A Review of Yoga Programs for Four Leading Risk Factors of Chronic Diseases Yoga , a form of physical activity , is rapidly gaining in popularity and has many health benefits . Yet healthcare providers have been slow to recognize yoga for its ability to improve health conditions , and few interventions have been developed that take full advantage of its benefits . The purpose of this article is to review published studies using yoga programs and to determine the effect of yoga interventions on common risk factors of chronic diseases -LRB- overweight , hypertension , high glucose level and high cholesterol -RRB- . A systematic search yielded 32 articles published between 1980 and April 2007 . The studies found that yoga interventions are generally effective in reducing body weight , blood pressure , glucose level and high cholesterol , but only a few studies examined long-term adherence . Additionally , not enough studies included diverse populations at high risk for diabetes and its related common health problems . Chronic diseases such as heart disease , stroke and diabetes are leading causes of death in the US -LRB- 1 -RRB- . Common conditions for these chronic diseases are overweight , high blood pressure -LRB- BP -RRB- , high glucose and high cholesterol . These conditions are commonly associated with each other . According to a prospective cohort study focusing on men -LRB- 2 -RRB- , there were positive relationships between body mass index -LRB- BMI -RRB- and hypertension incidence . Men with a higher BMI have a higher likelihood to have diabetes and high cholesterol . Another study with men and women showed that overweight is linked to type 2 diabetes -LRB- 3 -RRB- . Even among patients newly diagnosed with type 2 diabetes , the Hypertension in Diabetes Study found that ∼ 40 % had hypertension , and that hypertension considerably increased mortality in people with type 2 diabetes -LRB- 4 -RRB- . Another recent study found a 79 % rate of hypertension in patients who had received outpatient care for type 2 diabetes for at least 2 years -LRB- 5 -RRB- . Individuals with impaired glucose tolerance also are more likely to have risk factors for cardiovascular disease such as elevated levels of triglycerides and low-density lipoprotein -LRB- LDL -RRB- and low levels of high-density lipoprotein -LRB- HDL -RRB- -LRB- 6 -RRB- . Promising in this regard is appropriate physical activity because it can reduce body weight , BP , glucose level and cholesterol -LRB- 7,8 -RRB- . Yoga , a form of physical activity consisting of various postures -LRB- Asana -RRB- and breathing and meditation techniques -LRB- Pranayama -RRB- -LRB- 9 -RRB- , has been shown to have therapeutic benefits for individuals with a wide range of health conditions , including hypertension -LRB- 10 -RRB- and diabetes -LRB- 11 -RRB- . Yoga also appears to be effective in reducing stress -LRB- 12 -RRB- and improving exercise tolerance as it is related to cardiovascular response -LRB- 13 -RRB- . The number of people practicing yoga in the US increased significantly between 1997 and 2002 -LRB- 14 -RRB- . According to the 2002 National Health Interview Survey -LRB- 14 -RRB- , 5 % of American adults practiced yoga in the month previous to the study . Yoga also is well received as a therapeutic intervention ; for example , participants in a yoga intervention for insomnia found that it was easily learned and performed -LRB- 15 -RRB- . Despite its popularity and positive physiologic effects , however , yoga has not been widely recognized in efforts to prevent and treat major chronic health conditions . The purpose of this article is to review published studies using yoga practice to determine the effects of yoga on common health problems , such as overweight , hypertension , high glucose level and high cholesterol . Methods Articles were retrieved from electronic databases -LRB- CINAHL , Ovid MEDLINE and PsychInfo -RRB- using yoga as a keyword . This initial retrieval , performed in April 2007 , yielded 2349 articles , of which 861 have been published since 1980 . A search within those 861 articles , using the keywords overweight , blood pressure , glucose and cholesterol , identified 56 research articles . After the author had read the full text of the 56 articles and identified those that met the purpose of the study , 24 articles were excluded , mainly because they described outcome variables and characteristics of yoga that were irrelevant . Poor quality was not a reason for exclusion , but studies were excluded if they focused only on meditation or relaxation -LRB- Pranayama -RRB- or if they were case studies . This process resulted in a final total of 32 articles to be reviewed . The review comprised studies involving yoga interventions and using an experimental or quasi-experimental design . In addition , observational studies were included because they often supply important information beyond