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Client Linked Budgets

Partner Institute: 
Institute of Health Policy & Management, Erasmus University Rotterdam
Survey no: 
Anniek Peelen, Wendy van der Kraan & Jan-Kees Helderman
Health Policy Issues: 
Pflege, Organisation/Integration des Systems, Finanzierung, Patientenbelange
Current Process Stages
Idee Pilotprojekt Strategiepapier Gesetzgebung Umsetzung Evaluation Veränderung/Richtungswechsel
Implemented in this survey? ja ja ja ja ja ja ja
Featured in half-yearly report: G-politik in Industrieländern 3


Client-linked budgets were extended to respond to consumers' demands and needs: Since April 1, 2003, the AWBZ is based on functional care categories instead of sector-specific and organisational categories. Seven types of care or functional indication are distinguished: (1) housekeeping care; (2) personal care / home care; (3) medical care; (4) activitating and revalidating care; (5) cure; (6) hotel function; and (7) other types of supporting care.

Purpose of health policy or idea


  • Dutch health care is changing from a supply-driven to a demand-driven system. Patients want consumer-friendly health care, varied provision that reflects and respond to individual demands and needs; freedom of choice, complete information, no waiting lists and good coordination between care providers.
  • Client-linked budgets are aimed to respond to this claim.
  • The level of the budget that each patient receives is to be determined by Regional Indication Offices (RIO).
  • The CLB makes it possible that demanders of care are able to purchase care by themselves. Health care demander will have the opportunity to choose between individual providers or health care organisations.
  • A compulsory national health insurance scheme (AWBZ) covers long-term and mental health care. The AWBZ is administered by regional care offices, which are mandated by sickness funds and private health insurance companies. Since they are fully retrospectively reimbursed for all medical expenses covered by the AWBZ, they bear no financial risk.
  • Since April 1, 2003, the AWBZ is based on functional care categories instead of sector-specific and organisational categories. In this so-called functional indication, seven types of care are distinguished: (1) household care; (2) personal care; (3) medical care; (4) activitating and revalidating care; (5) cure; (6) hotel function; and (7) supporting care.
  • Medical cure and long term therapy are excluded from the CLB. Long term care in a nursing home is also excluded from the CLB. Short term stay in a nursing home is included.
  • Budgetholders are monitored by the Regional Care Offices.
  • The provision chain of the AWBZ care: demand of care ® Regional Indication Office (RIO) ® Regional Care Office ® Provider of Care / Budgetholder

Groups affected

Consumers, Insurers, Providers


Characteristics of this policy

Innovationsgrad traditionell recht innovativ innovativ
Kontroversität unumstritten kaum umstritten kontrovers
Strukturelle Wirkung marginal neutral fundamental
Medienpräsenz sehr gering neutral sehr hoch
Übertragbarkeit sehr systemabhängig recht systemneutral systemneutral

Political and economic background

The present health care system in the Netherlands does not adequately meet patients' demands. This shortcoming manifests itself in problem areas such as limited choice, inadequate cohesion and poor coordination of supply and demand (in terms of both quality and quantity).

Client Linked Budgets began as an experiment in 1998. When the experiment was accomplished, CLBs were a kind of subvention arrangement. Since April 1st, 2003, the new settlement for CLBs is introduced.

There is a need for a better relation between supply and demand. Thereby the consumers, young or old, want to stay at home as long as possible.  Besides the need for better quality of care, also a need for more care is visible. A long-term problem is the growing demand as a result of the rising amount of elderly. To comply with all those needs, providers are taking an important role. The problem here is the shortage of providers.

Furthermore, consumers will be empowered. They demand more individual related care. CLBs are expected to contribute to this.

Purpose and process analysis

Current Process Stages

Idee Pilotprojekt Strategiepapier Gesetzgebung Umsetzung Evaluation Veränderung/Richtungswechsel
Implemented in this survey? ja ja ja ja ja ja ja

Origins of health policy idea

It was the Dekker committee (1987) who gave the initial impetus to doubt the supply steering in the Netherlands. The committee concluded that supply steering end in shortcomings, too much bureaucracy and that healthcare isn't anticipating at the consumers' request. Since this report, the government is working at a more demand-oriented system. This includes empowerment of the patients / consumers. (For further information see survey number 1/2003)

Modernization of the AWBZ started in 2001.

Patient linked budgets are not a novel concept. At the end of the nineties, personal linked budgets were already used in mental care. The new budget is still for mental care, but also for the other AWBZ-claims (see above "background information").

It is also possible for people to pay for care that is not covered by their insurance. This happens only on a very limited scale.

The main actors for the introduction of the modernization are the patients themselves. Patients are nowadays able to search at the Internet and use that information to empower their position. They ask for more and better care. The government anticipated by introducing the modernization with the CLB.

As of April 1st, 2003, new procedures for the CLB have been implemented.

