European Policy Analysis Volume 2, Number 1, Spring 2016 | Page 201

European Policy Analysis

(Hoeijmakers et al. 2007). In this Dutch
study, our aim was to examine Kingdon’s
streams in terms of the behavior of
actors in those streams, the presence and
activities of any policy entrepreneurs, a
number of “context” factors, and—based
on the partly participatory research
approach—discover whether there was a
difference in health policy development
between two municipalities that at the
start of the project had expressed an
interest in health policy, and two matched
ones that did not.

Making policy for health
is a statutory requirement in The
Netherlands. Under the Dutch Collective
Prevention legislation, municipalities
in The Netherlands must develop
and implement local health policies.
These were supposed to be policies for
health, inspired by the national Dutch
government’s efforts in the 1980s through
what was called “Nota 2000,” a policy
paradigm directly related to the European
WHO Health for all by the Year 2000
strategies (de Leeuw and Polman 1995).
In the first iteration of the legislation such
a broad perspective was reaffirmed, and
specified in its background documents
and evaluations of its predecessors
(Lemstra 1996; Ministerie van VWS
2000; Ministerie van VWS et al. 2001).
Explicitly and expressly, these local health
policies aim at the promotion of health
across sectors, with a strong community
involvement, and based on available
epidemiological information. However, in
the successive—amended—Public Health
Law, the broad understanding of local
health policy prescribed more precisely
the particular (public health) policy
elements. This may have traded off the
opportunity to develop broad systemic
health policy against the willingness of

local governments to engage. Since the
adoption of the legislation virtually every
stakeholder in this policy community has
been challenged in driving this process
forward or even assuming appropriate
ownership and responsibility (de Goede
et al. 2010; Harting et al. 2011; Jansen
et al. 2010). No one at the local level has
assumed ownership of broadly-definedhealth. Hoeijmakers et al. (2007), applied
the social network theory (e.g., Wasserman
and Faust 1994) and concluded the same
in studying local health policy making.
This is no surprise, as in the local
discourse few actors advocate for health;
rather, they advocate for absence of disease
(e.g., the Public Health Service), access to
and efficiency of services (healthcare and
social work providers), or patient interests
(QUANGOs such as local chapters of
Cancer Council, or the Patient and
Consumer Platform). Municipalities
report a lack of operational knowledge
and due to lack of sufficient resources, they
are professionally unable to formulate
comprehensive health policies (Jansen et
al. 2010). In desperate quests for “health”
advice they end up in the preventive care
realm and focus on healthy lifestyle issues
rather than systemic change. Besides,
since the Public Health Law does not
control and enforce whether policies are
broadly defined, no explicit incentive (or
sanctioning) mechanism is present in its
legal framework.

This notion that “health” is an
intangible, fluid and orphaned policy
issue is mirrored by the findings of
Putland, Baum, and Ziersch (2011) who
investigated lay understandings of (the
causes of) health inequity. The authors
concluded that “… the findings in this study
are evocative of a kind of collective inertia
within the public health field. The lack of

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