyProsperity’good care is primarily cost-effective care for those who really need it.

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Table3

Fournormativeperspectivesonpublichealth:deﬁnitionsofhealth,prevention,careandqualityofcareandcrucialoutcomes.

Deﬁnitionofhealth You’rehealthyifyoudo

nothaveadisease;a healthylifestyleisa healthydiet,sufﬁcient

exerciseandnotsmoking.

You’rewellifyou participate.

Healthprimarilymeans

qualityoflife;individuals

determineforthemselves

whatthatinvolves.

You’rehealthyifyou generatenocostsfor curativeorlong-termcare.

Deﬁnitionofprevention

andcare

Careconsistsofprevention andcurativetreatment.

Careextendsbeyond

medicalcareandincludes

servicesforwelfare, occupationalhealth,

mentalhealthand

rehabilitation.

Preventionandcareare

broadnotionsthatmay

includealternative medicineandlifecoaching.

Collectivelyfundedcareis

narrowedtoessential

services.

Deﬁnitionofhealthcare quality

Qualitycaremeanscuring

theillandpreventing

prematuredeath.

Qualitycareenablessocial participation,witha particularfocusonthe vulnerable.

Qualitycareensures

well-being,asdetermined

byeachindividual.

Qualitycareisrelevantand cost-effective,as

determinedbythehealth

ministryandinsurance

companies.

Crucialoutcomes Meanoverallpopulation

measuresoflife expectancy,recoveryrates andlifestyles.

Differencesbetween

populationgroupsin

employment,education

andsocietalinclusion.

Individualself-reported qualityofhealth.

Overallbudgetimpact.

Threeindicatorsforexpert sessions

-Lifeexpectancyatbirth

-Percentagepeoplewith

chronicillnessin population

-Burdenofdisease(in DALYs)

-Employmentofpeople

withchronicdisease

-Socialparticipationwith physicaldisabilities -Socio-economic differencesinperceived qualityofhealth -Self-control -Self-reportedqualityof health

-Shareddecisionmaking

-Percapitahealthcare costs

-Householdconsumption

-Laborproductivityper hour

4.3. Opportunitiesandoptionsforpublichealthpolicymaking Toidentifypotentialinterrelationshipsbetweenthefourpublic healthperspectives,weorganisedfourexpertmeetingstoexplore howengagementbased oneach particularperspective (seethe columnsinTable4)wouldaffectindicatorsofthesocietal chal-lenges(seetherows).ThegreendiagonalinTable4isself-evident: allperspectivesareexpectedtofosterimprovementsontheirown indicators.

Table4indicatesthataccordingtotheexpertspromotinghealth andlongevityfromtheBestofHealthperspective,resultsinfewer activitylimitationsforpeoplewithlong-termillnesses.Thatcould improvetheirparticipation–oneoftheconcernsintheEveryone Participatesperspective.Conversely,whenfromtheEveryone Par-ticipatesperspective moreeffortgoesintoboosting educational andlaborparticipationinvulnerablesocialgroups,theoverall bur-denofdiseasecouldlighten–oneconcernintheBestofHealth perspective.Induecourse,improvementsinhealth,educationand laborproductivitywilljointlyfostergreaterafﬂuence,animportant outcomeintheHealthyProsperityperspective.However,putting moreeffortintoimprovinghealthandparticipationmayleadto higherhealthcareexpenditure.Thatcouldbeatoddswithanother importantgoalintheHealthyProsperityperspective–controlling healthcareexpenditures.Moreparticipationandmorehealthcare expenditurescouldhaveconﬂictingeffectsonsocietalprosperity.

Ifmoreroomiscreatedfordiversityandfreedomofchoice– concernsundertheTakingPersonalControlperspective– there willbesomevulnerablegroupsthatareinsufﬁcientlyequippedto copewithit[51].Thatmakesthemunabletofullyparticipatein society,aconcernintheEveryoneParticipatesperspective.Ifeffort ismadetoenhanceparticipationinvulnerablesocialgroupsonthe basisoftheEveryoneParticipatesperspective,theirparticipation willimprove.Inturnthatcouldenhancewell-being,autonomyand shareddecision-making–concernsintheTakingPersonalControl perspective.Providingsupportandassistancetovulnerablegroups couldlightenthediseaseburdenfortheentirepopulation,which isoneconcernintheBestofHealthperspective.

