Local health systems in 21st century: who cares?-An exploratory study on health system governance in Amsterdam.
BACKGROUND
There is a growing awareness that there should be a public health perspective to health system governance. Its intrinsic population health orientation provides the ultimate ground for determining the health needs and governing collaborative care arrangements within which these needs can be met. Notwithstanding differences across countries, population health concerns are not central to European health reforms. Governments currently withdraw leaving governance roles to care providers and/or financiers. Thereby, incentives that trigger the uptake of a public health perspective are often ignored.


METHODS
In this study we addressed this issue in the city of Amsterdam. Using a qualitative study design, we explored whether there is a public health perspective to the governance practices of the municipality and the major sickness fund in Amsterdam. And if so, what the scope of this perspective is. And if not, why not.


RESULTS
Findings indicate that the municipality has a public health perspective to local health system governance, but its scope is limited. The municipality facilitates rather than governs health care provision in Amsterdam. Furthermore, the sickness fund runs major financial risks when adapting a public health perspective. It covers an insured population that partly overlaps the Amsterdam population. Returns on investments in population health are therefore uncertain, as competitors would also profit from the sickness fund's investments.


CONCLUSIONS
The local health system in Amsterdam is not consistently aligned to the health needs of the Amsterdam population. The Amsterdam case is not unique and general consequences for local health system governance are discussed.
Department of Social Medicine, Academic Medical Center/University of Amsterdam, The Netherlands. t.plochg@amc.uva.nl
T
T
Plochg
D M J
DM
Delnoij
W V G
WV
Hogervorst
P
P
van Dijk
S
S
Belleman
N S
NS
Klazinga
D002947:Cities / Q000331:legislation & jurisprudence*; D018672:Community Health Planning / Q000458:organization & administration; D018166:Health Care Reform; D006291:Health Policy / Q000331:legislation & jurisprudence; D006297:Health Services Accessibility; D006801:Humans; D007348:Insurance, Health; D018854:Managed Competition; D009313:National Health Programs / Q000331:legislation & jurisprudence; D009426:Netherlands; D011635:Public Health Administration / Q000331:legislation & jurisprudence; D036301:Qualitative Research; D019037:Urban Health Services / Q000191:economics