International Journal of Health Policy and Management

International Journal of Health Policy and Management

What Value Do Dutch Citizens Place on Health Interventions That Provide Greater Health Gains to Lower-Income Groups? A Discrete Choice Experiment

Document Type : Original Article

Authors
Iris Meulman 1, 2
Adrienne Rotteveel 1
Ellen Uiters 3
Mariëlle Cloin 2
Johan Polder 1, 2
Niek Stadhouders 4, 5
1 Center for Public Health, Healthcare and Society, National Institute for Public Health and the Environment, Bilthoven, The Netherlands
2 Tranzo, Tilburg School of Social and Behavioral Sciences, Tilburg University, Tilburg, The Netherlands
3 Netherlands School of Public & Occupational Health, Utrecht, The Netherlands
4 Scientific Center for Quality of Healthcare, Radboud University Medical Center, Nijmegen, The Netherlands
5 Department of Health Economics, School of Business and Economics & Talma Institute, Vrije Universiteit, Amsterdam, The Netherlands
10.34172/ijhpm.9095
Abstract
Background 
Reimbursement decisions for new health interventions focus on maximizing health gains, with limited attention to who benefits from these gains or the impact on income related health inequalities. This study aimed to examine the preferences of Dutch citizens regarding the distribution of health gains of new interventions across income groups.
 
Methods 
A discrete choice experiment (DCE) was completed by 614 Dutch adults. Respondents were presented with 12 choice tasks. In each choice task, they were asked to choose between two health interventions that differed on the following attributes: total healthy life years gained, distribution of healthy life years gained across income groups, additional costs in terms of health insurance premium increases and whether the intervention was curative or preventive. Preferences were estimated using multinomial logit (MNL) models, relative attribute importance, willingness-to-pay, and willingness-to-trade total health gains. Preference heterogeneity was examined using latent class (LC) analyses.
 
Results 
Respondents found the distribution of health gains by income the most important attribute in their decision between health interventions (relative importance [RI] = 40.5%, 95% CI: 38.3%–42.7%). Overall, respondents preferred an equal distribution of healthy life years gained across income groups (βhigher income groups = -1.427, 95% CI: -1.547–-1.307; βlower-income groups = -0.315, 95% CI: -0.395–-0.235). A health intervention should yield 14 283 (95% CI: 10 463–18, 102) additional healthy life years or reduce the yearly health insurance premium by €39.96 (95% CI: €29.03–€50.89) if it mainly favors lower-income groups. Preventive interventions were generally preferred over equally effective or more effective curative interventions (βprevention = 0.270, 95% CI: 0.204–0.336). While preferences displayed a similar direction across LCs, the classes differed in the RI assigned to the attributes.
 
Conclusion 
Our findings suggest societal support for interventions that prioritize preventive programs over equally effective or more effective curative interventions and prioritize interventions that provide equal benefits across different income groups.
Keywords
Discrete Choice Experiment
Healthcare Resource Allocation
Socioeconomic Health Inequality
Equity-Efficiency Trade-Off
Prevention
Priority Setting
  1. Werner G, Riel AV, Gijsberts M, Visser MD. Financial, Staffing and Societal Sustainability of Dutch Health Care: An Urgent Need for Clear Choices. Springer Nature; 2024. doi:1007/978-3-031-58564-7
  2. Weinstein MC, Torrance G, McGuire A. QALYs: the basics. Value Health. 2009;12 Suppl 1:S5-S9. doi:1111/j.1524-4733.2009.00515.x
  3. Dunning AJ, Commissie Keuzen in de zorg, Ministerie van Welzijn Volksgezondheid en Cultuur, Centrale Directie Voorlichting Documentatie en Bibliotheek Afdeling Publieksvoorlichting. Kiezen en delen / 1, Rapport van de Commissie Keuzen in de zorg. [Rijswijk, 's-Gravenhage: Ministerie van Welzijn, Volksgezondheid en Cultuur, Afd. Publieksvoorlichting]: Distributiecentrum DOP; 1991.