the results of clinical trials -LRB- 16 -RRB- . Studies that used yoga as a control , not as an intervention , were included as long as they provided evidence of the effectiveness of yoga on variables of interest -LRB- overweight , BP , glucose and cholesterol -RRB- . Findings Of the 32 articles reviewed , 12 described experimental studies , 18 described quasi-experimental studies and two described observational studies . Only 2 of the 12 true experimental studies -LRB- 17,18 -RRB- described the randomization method . Even though risk factors for chronic health conditions were used as keywords in the search strategy , many of the studies used healthy adult samples ; only half of the 32 studies actually focused on subjects with diabetes -LRB- 19 -- 23 -RRB- , hypertension -LRB- 10,11,18,24 -- 27 -RRB- , or cardiovascular disease -LRB- 28 -- 31 -RRB- . Seven of the studies were conducted in the US ; the others , in India and other countries . Content of Yoga Programs Other than duration and frequency , most articles did not describe the yoga sessions in detail . Only a few articles -LRB- 17,20,22,31,32 -RRB- provided details of the yoga sequences used . Some listed the names of postures and breathing techniques . Of the few articles that identified the type of yoga studied , the most common was Hatha yoga , a popular form of yoga in the Western world . The Compendium of Physical Activities , -LRB- 33 -RRB- a coding scheme that classifies physical activity based on energy expenditure , does not define energy expenditure while performing various types of yoga . However , Hatha yoga is classified as a conditioning exercise , in the same category as stretching , which has a metabolic equivalent -LRB- MET -RRB- of 2.5 -LRB- 1 MET equals the amount of energy used for resting -RRB- . A recent study -LRB- 34 -RRB- found that when young adult women -LRB- 19 to 40-years old -RRB- performed a 30-min session of Hatha yoga , the MET was 2.17 . However , if the session was made more active using Sun Salutations , a flowing series of physical postures , the MET increased to 3.74 -LRB- SD = 0.70 -RRB- . Frequency and Duration of Yoga Sessions The total dose of yoga training , which depends on both the duration and frequency of yoga sessions , also needs to be considered in evaluating and comparing yoga studies . The most common duration and frequency of yoga sessions in the studies were 30 -- 60 min per session and sessions meeting daily for 4 -- 10 weeks , but many studies used sessions meeting 2 -- 3 times per week for 8 -- 12 weeks . Some yoga programs met more frequently than others but for a shorter time span . For example , in a study by Damodaran et al. -LRB- 24 -RRB- , persons with essential hypertension received 1 h of yoga training daily for 3 months , which is counted as 84 h of training , whereas Ray et al. -LRB- 32 -RRB- studied healthy young adults who received 1 h of yoga training three times a week for 10 months , for a total of 120 h . Some findings can be useful in trying to determine effective durations of yoga sessions . For example , in one study , 1 h daily yoga practice was associated with significant reductions in body weight and cholesterol levels after 4 weeks , and those significant effects lasted for 14 weeks -LRB- 28 -RRB- . In a study of 20 patients with essential hypertension , daily 30-min sessions of yoga led to a decrease in BP by the fifth day -LRB- 27 -RRB- . Adherence to the Yoga Program Any persistent benefits from yoga would rely on long-term adherence , which was examined in only a few of the reviewed studies . In some studies , after yoga training , subjects were asked to continue their programs with daily home practice -LRB- 28,35 -RRB- . One of these -LRB- 35 -RRB- compared adherence to yoga practice after a 10-week yoga intervention between white and black American adults -LRB- mean age : 69 years for whites and 70 years for blacks -RRB- . Although the dropout rate did not differ significantly -LRB- 16 % for whites , 22 % for blacks -RRB- , the black participants did not engage in yoga at home as frequently as whites . A different study -LRB- 36 -RRB- found greater compliance with subsequent home practice among participants in a yoga class that met three times per week than in those who attended a weekly yoga class -LRB- 86 % versus 65 % , P < 0.05 -RRB- . However , found no difference in compliance with home practice between groups engaged in yoga or aerobic exercise -LRB- 36 -RRB- . Weight Decreased According to a retrospective observational study of 15,550 adults aged 53 -- 57 years -LRB- 37 -RRB- , regular yoga practice for 4 or more years was significantly associated with weight loss by overweight participants . Several intervention studies -LRB- 10,26,29,31,38 -- 41 -RRB- also showed that yoga practice was effective in reducing body weight . After 4-day residential yoga practice followed by 14 weeks of 1 h daily home