There is probably no other sector of the welfare state where the gap between citizen's expectations and government's opportunities is deepening so intensely and has such a complex and politicized reform agenda as the health care sector. Health care is a critical case par excellence to study the relation between efficiency and legitimization of welfare state reform. The leading question of this special issue of Beleid & Maatschappij is: how does the Dutch health care system and the connected public policymaking accommodate the different and often conflicting goals (input), organizing concepts (throughput) and outcomes (output)? With these questions in mind the dominant governance principles of Dutch health care, especially the system of regulated competition, are scrutinized. One of the findings is, that 'second best' solutions are the highest achievable in this field, a notion that reform policies should take into account.

This article provides an overview of the various initiatives in the past decades to measure the outcomes of health care systems from a public health perspective. It is described how on the one hand the performance measurement techniques and its associated indicators have become more sophisticated over the years but on the other hand how the indicators meet difficulties in being incorporated in policy and management by policymakers and politicians. The present health care reform in The Netherlands will enforce the debate on competing health care outcomes (effectiveness, efficiency, equity). Steps are described how to take the steering on health outcomes as a more central notion in health system redesign.

This paper analyzes the way the Flemish administration dealt with the competence transfer in the field of agriculture it experienced in 2001-2002. The main research question goes as follows: “Which factors have an impact on a successful competence transfer in the context of a state reform”. This research shows that the decision-making process has a negative impact on that success because of the difficulties the administration experiences with the translation of the vague political compromises in the law. On the other hand, there is evidence that the change management willingness and capacity of the ‘receiving’ Flemish and ‘losing’ federal administration have a positive influence on that success.