At this moment there are about 60.000 budget keepers. Of these 60.000, 40.000 persons have a 'new' CLB. Gradually the other 20.000 will transfer to the new CLB or leave the CLB system (through death, intake in a institution and recovery).

In the light of the tackling of the waiting lists for CLBs and the national introduction of the CLB in the mental health care sector, it is to be expected that the number of budget keepers will grow.

Stakeholder positions

Stakeholders are the customers / care demanders, providers, social service office, indication organ and the government.

The consumers of care are very supportive. An individual funding set-up provides an excellent opportunity for people to choose for themselves. This is particularly true of people who are dependent on health care in the long term. It means that they can regain control over their lives.

Consumers report problems with accounting for their costs and expenditures. The administrative account forms which they have to fill in turn out to be too complex and result in a bureaucratic process. Result: consumers don't fill in the forms or fill them in half or incorrect.

Because of the problems mentioned before, it looks like the CLB will only be used by a small group of patients.

The Public Health and Health Care Council claims that CLBs can also be implemented in the cure (diabetics e.g.).

Providers will be obligated to compete more with each other. They have to negotiate with patients instead of the insurers. Because of this, providers are more defensive about the idea.

The indication organ is neutral about the implementation of the CLBs.

The social service office is supportive. They encourage the idea. However they think the regulation is too complicated, especially the filling in of the justification forms.

The government stays responsible to ensure quality of care, accessibility to care and the payability of care.

Influences in policy making and legislation

Before the introduction of the new procedures for the CLB at April 1st, 2003, legislation has been adapted and new instruments have been developed. This means:

  1. Introduction of a functional definition of the claims as described in the "Besluit Zorgaanspraken".
  2. Adjustment of the Social Service Indication Resolution. Indication will be done in functions and classes.
  3. CLB settlement in the whole AWBZ and more promotion for the CLB.
  4. Introduction of a transitional arrangement from the help in kind to CLBs.
  5. Introduction of policy rules to establish a AWBZ-wide introduction of CLBs.
  6. A general and technical service company for the budget keepers.
  7. The rise of information of the modernization for all customers. 

AWBZ is a public law, so the government is responsible for steering.

Financing of the claims is organised in such a way that it will connect with the current system. This means maintenance of the budget system and the system of product agreement as regulated in the WTG.

Adoption and implementation

In the adoption process towards implementation of the CLB the next stakeholders will be involved: patients / consumers (-organisations), regional care office (zorgkantoor) and the providers.

The way in which patients / consumers use the CLB can make it successful or not. If patients / consumers only choose for care in kind, CLBs will fail.

The interest group for patients is called "Per Saldo". They have an important role in making the CLB more used.

The social service office has the obligation to purchase enough care for there insured and they are obligated to assign budgets to the patients. They also have to control they way CLBs are used by the consumer.

Providers are obligated to give care. Thereby they have to negotiate with the individual patient about the care that will be given.

Because of the public statutory feature of the AWBZ, the government is responsible for a good legislative frame, fore accessibility and for supervision.

The most recent results of the implementation of the CLB turn out to be successful, although there are a few problems. There are problems with the bureaucratic design of the process.

Monitoring and evaluation

In 1998 an experiment took place upon request from the Council of National Healthcare. The goal of this experiment was to give more insights of the consequences of the introduction of CLBs next to help in kind. The CLB pilot showed that 45 % of the consumers who had the choice to use a CLB, actually opted for the CLB. These consumers were younger then the consumers who chose professional support or 'help in kind'. It turns out that the CLB is not suitable for all patients or consumers since it requires specific capabilities of them.

Results of evaluation


Expected outcome

Expectations are high and positive. It is expected that demanders of care will get more freedom of choice, which is one of the preconditions of demand driven care. Nevertheless, many patients will prefer to stay in the old system of care in-kind. Transforming heatlh care from a supply-driven towards a demand-driven system takes time.

Impact of this policy

Qualität kaum Einfluss neutral starker Einfluss
Gerechtigkeit System weniger gerecht neutral System gerechter
Kosteneffizienz sehr gering neutral sehr hoch


Sources of Information


  • Policy papers of the Ministry of Health (VWS).
  • Information material Ministery of Health, Welfare and Sport (VWS) "Modernisering AWBZ, klanten kiezen".
  • Kraan, W.G.M. van der. 2001. "vraaggericht en Vraaggestuurd, een   literatuuronderzoek naar vraaggerichtheid in de gezondheidszorg". ZonMW /  iBMG. [page 60].
  • Report "Kernmonitor CLB nieuwe stijl" published by the Health Care Insurance Board (CVZ).

[Literature is all in Dutch.]

Author/s and/or contributors to this survey

Anniek Peelen, Wendy van der Kraan & Jan-Kees Helderman

Empfohlene Zitierweise für diesen Online-Artikel:

Anniek Peelen, Wendy van der Kraan & Jan-Kees Helderman. "Client Linked Budgets". Health Policy Monitor, April 2004. Available at