practice , one study -LRB- 28 -RRB- found a significant loss in mean body weight from 72.26 to 70.48 kg among subjects with risk factors for coronary artery disease -LRB- CAD -RRB- . Other studies found that yoga was associated with significant weight loss by subjects with CAD -LRB- 29 -- 31 -RRB- and subjects without CAD -LRB- 30 -RRB- . Manchanda et al. -LRB- 29 -RRB- showed a 7 % loss of body weight among adult men with CAD after 1 year of yoga practice , and in a study by Schmidt and colleagues , healthy adults lost an average of 5.7 kg after 3 months of yoga practice -LRB- 39 -RRB- . All overweight adults studied by Yogendra et al. reached a normal weight within 1 year after initiating yoga-based lifestyle modifications -LRB- 31 -RRB- . However , this article did not show the effect size of this change . Blood Glucose Level Lowered Of the six studies that examined blood glucose , all found that yoga was effective in reducing blood glucose level -LRB- 11,19 -- 22,31 -RRB- . For example , after 4 months of yoga practice , fasting glucose fell significantly -LRB- from 144 to 119 mg dl − 1 , P < 0.005 -RRB- in a group of adults with type 2 diabetes , -LRB- 19 -RRB- . Another sample of 24 adults with type 2 diabetes had significantly decreased fasting glucose -LRB- from 190.1 to 141.5 mg dl − 1 , P < 0.001 -RRB- after 40 consecutive days of yoga practice , -LRB- 20 -RRB- . Adults with normal blood glucose levels -LRB- 11 -RRB- also had significantly lower glucose levels after 3 -- 4 h of yoga practice for 8 days -LRB- P < 0.001 -RRB- . BP Decreased This review found ample evidence that yoga was effective in reducing BP . In a group of low-income elderly people , effects on systolic BP did not differ between a yoga class and an aerobic exercise class , both held three times a week for 10 weeks -LRB- 36 -RRB- . However , eight other studies found that yoga practice was effective in lowering BP in healthy samples , regardless of the type of yoga -LRB- 13,32,38 -- 44 -RRB- . Yoga practice also significantly improved BP among people with hypertension -LRB- 10,11,18,24 -- 27 -RRB- , cardiovascular disease -LRB- 28 -- 31 -RRB- or type 2 diabetes -LRB- 19 -- 23 -RRB- . For example , in 13 patients , aged 41 -- 60 years , with essential hypertension -LRB- 25 -RRB- , BP dropped significantly during the third week of a 4-week yoga program -LRB- 1 h per day , 6 days per week -RRB- , and it fell further after the program . For example , systolic BP dropped from 141.7 to 127.9 mmHg by the third week and to 120.7 mmHg by the fourth week . Cholesterol Level Improved The practice of yoga was associated with significant decreases in cholesterol among subjects with cardiovascular disease -LRB- 28,29 -RRB- , hypertension -LRB- 11 -RRB- or type 2 diabetes -LRB- 19 -RRB- . One study -LRB- 28 -RRB- examined a regimen involving 4 days of a yoga program at a residential course , followed by 1 year of yoga practice at home . In both men with angina and asymptomatic participants with CAD risk factors , all lipid variables except HDL decreased beginning the fourth week of yoga practice -LRB- e.g. total cholesterol fell from 206.6 to 193.6 mg dl − 1 -RRB- , and the level of total cholesterol continued falling to 176.06 mg dl − 1 at 14 weeks . A study of subjects at risk for cardiovascular disease and diabetes -LRB- 11 -RRB- found significant improvements -LRB- P < 0.01 -RRB- in total cholesterol , triglycerides , LDL , HDL and very-LDL -LRB- VLDL , defined as total cholesterol minus LDL minus HDL -RRB- after short-term intensive yoga practice -LRB- 3 -- 4 h per day for 8 days -RRB- . Notably , for subjects whose baseline total cholesterol was 200 mg dl − 1 or higher , the reduction in triglycerides -LRB- from 151.5 ± 48.9 to 132.7 ± 50.5 mg dl − 1 , P < 0.001 -RRB- and VLDL -LRB- from 36.7 ± 13.8 to 30.2 ± 14.6 mg dl − 1 , P < 0.001 -RRB- was significantly greater than in subjects with lower baseline total cholesterol -LRB- triglycerides falling from 113.6 ± 46.5 to 110.5 ± 38.1 mg dl − 1 , P > 0.05 ; VLDL from 23.7 ± 12.8 to 23.2 ± 12.5 mg dl − 1 , P > 0.05 -RRB- . Finally , a study of healthy adults over 40 years old found that 5 years of yoga practice reduced age-related deterioration in cardiovascular functions -LRB- 45 -RRB- . Although the article describing this observational study did not detail the type of yoga performed nor the frequency or intensity of the yoga sessions , the data showed a long-term change indicating the effectiveness of yoga on cardiovascular functioning . Four studies used aerobic training as an intervention and yoga as a control -LRB- 38,43,46,47 -RRB- . One of these , a study of healthy active people aged 65 years or older -LRB- 38 -RRB- , found that aerobic exercise produced no significant reduction in weight or BP , whereas 4 weeks of yoga practice did lead to some reduction in weight or BP -LRB- for example , systolic BP decreased from 146 to 139 