  4. Zwaap J, Kooijman H. Pakketbeheer in de Praktijk 4: Pakketbeheer als solide basis voor passende zorg. Zorginstituut Nederland; 2023.
  5. van Gils PF, Schoemaker CG, Polder JJ. [How much should a gained life-year cost? Study on the assessment of a QALY]. Ned Tijdschr Geneeskd. 2013;157(52):A6507. [Dutch].
  6. Zorginsitituut Nederland. Ziektelast in de praktijk. De theorie en praktijk van het berekenen van ziektelast bij pakketbeoordelingen. Zorginsitituut Nederland; 2018.
  7. Reckers-Droog VT, van Exel NJ, Brouwer WB. Looking back and moving forward: on the application of proportional shortfall in healthcare priority setting in the Netherlands. Health Policy. 2018;122(6):621-629. doi:1016/j.healthpol.2018.04.001
  8. Technical Working Group Cost and Benefits of Prevention. Preventie op waarde schatten. 2023. https://open.overheid.nl/documenten/92ad7df5-0b1f-4dcc-b7f1-efb7cd6ee6b5/file.
  9. Rotteveel A, Knies S, de Wit A, Polder J, Wouterse B. Valuing prevention: lessons and recommendations from a Dutch expert committee. Expert Rev Pharmacoecon Outcomes Res. 2025;25(6):849-854. doi:1080/14737167.2025.2504946
  10. Zorginsitituut Nederland. Pakketadvies in de praktijk: wikken en wegen voor een rechtvaardig pakket. Zorginsitituut Nederland; 2017.
  11. Statline - Statistics Netherlands. Gezonde levensverwachting; geslacht, leeftijd en onderwijsniveau. 2023. https://opendata.cbs.nl/#/CBS/nl/dataset/84842NED/table?ts=1641978482394.
  12. McNamara S, Holmes J, Stevely AK, Tsuchiya A. How averse are the UK general public to inequalities in health between socioeconomic groups? A systematic review. Eur J Health Econ. 2020;21(2):275-285. doi:1007/s10198-019-01126-2
  13. Robson M, Asaria M, Cookson R, Tsuchiya A, Ali S. Eliciting the level of health inequality aversion in England. Health Econ. 2017;26(10):1328-1334. doi:1002/hec.3430
  14. Hurley J, Mentzakis E, Walli-Attaei M. Inequality aversion in income, health, and income-related health. J Health Econ. 2020;70:102276. doi:1016/j.jhealeco.2019.102276
  15. Attema AE, L'Haridon O, van de Kuilen G. Decomposing social risk preferences for health and wealth. J Health Econ. 2023;90:102757. doi:1016/j.jhealeco.2023.102757
  16. Cookson R, Mirelman AJ, Griffin S, et al. Using cost-effectiveness analysis to address health equity concerns. Value Health. 2017;20(2):206-212. doi:1016/j.jval.2016.11.027
  17. Levesque JF, Harris MF, Russell G. Patient-centred access to health care: conceptualising access at the interface of health systems and populations. Int J Equity Health. 2013;12:18. doi:1186/1475-9276-12-18
  18. Lorenc T, Petticrew M, Welch V, Tugwell P. What types of interventions generate inequalities? Evidence from systematic reviews. J Epidemiol Community Health. 2013;67(2):190-193. doi:1136/jech-2012-201257
  19. Mackenbach JP. The persistence of health inequalities in modern welfare states: the explanation of a paradox. Soc Sci Med. 2012;75(4):761-769. doi:1016/j.socscimed.2012.02.031
  20. Sacre A, Bambra C, Wildman JM, et al. Socioeconomic inequalities in vaccine uptake: a global umbrella review. PLoS One. 2023;18(12):e0294688. doi:1371/journal.pone.0294688
  21. Thomson K, Hillier-Brown F, Todd A, McNamara C, Huijts T, Bambra C. The effects of public health policies on health inequalities in high-income countries: an umbrella review. BMC Public Health. 2018;18(1):869. doi:1186/s12889-018-5677-1
  22. van der Aa M, Hiligsmann M, Paulus A, Evers S. Healthcare deservingness opinions of the general public and policymakers compared: a discrete choice experiment. In: The Social Legitimacy of Targeted Welfare: Attitudes to Welfare Deservingness. Edward Elgar Publishing, 2017:241-260.
