Chapter 1 10 General introduction Healthcare in the Netherlands The prevalence of chronic diseases is rising, triggered by increasing life expectancy and changing lifestyles [1], resulting in an increasing demand for long-term healthcare [2]. This increased demand causes costs to rise, and a shortage of personnel is looming. In the Netherlands, between 2022-2025, healthcare costs will increase by an average of 2.7% per year and annual healthcare employment will grow over the same period with 2.1% [2]. To control rising costs and personnel shortages, the healthcare system needs to transform. The transition in healthcare is evident in the government's vision, which has changed from "care for" to "care that" [3], and the changing view of health as the absence of disease transforming into "the ability to adapt and self-manage in the face of social, physical and emotional challenges” [4]. The focus is on health, behavior and cost savings. The transformation requires a different practice of healthcare, with new roles for patients, for physicians and other healthcare providers, and for health services [5]. Chronic diseases are the most prevalent reason why patients visit physicians, and the reason for 70% of health care expenditures [5]. Chronic diseases are longlasting conditions that usually can be controlled but not cured, so, management over time is essential. To reduce pressure on healthcare and to keep healthcare affordable, chronic disease management should preferably consist of selfmanagement. With more patient self-management, care becomes less laborintensive, which can reduce pressure on healthcare (reducing healthcare utilization) and potentially reduce healthcare costs [5, 6]. To achieve this, patient and healthcare provider must share complementary knowledge and authority in the healthcare process [5]. Patients have to change behaviors to improve symptoms or slow disease progression, with less support of a healthcare provider. This selfmanagement of patients in changing their behavior requires long-term adherence e.g., with regard to an exercise program. Poor adherence to following an exercise program, might lead to many unnecessary health care costs, such as unnecessary additional examinations or unnecessary hospital admissions [7]. Non-adherence is therefore associated with poor treatment outcomes, an increase in complaints, inefficient use of healthcare and an estimated burden of millions per year in avoidable direct healthcare costs [8].The Dutch Ministry of Health, Welfare and Sports (VWS) recognizes that non-adherence is a widespread problem in the Netherlands, and that it affects all kinds of therapy, including physiotherapy, dietary instruction and taking medication [9]. Inadequate adherence to all forms of therapy, results in unnecessary hospitalizations and consultations with general practitioners. Therefore, VWS advises to increase adherence in order to achieve a substantial effect on better quality as well as efficiency of care to be achieved [9].
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