mmHg -RRB- . DiPietro et al. -LRB- 47 -RRB- found no change in glucose and insulin responses in their yoga control group . However , the yoga control group was monitored to ensure that pulse rates did not exceed 90 beats per min during yoga practice -LRB- 47 -RRB- . Therefore , this restriction should be considered in interpreting this result . Discussion The reviews showed that yoga had beneficial effects on body weight , BP , blood glucose level and cholesterol level -LRB- Fig. 1 -RRB- . Nonetheless , several shortcomings in research on this topic need to be addressed , in order for clinical programs to capitalize on these health benefits . Figure 1 . The possible effects of yoga on behavioral , psychological and physiological measures are illustrated . This article focuses on current evidences for physiological changes . Of the articles describing interventions , only a few provided details regarding the yoga programs or the names and sequence of yoga postures . Asana and Pranayama provide different types of health benefits , and therapeutic yoga programs can involve various combinations of these two components . An optimal comparison of study results thus requires knowing the combination of Asana and Pranayama used . The sequence of yoga postures can be inferred from the list of posture names , but more straightforward information is essential to future studies seeking to replicate or generalize the results . A related issue that remains to be resolved is how to standardize yoga exercises for research purposes . The optimal duration and intensity required to maximize the effectiveness of yoga need to be determined , as does the need for a booster to provide long-term effects . Because the MET of yoga is low , increasing the frequency may increase the benefits . However , these factors can not be judged from the reviews studies ; many articles did not clearly identify the dosage of the yoga program studied , and they focused on the short-term health benefits of yoga . Only a few studies included follow-up data beyond 6 months . It also remains to be determined whether more intensive training , that is , a greater dosage , improves the likelihood of adopting and maintaining active behavior in the long run . The samples in the reviewed studies pose additional dilemmas . It was not a surprise that a large portion of the studies were conducted in India , where the philosophy and practice of yoga originated . However , this focus on one geographical region , where yoga is particularly ingrained in the culture , limits the generalizability of results . Few studies have addressed variables of interest specific to minorities in the US -LRB- Blacks , Hispanics and Asians -RRB- , which are populations believed to be more vulnerable to type 2 diabetes -LRB- 48,49 -RRB- and physical inactivity -LRB- 8 -RRB- . Yoga has beneficial effects on various health conditions . A large portion of the reviewed studies analyzed the effects of yoga with healthy samples . There is evidence that yoga practice was more effective in lowering triglycerides among people with higher cholesterol than those with a lower cholesterol level -LRB- 11 -RRB- . Therefore , it is important to consider participants ' health conditions because there are possible differences in the effects of yoga by their health severity . Conclusions Analyses of yoga intervention should be designed and conducted to identify programs best suited for diverse populations and for specific populations with high-risk factors for chronic health conditions . Such studies could guide the development of more practical and effective interventions .

O O O B O O O O B I O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O B O O O B I O O O O B O B O O B O O O B O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O B O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O B O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O B O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O B O O O B O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O B O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O B O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O B O O O O O O O B O B O O B O O O B O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O B O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O B O O O O O B O O O B O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O B O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O B O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O B O O O O O O O O O O O B O O O O O O O O O O O B O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O B O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O B O O O O O O O O O O O O O O O O O B O O O O O B O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O B O O O O O O O O O O O O O B O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O B O O O O B O O O O O B O O O O O O O O O O O O O O B