  23. Bijlmakers L, Jansen M, Boer B, et al. Increasing the legitimacy of tough choices in healthcare reimbursement: approach and results of a citizen forum in the Netherlands. Value Health. 2020;23(1):32-38. doi:1016/j.jval.2019.07.015
  24. van Exel J, Baker R, Mason H, Donaldson C, Brouwer W. Public views on principles for health care priority setting: findings of a European cross-country study using Q methodology. Soc Sci Med. 2015;126:128-137. doi:1016/j.socscimed.2014.12.023
  25. Mason H, van Exel J, Baker R, Brouwer W, Donaldson C. From representing views to representativeness of views: illustrating a new (Q2S) approach in the context of health care priority setting in nine European countries. Soc Sci Med. 2016;166:205-213. doi:1016/j.socscimed.2016.08.036
  26. McNamara S, Tsuchiya A, Holmes J. Does the UK-public's aversion to inequalities in health differ by group-labelling and health-gain type? A choice-experiment. Soc Sci Med. 2021;269:113573. doi:1016/j.socscimed.2020.113573
  27. Robson M, O'Donnell O, Van Ourti T. Aversion to health inequality - pure, income-related and income-caused. J Health Econ. 2024;94:102856. doi:1016/j.jhealeco.2024.102856
  28. Robson M, O'Donnell O, Van Ourti T. Responsibility-sensitive welfare weights for health. J Health Econ. 2025;102:103018. doi:1016/j.jhealeco.2025.103018
  29. Card KG, Adshade M, Hogg RS, Jollimore J, Lachowsky NJ. What public health interventions do people in Canada prefer to fund? A discrete choice experiment. BMC Public Health. 2022;22(1):1178. doi:1186/s12889-022-13539-5
  30. Khor S, Elsisi ZA, Carlson JJ. How much does the us public value equity in health? A systematic review. Value Health. 2023;26(3):418-426. doi:1016/j.jval.2022.08.009
  31. Blacksher E, Rigby E, Espey C. Public values, health inequality, and alternative notions of a "fair" response. J Health Polit Policy Law. 2010;35(6):889-920. doi:1215/03616878-2010-033
  32. Gongora-Salazar P, Perera R, Rivero-Arias O, Tsiachristas A. Unravelling elements of value of healthcare and assessing their importance using evidence from two discrete-choice experiments in England. Pharmacoeconomics. 2024;42(10):1145-1159. doi:1007/s40273-024-01416-5
  33. Boujaoude MA, Dalziel K, Cookson R, Devlin N, Carvalho N. Aversion to income, ethnic, and geographic related health inequality: evidence from Australia. Soc Sci Med. 2025;364:117495. doi:1016/j.socscimed.2024.117495
  34. Luyten J, Kessels R, Goos P, Beutels P. Public preferences for prioritizing preventive and curative health care interventions: a discrete choice experiment. Value Health. 2015;18(2):224-233. doi:1016/j.jval.2014.12.007
  35. Bosworth R, Cameron TA, DeShazo JR. Is an ounce of prevention worth a pound of cure? Comparing demand for public prevention and treatment policies. Med Decis Making. 2010;30(4):E40-E56. doi:1177/0272989x10371681
  36. Meertens RM, Van de Gaar VM, Spronken M, de Vries NK. Prevention praised, cure preferred: results of between-subjects experimental studies comparing (monetary) appreciation for preventive and curative interventions. BMC Med Inform Decis Mak. 2013;13:136. doi:1186/1472-6947-13-136
  37. Wolff E, Larsson S, Svensson M. Willingness to pay for health improvements using stated preferences: prevention versus treatment. Value Health. 2020;23(10):1384-1390. doi:1016/j.jval.2020.06.008
  38. Boxebeld S, Geijsen T, Tuit C, et al. Public preferences for the allocation of societal resources over different healthcare purposes. Soc Sci Med. 2024;341:116536. doi:1016/j.socscimed.2023.116536
  39. Hansen J, Arts W, Muffels R. Solidair tegen (w)elke prijs? Een quasi-experimenteel onderzoek naar de voorkeuren van Nederlanders voor ruimere of beperktere pakketten in de zorgverzekering. Soc Wetenschap. 2005;48(1-2):61-84.
