In the coming years, there will be changes in health care, both in terms of supply and demand and health care costs will rise. The number of elderly people in the Dutch population is growing, and they will live longer. There is an ongoing debate concerning the quality of care for the elderly, which puts pressure on long-term care. At the same time, staff shortages in the health care system will continue to worsen during the upcoming period. Despite limited resources, the system must continue to deliver good quality care. Prevention will have a major part to play in this situation. Innovations in the field of medical and health care technology have an impact on the health care system, as does the fact that health care is becoming increasingly personalised. The social challenge is to deliver top-quality care in the right place, with minimal risk, while achieving the right balance of costs and benefits.

RIVM SPR Strategic Programme RIVM (Strategic Programme RIVM) theme "Sustainable care and prevention" aims to help make health care affordable and accessible over the long term.
This theme focuses on three aspects:
A. Health care modernisation and innovation
B. Organisation and funding of health care
C. Prevention

Health care modernisation and innovation

New technologies in health care, such as e-health, contribute to better health. But how great is their added value and does it outweigh the costs? To be able to make the right choices, insight is needed into the effects, costs and benefits of new technologies. Not only the characteristics of such a technology are important, but also how it is implementated.

It is important to be able to estimate at an early stage which technologies are promising and how they can best be used. The needs of care users and caregivers play a role here, as does the question of whether a new technology replaces or adds value to another treatment. The SPR Strategic RIVM Programme theme "Sustainable care and prevention" focuses on the further development of social cost-benefit analyses (SCBA social cost-benefit analyses) as an instrument for investigating these types of questions.

Organisation and funding of health care

The expected changes in society call for a different organisation of health care. It is a challenge to realise care in the right place, with good quality, low risks and the right balance between costs and benefits.

An important goal of sustainable health care is to offer the right care in the right place. This means that people have to live at home for a longer period. But people who live at home for longer appear to make more use of hospital care than people in a nursing home. How does this relate to each other? Integral considerations in which all aspects are taken into account are therefore important. A different organisation of formal care also has consequences for informal care. For example, the pressure on informal carers can increase.

In addition, there is a need for new methods, for example, for making future studies or measuring the quality of care. New innovative models are also needed to estimate future health care expenditure, or the number of informal carers or staff required, and to find ways of dealing with the growing care gap that is emerging between higher and lower educated people.


Prevention is a good and cost-effective way to improve public health. If prevention is to contribute to sustainable health care, it is important to find solutions to several challenges. For example, how do we ensure that people adopt healthy lifestyles? Are nudges a solution for this or are other solutions needed? Finally, yet importantly, how can we optimise prevention and how do we ensure proper funding?


For the SPR theme "Sustainable care and prevention", RIVM carries out the following eight studies:


RIVM will describe the proportion of elderly in the acute health care chain and will characterise this group based on health care data (e.g. care use, costs, diagnosis) and social-economic and demographic background (e.g. household, region, marital status). The resulting ‘health care profiles’ will be used to describe the pathways or journeys in the acute health care chain, while making regional differences transparent.


There is much pressure on the accessibility of the acute care chain (General Practitioner posts, ambulance, emergency room and the mental health care crisis service) in the Netherlands. There is increasing attention in international literature for those who frequently use the acute care chain. These are, for example, elderly people aged 65 and over. However, the precise framing of this group in terms of health care use and social and regional differences is only known in broad terms.


To develop the health care profiles of the elderly in the acute health care chain, RIVM will compile a dataset, in which both health care declaration data and background (patient-level) and health care data (organisational level) are brought together. RIVM will then carry out the analyses on this dataset.

Within the social cost-benefit analyses (SCBA social cost-benefit analyses) contingent valuation methods are often used, such as Willingness to Pay or Discrete Choice Experiments (DCE) to measure citizens' preferences. This approach assumes that the welfare effects of policy can be derived from fictitious choices (stated preference) that people make with their private resources, such as net income. It is assumed that not only the value of consumer goods but also the value of government projects can be derived from choices that individuals make with their income. However, willingness to pay may not be a good approach to valuing government policy, because the trade-offs that individuals make between private resources and private goods may differ from how the same individuals feel that the government should (on their behalf) make trade-offs between public resources and public goods. In other words: individuals make different considerations for themselves than they think the government should do (on their behalf) when it comes to public resources and public goods.


