Joint efforts needed for improving health levels of Dutch citizens
20th of April, 2018- an important date for the Dutch health care system and its citizens. On this date, the negotiation for the Coalition Prevention Agreement started in the Netherlands. With over seventy parties having different interests and a similar goal of making binding agreements, this was no simple task to start with. Even if the interest of the many of the different parties involved are often not aligned with each other, the expected end result may interest all and help put the differences aside. Namely, the goal of the agreement is developing a coherent measurable package including all parties working together towards making the Netherlands healthier.
What would it look like?
Even though making the Netherlands healthier sounds good in theory, what does it mean in practice? How would a healthier Netherlands look like in two decades? The most noticeable difference in 2040 is that our focus will be much more on prevention and less on care, with the biggest emphasis on a healthy lifestyle. As an example, in 2040, children and young people will be surrounded by a substantially healthier living environment: Imagine children no longer knowing the smell of tobacco smoke, a smoke-free generation, living in an environment free of tobacco! The few adults that still do smoke in the future don’t do it in a public environment like at work, at a sports club, in the street where they live, in the schoolyard where they will pick up their children. Sounds great but how will they achieve it?
Current situation and need for change
The National Prevention Agreement opted for an approach focused on three main areas: smoking, problematic alcohol use and overweight. The main reason for choosing smoking, alcohol use and overweight is because those three bad habits have the largest burden on the Netherland’s health system and citizens, costing 35,000 deaths and over 9 billion euros in health care expenditure yearly.
If we compare the final ambitions alongside the current situation in Dutch society, it appears that there is a big challenge for all parties involved. To this day, every week, hundreds of children get addicted to smoking. As a result, smoking is by far the most important preventable cause of illness and mortality. In addition to smoking, it is important to address the number of young people who are overweight and have diabetes. Finally, young people seem to start drinking at a later age than in the past (on average 13.2 years), but those who drink do so often and use large quantities of alcohol. Prevention of these negative behaviors plays a crucial role in reaching the initial ambition of making the Netherlands healthier.
Another problematic negative effect is that smoking and obesity are more common in people with disabilities. Smoking, overweight and problematic alcohol consumption thus lead to enormous health inequalities and social damage. Equally significant to address are the health differences between population groups. Namely, people with low education and low income are much worse off in our society when it comes to health. They smoke more, more often have problems with being overweight, they exercise too little and eat unhealthily. Health problems are often not isolated but are part of a broader underlying problem ( debts, poverty, unemployment, etc.). Poverty is both a cause and a consequence of poor health. Poverty increases the chances of poor health. Poor health, in turn, traps communities in poverty. As a result, those with lower education and income levels have, on average, a 7 years shorter life cycle and feel unhealthy for eighteen years of their life. Even more worrisome are the figures showing that this trend seems to increase rather than decrease. These results are staggering and demand our attention. The current Agreement for prevention addressing smoking, overweight and alcohol consumption provides a chance for a direct positive influence on the people having low income and a low level of education. Those people could live and feel healthy longer, have less burden on their health care system, they could work longer and provide their own children with a better start in their life. The potential health benefits for society as a whole are enormous.
Governance, assurance, and monitoring
The National Prevention Agreement wants to meet the current health challenges by involving governments, the business community, healthcare, welfare, education, and science together, by public-private cooperation, binding agreements and the use of innovations. For years, different parties worked in different ways trying to achieve a healthier Netherlands, this is the perfect time to join forces and build on what has already been done in order to fulfill the ambitions of the agreement made.
Some examples of different organization and individuals currently working on a healthier Netherlands are the nurse who made the Netherlands in the fifties of the healthiest country in the world- through the national vaccination program that has saved many lives, the current programs from the government such as ‘Healthy in the City’, ‘Everything is Health’, ‘Healthy School’, ‘Young People at a Healthy Weight (YPHW), cooperation agreements such as the Green Deal for Sustainable Care and social initiatives such as the Smoke Generation and the Healthy Generation: all serving as a solid basis for the development of new and joint prevention policies. The implementation of the National Prevention Agreement will build upon all of these achievements.
Since the prevention of smoking, problematic alcohol use, and overweight requires an integrated and coherent approach, local and tailor-made approaches are needed and supported by the association of Dutch municipalities (VNG). The idea is that municipalities manage and work together with social partners, based on the results from an analysis of local health issues. The local approach largely addresses the achievement of possible health gain in accordance with the aforementioned recommendations of the WRR.
Knowledge and research insights
Through existing programs and scientific research, we know more now than ever about the different underlying factors of human behavior, as well as which effective interventions bring long-term success in the area of prevention. The best example for this case is smoking. 50 years ago smoking was advertised with the use of physicians, nowadays, smoking is considered as one of the most unhealthy habits and it is hard to imagine any physician around the world recommending it to their patients
Moreover, the parties involved in the agreement want to achieve a change from ad hoc initiatives to a broad integrated and coherent approach that is evidence-based. It is of great importance to support cooperation with the science (National Science Agenda) and knowledge institutes so that policy, practice, and science are connected and a learning process between them is created.
“Better safe than sorry” approach
When complex problems like improved health are addressed, there is often a great diversity of measures and solutions. This is no different for the topic of prevention. From very simple straightforward ideas – an excersize garden for the elderly – to more complicated measures that affect the system as a whole, there are many solutions leading to the same result. A solution can be implemented indirectly, in an integral way by helping people find work, by health insurers helping with debt repayment and by a greener (and healthier) environment, or more directly, with straightforward regulations. Some other ways of increasing health in society are youth-specific programs (such as JOGG and Healthy School). The key is having one integrated approach to the problem, with close cooperation between governments, business, and social organizations, and the people involved. Growth and learning are expected, based on active cooperation with the science and knowledge institutions.
The parties taking part in the National Prevention Agreement have to follow a number of rules.
1. The RIVM (in consultation with CBS, GGD GHOR Netherlands, Pharos, Trimbos Institute and CPB) will annually report progress on the implementation of the measures identifying lifestyle indicators that relate to the three themes (smoking, overweight, drinking).
2. The RIVM will complete the progress report once every four years with a projection of the ambitions aimed at 2040.
3. The progress report of the RIVM will be discussed with the participating parties the National Prevention Agreement has signed with. The report will also be discussed with an independent chairman.
4. If necessary, agreements and measures will be made by the parties involved at these tables tightened if they contribute to the ambitions.
5. New measures can be added if they match the formulated vision and contribute to the ambitions.
6. New partners can join if they endorse the ambitions and are willing to contribute to the realization of the ambitions in this agreement.
7. Prevention is a long-term issue and requires a consistent long-term commitment of many parties in close cooperation. Therefore the goal is to stick to the long-term objectives and be flexible in the way of getting there.
There is an already strong foundation on the road towards a healthier Netherlands. The next step is to join forces and work hard together in order to meet this ambitious but realistic goal. The National Prevention Agreement is an important step towards a healthier Netherlands. Together with the parties involved, they are initiators of much-needed change. However, they do not focus only on parties that already signed the agreement. They invite everyone to participate. Since our individual efforts in improving health for our citizens have been proven to have limited effect, it is time to connect and together develop a healthier society!