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Law on Social Support

Partner Institute: 
University of Maastricht, Department of Health Organization, Policy and Economics (BEOZ)
Survey no: 
Hans Maarse
Health Policy Issues: 
Role Private Sector, Long term care, System Organisation/ Integration, Funding / Pooling, Quality Improvement, Benefit Basket, Access, Remuneration / Payment, Responsiveness
Current Process Stages
Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no no yes yes no no
Featured in half-yearly report: Health Policy Developments 7/8


Cost-effective home care

Purpose of health policy or idea

The main purpose of the Law on Social Support (which came into effect in 2006) is to make municipalities responsible for a set of health-related social services including family help (domestic care; e.g. housekeeping, simple supportive health services like bath help) which were previously covered under the Exceptional Medical Expenses Act (Algemene Wet Bijzondere Ziektekosten: AWBZ). The underlying idea is that municipalities are better capable than health insurers to manage family help services and to organise integrated care for the sick and the frail elderly at the local level.

Main points

Main objectives

Cost-effective (integrated) home care; main tools are decentralisation to municipalties and competitive bidding.

Type of incentives

financial and non-financial (decentralisation)

Groups affected

Health insurers, municipalities, client groups (users of health-related social services), provider organizations

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Characteristics of this policy

Degree of Innovation traditional innovative innovative
Degree of Controversy consensual rather consensual highly controversial
Structural or Systemic Impact marginal fundamental fundamental
Public Visibility very low high very high
Transferability strongly system-dependent system-dependent system-neutral

An interesting policy idea; may be effective; highly unlikely that the reform will be revoked in future.


Political and economic background

One of the political backgrounds of the LSS is  to make consumers in health-related social services less dependent on public provision. If possible, they should organise these services themselves, for instance by means of informal care. Patients (clients) are only eligible to social support if there are no other options available. Another political background is that social care should be integrated with other public services, in particular housing, neighbourhood services, 'meals on wheels' and so on. The government believes that local government is better capable than health insurers to provide an integrated set of social support services. Opponents claim that the LSS is intended as a vehicle to implement expenditure cuts in health-related social support, but this is explicitly denied by the government. 

Complies with

EU regulations

There is a link with EU-legislation, because municipalities are obliged to meet the EU-regulations on public procurement (competitive bidding) when contracting with the provider organisations.

Change based on an overall national health policy statement

There is a need for cost-effective (interated) care at the local (municipal) level.

Purpose and process analysis

Current Process Stages

Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no no yes yes no no

Origins of health policy idea

The LSS which was initiated by the present government relates to the more general policy debate about the future of the AWBZ. The health-related social services now decentralised to municipalities were previously covered by the AWBZ, which is a social health insurance arrangement originally intended for exceptional medical expenses (mainly long-term care). However, since its inception in the mid-1960s various health services which had little or nothing to do with long-term care or exceptional medical expenses, were included in the health services package ('basket') of the AWBZ, mainly because of political opportunism. The LSS must not only create a more appropriate institutional setting for integrated care at the local level, but is also a policy tool to remove all those services from the basket of AWBZ which do not fit in its original goal: guaranteeing access to long-term care for the entire population. Thus, the LSS can be viewed an integral part of the ongoing health insurance reform (see also 2006-springtime report).

The LSS is best described as a new institutional framework for decentralising the provision of health-related social support to local government because municipalities  considered the most appropriate government agent for delivering an integrated set of social support services to people who need that support to live independently as long as possible.

Initiators of idea/main actors

  • Government: The LSS was the government's idea. The Ministry of Health was very much in favour because it had developed the idea and strongly believed that the LSS could help to resolve the problems in AWBZ and to achieve better integrated care at the local level. Municipalities were divided over the issue. On the one hand, they were supportive because the LSS would enhance their opportunities in health care policymaking. On the other, they were afraid that the national government would 'abuse' the LSS to implement expenditure cuts in social support services.
  • Providers: Providers were not very supportive. They preferred stable relations with health insurers. Provider organisations considered local governments as a source of uncertainty, because they would make use of the instrument of competitive bidding (public procurement) according to EU legislation. Com-petitive bidding could mean that they would lose a substantial part of their revenues to their competitors which could lead to bankruptcy.
  • Payers: Health insurers were neutral. There primary concern was that the shift of responsibility for health-related social support from health insurers to local government could lead to chaos.
  • Patients, Consumers: Client organisations were not very supportive because of their fear for expenditure cuts. Furthermore, they considered local government as a ?unknown? partner in health care. A more fundamental objection raised was that the shift of social support services from social health insurance to local government could mean that clients would loose their right to social support services when qualified for it. Municipalities are not prohibited to make use of fixed budgets for social support services, whereas the concept of a fixed budget is not compatible, at least in principle, with the concept of insurance.

Approach of idea

The approach of the idea is described as:

Innovation or pilot project

Local level - responsible for home care
Within institution - competitive bidding

Stakeholder positions

See section "Initiators / main actors".

Actors and positions

Description of actors and their positions
Ministry of Healthvery supportivevery supportive strongly opposed
Municipalitiesvery supportivesupportive strongly opposed
Provider organisationsvery supportiveopposed strongly opposed
Health insurersvery supportiveneutral strongly opposed
Patients, Consumers
Client organisationsvery supportiveopposed strongly opposed

Influences in policy making and legislation

The LSS was rather controversial during the legislative process. A very important issue was how to protect the client right to social support services under the new regime. Whereas the AWBZ established a legal right to social support services when the client met the eligibility criteria, the LSS does not establish a similar right. Various political parties sought to reconfirm the right to social support services under the new regime, but it remains to be seen how it will work out in practice.


Legislative outcome


Actors and influence

Description of actors and their influence

Ministry of Healthvery strongvery strong none
Municipalitiesvery strongstrong none
Provider organisationsvery strongweak none
Health insurersvery strongneutral none
Patients, Consumers
Client organisationsvery strongweak none
Ministry of HealthMunicipalitiesHealth insurersProvider organisations, Client organisations

Positions and Influences at a glance

Graphical actors vs. influence map representing the above actors vs. influences table.

Adoption and implementation

The Law on Social Support is being implemented. A new interesting phenomenon is that local governments are now setting up procedures for competitive bidding in order to contract with provider organisations. The use of the competitive bidding instrument illustrates again the advance of market competition in health care delivery.


Monitoring and evaluation

No monitoring and evaluative reports available.


Review mechanisms

Mid-term review or evaluation

Results of evaluation

No systematic evaluation available. Some provider organisations complain in public that they lost competitive bidding. Some reports in the media on substantive dismissals.


Expected outcome

Outcomes are difficult to predict. Due to decentralisation one may expect local variations concerning the terms of the competitive bidding, co-payment rates, eligibility criteria, and so on.


Impact of this policy

Quality of Health Care Services marginal marginal fundamental
Level of Equity system less equitable system less equitable system more equitable
Cost Efficiency very low high very high

System may become less equitable due to inter-municipal variation. For example: municipality A may use other eligibility criteria than municipality B.



Sources of Information

  • Government reports
  • Various press releases


Author/s and/or contributors to this survey

Hans Maarse

Suggested citation for this online article

Hans Maarse. "Law on Social Support". Health Policy Monitor, October 2006. Available at