  40. Soekhai V, de Bekker-Grob EW, Ellis AR, Vass CM. Discrete choice experiments in health economics: past, present and future. Pharmacoeconomics. 2019;37(2):201-226. doi:1007/s40273-018-0734-2
  41. Meijer MA, Brabers AE, Stadhouders N, De Jong JD. The willingness to pay for basic health insurance in the Netherlands: quantitative and qualitative insights. Int J Health Plann Manage. 2025;40(4):871-882. doi:1002/hpm.3926
  42. Zwillinger D. CRC Standard Mathematical Tables and Formulae. Chapman & Hall, CRC Press; 2002.
  43. Traets F, Sanchez DG, Vandebroek M. Generating optimal designs for discrete choice experiments in R: the idefix package. J Stat Softw. 2020;96(3):1-41. doi:18637/jss.v096.i03
  44. Boxebeld S. Ordering effects in discrete choice experiments: a systematic literature review across domains. J Choice Model. 2024;51:100489. doi:1016/j.jocm.2024.100489
  45. de Bekker-Grob EW, Donkers B, Jonker MF, Stolk EA. Sample size requirements for discrete-choice experiments in healthcare: a practical guide. Patient. 2015;8(5):373-384. doi:1007/s40271-015-0118-z
  46. McFadden D. Conditional Logit Analysis of Qualitative Choice Behavior. Berkeley: University of California; 1972.
  47. Bradley M, Daly A, Stopher P, Lee-Gosselin M. Estimation of logit choice models using mixed stated-preference and revealed-preference information. In: Understanding Travel Behaviour in an Era of Change. Elsevier; 1996:209-231.
  48. Genie MG, Ryan M, Krucien N. To pay or not to pay? Cost information processing in the valuation of publicly funded healthcare. Soc Sci Med. 2021;276:113822. doi:1016/j.socscimed.2021.113822
  49. Gonzalez JM. A guide to measuring and interpreting attribute importance. Patient. 2019;12(3):287-295. doi:1007/s40271-019-00360-3
  50. Hess S, Palma D. Apollo Version 0.3.0, User Manual. Leeds: Choice Modeling Centre, University of Leeds; 2019.
  51. Sinha P, Calfee CS, Delucchi KL. Practitioner's guide to latent class analysis: methodological considerations and common pitfalls. Crit Care Med. 2021;49(1):e63-e79. doi:1097/ccm.0000000000004710
  52. Hess S, Palma D. Apollo: a flexible, powerful and customisable freeware package for choice model estimation and application. J Choice Model. 2019;32:100170. doi:1016/j.jocm.2019.100170
  53. R Core Team. R: A Language and Environment for Statistical Computing [Computer Program]. Vienna, Austria: R Core Team; 2022.
