While many countries, including the UK, Sweden and Finland have had national research efforts in the field of socioeconomic inequalities in health during the second half of the 1990's, the Dutch program is unique for its emphasis on evaluation of interventions. More generally, the main distinguishing feature of the Dutch approach is its focus on commissioning evaluations of interventions. Although this was done in a systematic way, using an explicit conceptual and methodological framework, the program also had its obvious limitations. It had a modest budget (totalling 3 million Euro over a period of 6 years) and funded not more than 12, rather small-scale intervention studies targeting relatively easily modifiable factors. The latter is not only due to the small budget of the program, but also to strict methodological requirements which in practice made it nearly impossible to study the effectiveness of broader policy measures [18
]. In hind-sight, we consider this the most important limitation of the program: the lack of studies on the possible impact of broader policy measures, mainly related to the strict methodological criteria that were applied in the process of selection of the research proposals. Even for the more specific and narrowly defined interventions selected for the program, some of the evaluation studies failed because the design could not be implemented. In the end, therefore, the contribution of the intervention studies to strategy development was modest.
The unique elements of the Dutch approach should not distract from the fact that the Dutch experience received important inputs from abroad. Its start is a late response to the British Black Report and is directly related to the efforts of the European Office of the World Health Organization to put health equity on national policy agendas [15
]. During the program there were close contacts between members of the committee and researchers and policy-makers in other European countries, through the European Network for Interventions and Policies to Reduce Inequalities in Health [19
], so that experiences in other countries could be taken into account. The report of the Independent Inquiry in Britain [20
] acted as a rich source of ideas, while a recent Swedish report on tackling inequalities in health [21
] strengthened the confidence in the usefulness of target setting for reducing inequalities in health.
The Dutch approach reflects the input of both researchers and policy-makers, although the balance between the two has oscillated over time. The first signals that health inequalities should be addressed came from researchers, but were picked up by policy-makers within the Ministry of Health in the mid-1980's who were then looking for opportunities to strengthen health policy (as opposed to health care policy) in the Netherlands. This small group of bureaucrats succeeded in launching and following through the first research program, but left the Ministry or changed posts before the program came to an end. Partly due to continuous personnel changes in the Ministry, the intensity of the exchanges between researchers and policy-makers gradually diminished during the second program. When the final report was published reactions from within the Ministry were rather cool, although the Minister, who had taken a personal interest in the matter, responded very favourably. At this stage, however, it seems that without a continuing "push" from the research-side the bureaucrats could easily loose interest altogether, particularly now that there are rapid changes of cabinet.
A major obstacle for a comprehensive package of policy measures seems to be the relatively weak position of the Ministry of Health as compared to other policy areas. It is obvious that a substantial reduction of health inequalities can be achieved only by involving other policy areas next to that of (preventive and curative) health care. This starting point seems to contrast with the ideas of the ministries in other policy areas, that seem to consider this issue as the responsibility of the Ministry of Health in particular. So far, the Ministry of Health does not seem to have a lot of success in convincing other policy areas of the importance of contributing to reducing inequalities in health.
The lack of success in mobilising other policy areas at the national level is probably partly related to the fact that the issue of inequalities is perceived as rather abstract by these other areas. This probably requires the issue of inequalities in health to be "re-phrased" for that specific policy area, in terms that fit within their ideas. Housing corporations for example do not consider themselves to be responsible for tackling health inequalities but they do feel responsibility for high quality living conditions, which then might automatically contribute to a better health status of people in lower socio-economic groups. Paradoxically, an approach in which the issue of inequalities in health is cut into small pieces, requires a steering. This forms the background of the plea of the committee for a steering group.
Remarkable progress has been made, not only in terms of knowledge production but also in terms of increased confidence among policy-makers and practitioners to take action to reduce inequalities in health. Many health agencies in the Netherlands are working to reduce socioeconomic inequalities in health. This is illustrated by the fact that the 'National Contract on Public Health', concluded in 2001 between many national and local agencies in the field of public health, has selected the reduction of socioeconomic inequalities in health as its first priority. Many local health agencies have already implemented some of the interventions discussed in this paper.