O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O B O O O O O O O O B O O O O O O O B O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O B O O O O O O B O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O B O O O O O O B O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O B O O O O O O O O O O O O O O B I O O O O O O O O O O O O B O O O O B O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O B O O O O O O O O B O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O B O O O O O O O O O O O O B O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O B O O O O O O B O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O B O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O B O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O 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The `` Health Benefit Basket '' in The Netherlands This contribution describes the entitlements in Dutch health care and explores how these entitlements are determined and to whom they apply . The focus is on services of curative care . No comprehensive positive or negative list of individual services is included in formal laws . Instead , the legislation states only what general types of medical services are covered and generally the `` usual care '' criterion determines to which interventions patients are entitled . This criterion is not very restrictive and yields local variations in service provision , which are moderated by practice guidelines . It is conceivable , however , that the recent introduction of the DBC financing system will change the reimbursement and therefore benefit-setting policy . This contribution gives a detailed account of entitlements in the Dutch health care system . Furthermore , it explains who decides about the services covered and the legal context in which this is done . It also describes which parts of the health benefit basket are defined more implicitly and which more explicitly , outlining the criteria used for the definition of the basket . We present the main characteristics of the Dutch health care system , highlighting those that impact on the entitlements of the insured . We then present a detailed account of health care entitlements in curative care . Finally , we conclude by identifying the aspects that determine the health care package and require special attention in a European context . We specifically ask what future developments are likely to impact on this system for definition of entitlements . The main characteristics of the system The Dutch Constitution states that the government should provide services to improve and protect public health . Therefore about 80 % of health expenditures are paid from public funds -LRB- mainly social insurance -RRB- , the rest being financed from private insurance and out-of-pocket payments -LSB- 1 -RSB- . The health insurance system broadly consists of three compartments -LRB- see Table 1 -RRB- . First , every citizen is entitled to long-term care covered under the Exceptional Medical Expenses Act -LRB- Algemene Wet Bijzondere Ziektekosten , AWBZ -RRB- . The AWBZ scheme pays for about 43 % of Dutch health expenditure . Secondly , for acute care individuals are either publicly insured under the Sickness Fund Act -LRB- Ziekenfondswet , ZFW -RRB- or privately insured -LRB- 37 % and 15 % of healthcare expenditure , respectively -RRB- . The ZFW scheme covers among other things the costs of hospital admissions , treatment by physicians , pharmaceutical care , and medical aids.Table 1 The three `` pillars '' of the Dutch health care systemFirst pillarSecond pillaraThird pillarType of careLong-term careBasic curative servicesAdditional servicesPrimary regulation -LRB- laws -RRB- AWBZb , cPrivate insurancec , WTZc , ZFWbComplementary insuranceb , cSecondary regulation -LRB- decrees -RRB- Decree on Entitlement to Exceptional Medical Expenses InsuranceHealth Insurance Treatment and Services Decree -- Tertiary regulation -LRB- discretion of Minister -RRB- Regulation on Subsidies in AWBZRegulations on Medical Specialist Care -- Regulations on Entitlements to AWBZ-careRegulations Governing the Provision of Paramedical Assistancea To be replaced in 2006 by a statutory health insurance scheme that covers the entire populationb Administered by sickness fundsc Administered by insurance companies Persons who do not qualify for compulsory health insurance but can not satisfy private insurers ' acceptance criteria -LRB- for example , if they represent a high risk -RRB- have access to a `` standard insurance package '' which is similar to that of the ZFW . This entitlement is specified in the Medical Insurance Access Act 1998 -LRB- Wet op de toegang tot ziektekostenverzekeringen , WTZ -RRB- . The third compartment consists of complementary insurance policies that may be bought to extend coverage . The basic insurance package is defined mainly at the central government level , although only categories