Table 2.

Layered institutional arrangement of Dutch healthcare

Institutional arrangement	Important actors	Steering instruments	Period
Market	Insurers, health care providers, patients	Competition, closing contracts, transparency	Officially introduced as the dominant arrangement in 2006, after an incremental change process
State and hierarchy	Ministry of Health, Healthcare Inspectorate	Top-down regulation through legislation (e.g. Quality of care act, Individual Healthcare Professions Act) and supervision	Always played a role, importance increased from the 2000s onward and especially after the implementation of the market-based system
Civil society/ association	Healthcare professionals, providers, insurers, patient organizations, government	Consultation and deliberation, e.g. in setting performance indicators. Was important in the development of the Quality of Care Act in the 1990s. And again in setting limits on economic growth of the healthcare sector in 2012	Especially important in the 1990s, still plays a role but less dominant then before
Professional community	Healthcare professionals	Medical training, peer review, guidelines, visitation, quality systems	Oldest, still highly important but less dominant than before