Because RIVM will continue to be an important executor of SCBAs in the future, it is important to critically follow the methodological developments within the SCBA and also to contribute to its further development. Participatory Value Assessment (PWE)  is a new stated preference method to measure the social value of policies from an allocation readiness approach. A well-developed PWE methodology can be integrated in the SCBA tools that have been developed as a follow-up to the CPB / PBL guideline on SCBAs, in terms of identifying citizen preferences. This study provides insight into the use of the PWE participatory value evaluation in addition to that of DCEs and other valuation methods.


Based on literature research and interviews with experts in the area of preferred methods of citizens, we will identify the problems users experience when using PWE. We then process the most promising solutions in an application of PWE and through user research, and we will analyse whether these solutions solve the problems. If possible, we will work with a control group to see whether the innovations increase the satisfaction of respondents and the PWEs and whether these innovations lead to different, more accurate results. The PWE method will be applied in the second phase of the project. Target group is the informal caregiver. Within this group, the needs and workload of informal caregivers will be investigated. In addition to a PWE, a DCE will be performed on the same subjects.

Expected results

This project is highly relevant because it can contribute to the improvement of the application of citizens' valuation of policy. In addition, it is scientifically innovative because until now, few PWEs have been implemented with regard to public health policy.

RIVM will publish the results in international peer-reviewed journals with open access. A symposium will also be organised for which experts in the field of preference research will be invited. The aim of this symposium is to present results and exchange ideas about the different methods of preference research, in particular, the PWE and the DCE.



We need more insight into the psychology and behaviour of smokers to understand why people make certain choices. This knowledge can be used to develop lifestyle interventions to help people stop smoking. The Smoke-free Lottery focuses mainly on people with a low level of education.


Smoking causes 20,000 deaths per year in the Netherlands. Half of all smokers die prematurely. Every year, around 40 per cent of smokers try to stop smoking. The majority of these attempts to stop smoking fail (90 per cent). The majority of smokers are low-skilled. We need to find different approaches to reach out and discourage them from smoking. The underlying problems are psychological, and not due to a lack of knowledge or motivation.


We build on the successful RIVMresearch ‘Commitment Lotteries’ (in Dutch: De Beweegloterij). Up to 1 year, commitment lotteries stimulated regular gym visits. In the Smoke-free lottery, we expand this research to smoking and evaluate its effectiveness.

Workers who would like to quit smoking are offered an evidence-based quitting-course. In addition, they commit to their goal by accepting multiple deadlines. At every deadline, a prize is drawn among the participants, and the winner is announced to all. The winners only get to keep their prize if they refrained from smoking that week. Unsuccessful winners inevitably learn what their winnings would have been, had they stuck to their goal. The possibility of regret at this point is designed to help the participants to attain their goal.


From the outset of the project, RIVM will work with stakeholders to measure the effectiveness of the smoke-free lottery. The course focuses on people with a lower education and will be developed in collaboration with them.

This project also falls under the SPR Strategic Programme RIVM (Strategic Programme RIVM) supporting theme "Perception and behaviour".


RIVM wants to improve the support to informal caregivers of elderly people living at home. This requires insight into how many people combine work and informal care, and if the support that they receive is in line with their needs.


More and more elderly people need care. Due to demographic, social and political developments, informal care is becoming increasingly important. Informal caregivers are often burdened on several fronts because they combine work and informal care. In the Netherlands, this is the case for 1 in 5 employees. Good support is essential to be able to maintain care and thus contribute to sustainable care. Informal carers are often unaware of what forms of support are available to them. The support offered is also insufficiently in line with their needs.