of services are identified . The AWBZ and ZFW -LRB- acts of Parliament -RRB- offer a list of the functional categories of health care services to which a patient is entitled -LRB- e.g. , pharmaceutical care , hospital care , rehabilitation services -RRB- . These formal laws indicate in general terms which areas of care are covered by the insurance scheme , but they do not specify the entitlements of the insured in detail . Usually further specification is provided in lower types of regulations by the government or the Ministry of Health , Welfare , and Sport and its advisory bodies . The lower forms of regulation specify the contents and the extent of the entitlements , specify conditions , and delegate responsibilities . Two important governmental decrees are associated with the AWBZ and the ZFW , respectively : the Decree on Entitlement to Exceptional Medical Expenses Insurance and the Health Insurance -LRB- Treatment and Services -RRB- Decree . The social health insurance system ensures that patients receive the care to which they are entitled . Management of the two-tiered public/private system , however , has proven difficult for the government , especially since the system lacks sufficient incentives for efficiency and has unfavorable equality characteristics . These conditions stimulated major reforms . Government involvement will be reduced significantly in 2006 when a new Health Insurance Act comes into force . This forms the final phase of the so-called Dekker plan -LRB- 1987 -RRB- . The Dekker proposals set out conditions for the introduction of regulated competition in health care which should make the system more responsive to the preferences of consumers and less burdensome to manage . Health insurers have become main actors in promoting cost containment since they now hold full budget responsibility and may enter into contracting with providers . The government has promoted competition by enforcing open enrollment with health insurers and through establishing agencies that should regulate competition -LRB- e.g. , an antitrust agency has been active in the health care sector since 1998 -RRB- . Nevertheless , the government will remain responsible for defining the health basket . A comprehensive description of the Dutch health insurance system is presented elsewhere -LSB- 2 -RSB- . The following section concentrates on the services made available in the health basket and the way in which these are decided . This description is limited to the curative sector . A complete account of health care services available in all health care sectors is offered by Stolk and Rutten -LSB- 3 -RSB- . Note that the integration of social and private insurance schemes into a national insurance implies that the coverage of the ZFW will be extended to the entire population . For this reason the present contribution describes only the ZFW benefit package . The benefit package for curative care The definition of entitlements for curative care is typical for the Dutch system : new interventions are usually implicitly introduced into a largely unspecified benefit package . A small negative list explicitly excludes services from reimbursement . This reflects the absence of a systematic procedure for the evaluation of curative services when defining the basket . Medical specialist care The ZFW specifies a general entitlement to specialist care by hospitals -LRB- both inpatient and outpatient care -RRB- : patients are entitled to medical , surgery , and obstetric care . Entitlement to hospital care also exists under the AWBZ if the patient must stay in hospital longer than 365 days . The provided care is limited merely by professional norms following the `` usual care '' principle -LRB- appropriateness according to professional standards -RRB- . Also , a general statement is made that health care should be provided efficiently . Therefore the definition of entitlements for hospital care is rather implicit and the `` usual care '' criterion is not very restrictive . However , the entitlements are conditional upon the referral by a general practitioner , by another specialist to whom a general practitioner had referred the insured , or , where obstetric care is concerned , by a midwife . A ministerial decree , the Regulations on Medical Specialist Care , further specifies entitlements by excluding specific forms of transplantation and plastic surgery . It also determines that only certain types of transplantations are covered , and states that entitlement to some services -LRB- e.g. , plastic surgery -RRB- only exist if specific conditions are met . Finally , this regulation explicitly excludes services such as eyelid , ear or body sculpturing , in vitro fertilization -LRB- IVF -RRB- , uvoloplasty for persons who snore , sterilization or undoing sterilization , and circumcision . It should be noted that IVF is a special case and its reimbursement policy changed several