Collaboration for regional healthcare transformation: lessons from the Dutch Integral Care Agreement

Background

The Netherlands faces increasing pressure on the healthcare system, stressing the need for healthcare transformation. The 2022 Integral Care Agreement (ICA) placed multi-organisational, multi-stakeholder collaboration (MOMSC) at the core of regional transformation, requiring regions to develop a regional picture and plan. MOMSC shows potential to drive transformation, but empirical insight into its functioning in practice is limited. We explore stakeholder perceptions of ICA-driven MOMSC.

Methods

We conducted 15 semi‑structured interviews with stakeholders involved in developing the ICA regional picture and/or plan in one region. Participants had a wide range of organizational backgrounds. Interviews were conducted in Dutch, transcribed verbatim, and analysed thematically. Analysis was guided by the Practice Framework for Transdisciplinary Collaboration.

Results

The presence of pre‑existing networks provided valuable relationships and insights, but also created tension between bottom‑up traditions and ICA’s top‑down structure. A shared vision united stakeholders, but operationalisation was hindered by process uncertainty. Power imbalances limited inclusive participation. Time pressure constrained meaningful engagement, while short‑term financing incentivised risk‑averse planning. Despite these challenges, MOMSC fostered new relationships and mutual understanding.

Conclusions

To ensure genuinely transformative rather than procedural MOMSC, coordinated action by national and regional actors is needed. Implementing hybrid governance allows national actors to provide strategic direction while preserving regional ownership. Integrating pre-existing networks into governance structures leverages existing collaboration capacity. Power imbalances require active countermeasures, such as formalized roles and mandates, to safeguard equitable participation of all stakeholders. Lastly, earmarked multi-year funding is essential to secure protected time and capacity.

Key messages

• ICA driven MOMSC strengthened regional relationships and cross-domain thinking, but was inhibited by power imbalances, time pressure, and short term financing, limiting its transformative potential.

• Effective regional healthcare transformation requires hybrid governance, equitable participation, and protected time and capacity to move beyond procedural collaboration.