Experiences with health system transformation from national, regional and local perspective.

Introduction: To guarantee a health system that remains accessible for all, reaches high standards of quality and does not stretch the limits of financial budgets, it is important to collaborate across domains and take on an integrated and incremental approach. Over the years different stakeholders across the Dutch health system engaged in the first steps to transform towards a sustainable health system. With a new Dutch integrated healthcare agreement signed in 2022 by the national representatives of health, care and patient organizations, this study aimed to reflect on past experiences in the process of health systems transformation, and formulate lessons learned for further development. Methods and Analysis: A qualitative study was conducted to reflect on the activities, experiences and outcomes linked to a national program focused on health system transformation. Interviews were held with national and regional representatives of patients and clients (organizations), municipalities, health insurers, health care organizations, health and care professionals, policy makers, (regional) program managers and other key players in the health sector (n=31). The semi-structured interviews were transcribed and deductively coded. The interviewees reflected on their ambition and experiences by scoring their expectation versus outcome. Insights were gained on persistent challenges and facilitating factors. After thematic analysis, the lessons learned were shared with the participants during a collective session (n=26). The aim of this session was to validate the lessons learned and to discuss potential solutions together. Preliminary Results: Participants are positive about the increasing collaboration and shared enthusiasm for the transition in the past years. However, there are concerns about the speed of change and structural assurance. It remains a challenge to reach concrete agreements and have a holistic view across the domains. It appeared that trust and equality between partners can only evolve if there is awareness of the differences in interests and needs. Furthermore, our results show the complexity of the transformation process as needs can vary on different levels (national, regional and local) and from different perspectives. Examples are the search for a balance between trust and control on national and regional level, the need of different actors to be equally valued in decision making (and not only consulted), and connecting the systemic world with the needs of citizens, clients and patients. In order to grow sustainable relationships, stimulate active participation and connect the system with citizens, clients and patients, time and financial resources to experiment appeared to be essential. Lessons learned and Next steps: As the transformation of health systems is an ongoing, iterative and long term process, developments will be monitored in the coming years. According to our insights, more connection and balance is needed between the different perspectives, goals and levels of action. A recommendation on the short term is to focus on equal input from all involved partners, especially health care professionals, citizens, clients and patients. With the start of a new national integrated healthcare agreement, we argue for the importance of an incremental approach and collaborative learning to pursue this transformation.