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    Demand-steering policies in healthcare are understandable but problematic answers to the desire for democratization that dates from the seventies of the former century. Prominent critics such as Achterhuis and Illich were very critical of the undemocratic character of health care. Yet their romantic idea of society excused them from the need to articulate democratic alternatives. The empty space that they left was filled by the concept of demand-steering. Demand-steering, however, rather than strengthening democratic practices, merely undermines them, by preferring exit above voice, by putting up new bureaucratic barriers between clients and professionals and by undermining the quality of the relationship between clients and professionals.

    Doing more justice to the democratic impulse is possible and desirable. A new step towards this aim is being taken by a fourth logic of steering, (next to the familiar logics of the market, bureaucracy and professionalism) that centers on improving the dialogue between clients and professionals. The one variant, democratic professionalism, starts from the position of the professional and aims at intensifying democratic control, while the other variant, collaboration, starts from the client and aims at providing him with more influence and responsibility for the health care process. This fourth logic however can only provide a new impulse to democratization when the vague notion of the dialogue is elaborated more thoroughly.


Evelien Tonkens
Evelien Tonkens is bijzonder hoogleraar actief burgerschap bij de afdeling sociologie en antropologie van de Universiteit van Amsterdam en opleidingsdirecteur/docent van de masteropleiding social policy and social work in urban areas van de Uva. Correspondentieadres: UvA – afdeling sociologie en antropologie, Oudezijds Achterburgwal 185, 1012 DK Amsterdam, e-mail: e.h.tonkens@uva.nl
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