times . Today , health insurers are subsidized to fund IVF treatment for the insured after the first attempt has been paid out of pocket . Pharmaceuticals dispensed in hospitals are part of the entitlement to hospital care . They are generally financed out of the hospital budget , but the insurer may separately reimburse an additional percentage -LRB- up to 80 % -RRB- of the cost for very expensive hospital drugs . The law remains rather vague about entitlements to hospital care , but a recently introduced pricing system has led to more explicit benefit definition . In 2005 a new system for hospital financing was introduced by law : the Diagnose Behandeling Combinaties -LRB- DBCs -RRB- , a DRG-like system describing all products that are provided in hospitals . Medical experts were involved in the determination of these DBCs , which are defined as the whole set of activities -LRB- diagnostic and therapeutic interventions -RRB- of the hospital and medical specialist starting from the first consultation and diagnosis of the medical specialist in the hospital until discharge . Each DBC is characterized by a code combining information on diagnosis -LRB- International Classification of Diseases , 10th edition -RRB- and treatment . This system facilitates negotiations between health insurers and hospitals on prices -LRB- on a bilateral level -RRB- , at the same time providing a catalogue of medical services . Table 2 shows how many different DBCs are defined within a medical specialty distinguishing between list A -LRB- prices fixed by the National Health Tariffs authority until further notice -RRB- and list B -LRB- prices negotiated by Sickness Funds and hospitals from January 2005 onwards -RRB- . This catalogue of DBCs allows the specification of which DBCs are included in the basis package : the `` red '' list presents the number of DBCs not covered by compulsory insurance as determined by the Health Care Insurance Board on the basis of the `` usual care '' criterion and current explicit exclusions . Also an `` orange '' list exists with DBCs for which reimbursement is limited to certain groups of patients . Finally , the table lists the number of product groups that have been defined to cluster DBCs into homogeneous price groups , as negotiation on the price of each single DBC would not be feasible.Table 2 Overview of the DBC system -LRB- January 2005 -RRB- SpecialtyNumber of DBCsProduct groupsaList AaList BaRed listbOrange listbOphthalmology1 ,7893181415 Otorhinolaryngology6926 -- 3514Surgery3 ,671182850553 Plastic surgery13 ,7126320554433 Orthopedics 3,0581412443 Urology37 ,71795011617438 Gynecology5362263434Neurosurgery1 ,25327151329 Dermatology39610323311Internal medicine3 ,33519 -- 61249Pediatrics3 ,4921091261 Gastroenterology10 ,946190 -- 34221Cardiology353 -- -- 4439Respiratory medicine1 ,054145537143 Rheumatology2 ,042129519617 Allergology599 -- -- 8Thorax surgery1 ,034 -- 105027Psychiatry648 -- -- -- 3Neurology2 ,73918446143 Geriatrics918 -- -- -- 16Radiotherapy468 -- -- 19514Radiology13 ,216 -- -- 4728Anesthesiology582 -- 103819Clinical genetics100 -- -- 3Total104 ,3501,3761,5113,649641 a Published at the website of the National Health Tariffs authority -LRB- CTG/ZAio -RRB- : http://www.ctg-zaio.nl/index.phpb Published at the website of the DBC maintenance organization : http://www.DBConderhoud.nl An exception to the way in which medical specialist services are regulated is mental health care , which is currently covered under the AWBZ . Also the first year of treatment is covered by the AWBZ and not by the ZFW , as is the case for other medical specialist services . The reason is that psychotherapy is often a long and intensive treatment . Ambulatory psychotherapy is reimbursed -LRB- maximum of 25 sessions , 50 in the case of personality disorders -RRB- if referral is by a general practitioner or psychiatrist . Patients ' entitlements to mental health care through the AWBZ include treatment -LRB- therapy sessions and medication -RRB- , supportive guidance , and accommodation . Special regulations apply to mental health care in children and to treatment of addictions . The objective is to make mental health care a part of the basic benefit package under the new Health Insurance Act and therefore shift it to compartment 2 in a competitive environment . To permit this change DBCs in mental health care are now being defined . Primary care , dental care , and paramedical services Primary care , i.e. , medical and surgical care provided by general practitioners , is covered under the ZFW , as specified in the Health Insurance -LRB- Treatment and Services -RRB- Decree . Care involves mainly consultations and visits , the prescription of pharmaceutical care , referral to medical specialists , and minor operations . Entitlements to these services are also defined implicitly : any type and quantity of care consistent with professional norms is covered