Manypolicypapersadvocateastrongerroleforindividual cit-izensandpatients.EffortsfromtheBestofHealthperspectiveto improvehealthandlongevitycouldincreasepressureonpeopleto practicehealthyliving,therebypotentiallyplacinglimitsontheir autonomyandonsharedhealthdecision-making–concernsinthe TakingPersonalControlperspective.Similarconsequencescould ariseiffreedomofchoiceinhealthcareweretobeconstrainedon thebasisoftheHealthyProsperityperspective,inanattemptto curbrisingexpenditures.Autonomyandfreedomofchoicecould beinjeopardyifpriorityisgiventootherconcerns.

5. Discussion

Policy-orientedpublichealthforesightreports aimtoinform decision-making processes. It is well established that political decision-making processes in public health involve trade-offs betweencompetinginterestsandvalues[2].Forvalue-ladenareas likepublichealth,descriptivescenarios(projections)maynot suf-ﬁceanddeliberativenormativescenariomethodsareneeded[22]. Inthesemethods,foresightisconsideredlessasproblemsolving thanasaprocessofargumentordebate[24].

Since1993,theDutchPublicHealthStatusandForecastsReports (PHSF)havedevelopedintothesourceparexcellenceforintegrated knowledgeaboutpublichealthintheNetherlands [27]. Forthe sixthPHSF:AHealthierNetherlands[37],themajorfuturetrends inpublichealth wereusedasa startingpointfor adeliberative dialogue withstakeholders to identifyand formulate themost importantsocietalchallengesforpublichealth.Workingwiththese stakeholders,weframedthesesocietalchallengesintofour norma-tivescenarios.Thesescenarioshelptoimaginearangeofpossible futures.InthePHSF-report,wedeliberately didnotformulatea preferenceforanyoneperspective[37,52].

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iden-Table4

Theoutcomesoffourexpertmeetingstoexplorehowengagementbasedoneachparticularperspective(seethecolumns)wouldaffectindicatorsofthesocietalchallenges (therows).

tiﬁedandformulated:tokeeppeoplehealthyaslongaspossible andcureillnesspromptly,tosupportvulnerablepeopleandenable socialparticipation,topromoteindividualautonomyandfreedom ofchoiceandtokeephealthcareaffordable.Thesechallengesand theircorrespondingperspectivesareclearlyrecognisable[1,45].

Theperspectivescanberecognisedinrecentacademicarticles onpublichealth[51,53].Forexample,threeofthem–‘IntheBest ofHealth’,‘TakingPersonalControl’and‘HealthyProsperity’–have beencapturedinthewell-knownTripleAimframeworkforquality improvementinhealthcare.Inarecentreview,Meryetal.proposed toincludeequityonapopulationlevel(agoalin‘Everyone Partic-ipates’)asanadditionalfourthaim[53].Furthermore,inatoolto includevaluesinevidence-basedpolicymakingforbreastcancer screening,allfourchallengeswereidentiﬁedasrelevantprinciples [1].

Theperspectivescanbeofhelpinstrategicdiscussionsthattake placewithinand betweenvariousgroups ofstakeholders.They clarifyissueswherechoicesoradditionaleffortsneedtobemade,as whenpreventionmeasuresclashwithindividualfreedomofchoice andautonomy.Itmayhelptosolvewickedpublichealthissuesthat seemincomprehensibleandresistanttosolution,andtoco-create solutionsthatwillhavetractionandlegitimacy[5].