First of all, the various aspects of informal care, particularly with regard to working informal caregivers, are mapped out. Also, RIVM will make an inventory of the number of elderly people living at home in need of care, as well as the current and future supply of informal care support. In addition, the needs for informal care support will be assessed, in which the working informal caregivers and elderly in need of care are closely involved (for example through citizen science).


Estimates of health care use and expenditure can be improved by using more data at the individual level on, for example, diagnosis, treatment and costs, age, gender, income and family composition. RIVM uses this data to improve estimates for several conditions and to translate them into population numbers and expenditures. Examples of this are RIVM’s Cost-of-Illness Study and the Public Health Foresight Study.

RIVM informs political and societal debate on the (financial) sustainability of health care and health expenditure through both the Cost-of-Illness Study and the Public Health Foresight Study. Personalised data, for example, about diagnosis, treatment, costs, age, gender or income, allows for an improvement in estimations of future growth of health care use and health expenditure.

This kind of information provides a more detailed picture of current and future health expenditures, which in turn makes will help to improve our knowledge on the possible consequences of societal, political or policy-driven decisions.


RIVM wants to contribute to the social debate on the sustainability of care and health care spending. In this project we will use depersonalised data to improve estimations on health expenditure and health care use at the national level. The results will, in turn, be used to improve future projections of health expenditure and (possibly) health care use. RIVM aims to develop new methods to better assess and link future demographical changes, epidemiological developments, health expenditure and – if possible – health care use. 


Patients are given the best possible picture of the care they have used and the costs involved. These results are then compared with existing methods, and the differences between them are examined. If the results are sufficiently reliable, BUTZ will use mathematical analyses to try to distinguish between various influencing factors, such as demography and epidemiology, and more person-related characteristics.



The costs and the quality of the care are important to keep the care sustainable. This means: affordable and accessible, of good quality, now and in the future. New developments must therefore, always be examined to see whether they improve sustainability.

For example, the following are important for sustainable care: costs and effects, society and the individual, ethics, health and safety. All these factors together determine the impact of new developments on health care. RIVM will identify the factors that ensure that the implementation of innovations succeeds or fails, and will design these into a matrix. Experts will use the matrix for medical innovations that are now almost ready to be implemented.


First, experts select medical innovations that have or have not been successfully implemented in the health care system. For each innovation, it is assessed which factors determined whether it was a success or failure. The development of the implementation matrix requires knowledge about: innovation and technology, predictive studies, implementation research, legislation on medical innovation, social perspective, health economy and different phases of the innovation process.

(including societal relevance and strategic aspects)


RIVM charts the current socio-economic differences in care use and care expenditure and compares these with those of 2003. So far, the data on care expenditure and the socio-economic groups that use it have been linked to a limited extent to diseases and other indicators of health.


Solidarity in the Dutch health care system, one of the most important pillars, is under pressure. Certain population groups make more use of health care services than others. This raises the question of whether the system still shows solidarity. The differences in health care expenditure are mainly explained by people's lifestyle and socio-economic characteristics.


The following questions are addressed in a literature review and an analysis of available data: 1. Is there a difference between the use and expenditures of care from people with a different level of education and income? 2. Are the use and expenditure of care for specific disorders different per educational and income level?

Exploring the possibilities and the added value of research into socioeconomic differences in the use of care and care expenditure when some indicators and/or composite measures of socioeconomic position are added, will be investigated.

Exploring complex health problems and resources 2040 ZO-OUD2040


In this project, RIVM will sketch an integrative picture of the 70-year-olds of 2040 and the two main groups of factors that determine the need for care and support for older people: complex health problems and resources. We will provide building blocks for the development of a long-term vision of future care and support for the elderly.


One of the tasks of RIVM is to map out public health, health care and services and the developments. This is done through the ‘Public Health Foresight Studies’(PHFS), in Dutch ’ Volksgezondheid Toekomst Verkenning’(VTV) ). These studies provide insight into the most important societal challenges for public health and health care in the Netherlands.


We select trends from PHFS and other foresight studies in literature. In addition, RIVM consults experts and we analyse the coherence of trends based on available data, such as the Doetinchem Cohort Study.