  54. Daly A, Hess S, de Jong G. Calculating errors for measures derived from choice modelling estimates. Transp Res B Methodol. 2012;46(2):333-341. doi:1016/j.trb.2011.10.008
  55. VERBI Software. MAXQDA 24 [Computer Program]. Berlin, Germany: VERBI Software; 2024.
  56. Wagstaff A. QALYs and the equity-efficiency trade-off. J Health Econ. 1991;10(1):21-41. doi:1016/0167-6296(91)90015-f
  57. Tsuchiya A, Dolan P. Equality of what in health? Distinguishing between outcome egalitarianism and gain egalitarianism. Health Econ. 2009;18(2):147-159. doi:1002/hec.1355
  58. van Lenthe FJ, Beenackers MA. Sociaal-economische gezondheidsverschillen: zonder oorzaken geen gevolg. Tijdschr Gezondheidswet. 2017;95(4):145-146. doi:1007/s12508-017-0044-7
  59. Broeders D, Das D, Jennissen R, Tiemeijer W, de Visser M. Van verschil naar potentieel: een realistisch perspectief op de sociaaleconomische gezondheidsverschillen. WRR-Policy Brief. 2018;7:1-46.
  60. Statline - Statistics Netherlands. Gezonde levensverwachting; inkomen en welvaart. 2024. https://www.cbs.nl/nl-nl/cijfers/detail/85445NED.
  61. Griffin S, Love-Koh J, Pennington B, Owen L. Evaluation of Intervention Impact on Health Inequality for Resource Allocation. Med Decis Making. 2019;39(3):171-182. doi:1177/0272989x19829726
  62. Yang F, Angus C, Duarte A, Gillespie D, Walker S, Griffin S. Impact of socioeconomic differences on distributional cost-effectiveness analysis. Med Decis Making. 2020;40(5):606-618. doi:1177/0272989x20935883
  63. Costa-Font J, Cowell F. Incorporating inequality aversion in health-care priority setting. Soc Just Res. 2019;32(2):172-185. doi:1007/s11211-019-00328-6
  64. Dieteren CM, Bonfrer I, Brouwer WB, van Exel J. Public preferences for policies promoting a healthy diet: a discrete choice experiment. Eur J Health Econ. 2023;24(9):1429-1440. doi:1007/s10198-022-01554-7
  65. Mouter N, Boxebeld S, Kessels R, et al. Public preferences for policies to promote COVID-19 vaccination uptake: a discrete choice experiment in the Netherlands. Value Health. 2022;25(8):1290-1297. doi:1016/j.jval.2022.03.013
  66. van Baal P, Perry-Duxbury M, Bakx P, Versteegh M, van Doorslaer E, Brouwer W. A cost-effectiveness threshold based on the marginal returns of cardiovascular hospital spending. Health Econ. 2019;28(1):87-100. doi:1002/hec.3831
  67. Bobinac A, van Exel NJ, Rutten FF, Brouwer WB. Valuing QALY gains by applying a societal perspective. Health Econ. 2013;22(10):1272-1281. doi:1002/hec.2879
  68. Hansen LD, Kjær T. Disentangling public preferences for health gains at end-of-life: further evidence of no support of an end-of-life premium. Soc Sci Med. 2019;236:112375. doi:1016/j.socscimed.2019.112375
  69. Reckers-Droog V, van Exel J, Brouwer W. Willingness to pay for quality and length of life gains in end of life patients of different ages. Soc Sci Med. 2021;279:113987. doi:1016/j.socscimed.2021.113987
  70. Quaife M, Terris-Prestholt F, Di Tanna GL, Vickerman P. How well do discrete choice experiments predict health choices? A systematic review and meta-analysis of external validity. Eur J Health Econ. 2018;19(8):1053-1066. doi:1007/s10198-018-0954-6
  71. Comerford DA, Tufte-Hewett A, Bridger EK. Public preferences to trade-off gains in total health for health equality: discrepancies between an abstract scenario versus the real-world scenario presented by COVID-19. Ration Soc. 2023;36(1):66-92. doi:1177/10434631231193599
International Journal of Health Policy and Management
Volume 15, Issue 1
2026
Pages 1-14

  • Received Date 18 March 2025
  • Revised Date 19 October 2025
  • Accepted Date 10 February 2026
  • First Published Date 14 February 2026
  • Published Date 01 December 2026