The ﬁrst PHSFs were published during a period of gradual changesinpublichealthpolicyintheNetherlands;theprimary emphasiswasoncontinuity.Thecentralprinciplesofpolicywere

tokeeppeoplehealthyaslongaspossible,tocuretheillasrapidly as possible,tosupportpeoplewith disabilitiesand topromote socialparticipation.Inhindsight,‘IntheBestofHealth’andtoa lesserextent‘EveryoneParticipates’weretheleadingperspectives intheearlierPHSFs.Thismayexplainthetensionbetweena med-ical,epidemiologicalapproach(publichealthframe)andamore societalframeofthepolicymakersinlocalhealthpolicymaking, aswasdescribedbyDeGoedeetal.[30].Sincethattime,changes inthefieldofpublichealthandhealthcarehavegainedquitesome momentum.Vocalcitizensnowmaketheirdemandsknownin pub-licdebate,indoctors’surgeriesandviasocialmedia.Commercial firmshavediscoveredhealthasagrowthmarketandaneconomic recessionhasdiminishedthebeliefinunlimitedgrowth[37].Asa result,policymakersinnationalandlocalpublichealthdefinitely needinsightsfromtheotherperspectivesaswell.

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In the Best of Health had been the leading perspective for thedevelopmentof clinicaltreatmentguidelines aswell[1,55]. However,inrecentguidelinesrecommendationstakeintoaccount resourceuse(HealthyProsperity),equityandﬁnancial accessibil-ity(Everyone Participates)and shareddecision making(Taking Personal Control). Interestingly, social outcomes in terms of employmentorsocialparticipation(EveryoneParticipates)are sel-domaddressedinclinicalguidelines[55].

Ourultimategoalwastohaveouranalysesbeingputtousein awiderangeofstrategicdiscussionsanddeterminations.Insome areasthisishappening.TheMinistryofHealth,WelfareandSports, forinstance,hasemployedthetrendscenarioinformulating long-termobjectivesforitsNationalPreventionProgramme(NPP)[56]. TheNetherlandsOrganisation forHealthResearchand Develop-ment(ZonMw),thefundingorganisationforhealthandhealthcare research,hasgiventhefourchallengesacentralplaceinitsFifth DiseasePreventionandHealthPromotionProgramme[57].

Tofamiliarisenationalandlocalhealthpolicymakerswiththe PHSF-2014,wedevelopeda seriousgame thatcanbeplayedat both national and local levels [58]. It is available in Dutchon thewebsite game.eengezondernederland.nl.Several community healthserviceshavecontactedusaboutemployingthisscenario method–whichinvolvesstakeholders,projectionsand perspec-tives–atthelocallevel[58].Interesthasalsobeenexpressedfrom thehealthcaresector,partlyinresponsetoaseriesofarticlesabout thePHSF-2014intheDutchmedicaljournal[42,52,55].Inthemost recentPHSF,publishedin2018,theperspectiveshavealsobeen used.Forexample,themostrelevanthealthtrendsinthefuture wereselectedtocover themainfacetsofthedifferent perspec-tives.Threeimportantchallengeswereselectedinsuchawaythat theywererelevantfromtwoormoreperspectives[59].

6. Conclusions

Noconsensus existsonthe mostdesirable future forpublic healthandhealthcareintheNetherlands.Theultimateanswerswill dependonthenormativepreferencesthatpeoplehaveaboutwhich societalchallengesaremostimportant.Thefourperspectivesthat wehavebeenexploringhavemadethatdiversityinvisionsmore explicit.Thiscanbeofhelpinstrategicdiscussionsthattakeplace withinandbetweenvariousgroupsofstakeholders.Wehave high-lightedanumberofdifferentopportunitiesforestablishinglinks betweenvariousstakeholdersandinterests.Oneconclusionofour explorationhasbeenthatmeasurestoaddresscertainchallenges mayalsolightenotherchallenges.Effortstoimprovehealthtendto stimulatesocialparticipation,therebyboostingsocietalprosperity. Fosteringparticipationbyvulnerablegroupsmayleadtogreater personalautonomy. Focusing explicitly on‘side-effects’suchas thesehelpstoforgelinksbetweenthevariouspublichealth chal-lenges.Andincaseswherechallengesdonotseemcompatible,such afocuson‘side-effects’canclarifyissueswherechoicesor addi-tionaleffortsneedtobemade,aswhenpreventionmeasuresclash withindividualfreedomofchoiceandautonomy.

Declarationsofinterest None.

Acknowledgements

ThePHSFwassupportedbytheMinistryofHealth,Welfareand Sport.Thefunderhadnoroleinstudydesign;inthecollection, analysisandinterpretationofdata;andinthedecisiontosubmit thearticleforpublication.

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