by the scheme . Entitlements to dental care have been limited in the past and are defined explicitly . The ministerial regulation `` Dental Care Health Insurance '' stipulates that persons up to the age of 18 years are entitled to dental care under the ZFW . Dental care includes 14 types of services , among which are periodic checkups , fluoride application treatment , sealing , and periodontal care . Adults are entitled to dental care only under special circumstances : special dental conditions and physical or mental disabilities . Paramedical care -- consisting of physiotherapy , Mensendieck or Cesar remedial therapy , speech therapy and ergotherapy -- is partly covered . The first nine sessions are excluded from reimbursement , but thereafter some patients over the age of 18 years are entitled to physiotherapy , Mensendieck or Cesar remedial therapy for the treatment of chronic conditions that are defined in the Regulations Governing the Provision of Paramedical Assistance . Curative care at home Under exceptional conditions and with authorization by the sickness fund , specialized services of curative care may be provided at home . First , persons are entitled to kidney dialysis at home or in a dialysis center under ZFW . If the dialysis takes place at home , the costs of training a person to carry out dialysis or providing assistance during the procedure are also covered . The costs of inspecting and maintaining equipment , modifying the home , providing special sanitary fittings , and heating are also reimbursable . Second , the ZFW regulates the use of treatment for chronic intermittent ventilation . Those covered by the ZFW are entitled to treatment at a ventilation center . A center may lend the patient the equipment for use at home or in a location where several persons can use the equipment . Specialist and pharmaceutical care provided by or on the advice of the ventilation center are also included . Discussion A liberal benefit package ? In The Netherlands decisions about the medical services offered to a patient are often left to the physician -LRB- and/or the health insurer -RRB- . Negative lists are in certain categories used to exclude services -LRB- e.g. , the new red and orange lists of DBCs -RRB- . The extent to which new or old technologies -LRB- therapy , diagnostic services , and pharmaceuticals -RRB- are provided to the patient in the context of a DBC is left to the providers . However , some medical services were explicitly excluded for not being considered to belong to the domain of health care -LRB- e.g. , plastic surgery -RRB- . Additionally , limits were set to the provision of physiotherapy and psychotherapy for a lack of demonstrated effectiveness . Restrictive legislation only exists in the pharmaceutical sector where an itemized positive list of individual products is frequently updated -LSB- 4 -RSB- . For several other functional categories there are also positive lists , but these are not frequently updated -LRB- e.g. , for medical devices and vaccines -RRB- . Regarding pharmaceuticals it is interesting to observe that the reimbursement of extramural drugs -LRB- prescription filled by the community pharmacist -RRB- is centrally regulated , while for the use of drugs in the hospital the policy is liberal . The liberal policy has led to wide variations in the availability of certain expensive drugs across hospitals and to referral of `` expensive '' patients to specialized centers . The new hospital financing system will change this and will probably force decision makers to regulate the provision of expensive drugs within a DBC . Procedures and criteria for limiting the health basket The package can be limited by management of positive or negative lists , copayments , the definitions of conditions restricting eligibility , and promoting best practice , i.e. , effective and efficient provision of care . Each instrument is applied within the Dutch system , although some sectors are more loosely managed than others . On the whole , emphasis is put on offering incentives for efficiency . Recently a no-claim system was introduced : if someone insured under ZFW has no expenses , he receives a bonus of $ 255 from his insurer or the difference if his expenses are less than $ 255 . The liberal character of the basket is further illustrated by the fact that there is no systematic and central effort to use common criteria for defining the package as a whole . Nonetheless , decisions tend to be guided by a quite homogeneous set of considerations . The respective Ministers of Health and more specifically the Health Care Insurance Board have been using health technology assessment -LRB- and cost-effectiveness information -RRB- since the middle 1980s as a tool for deciding on large public programs -LRB- e.g. , national cancer screening programs -RRB- and on the addition of expensive curative programs -LRB- e.g. , transplant programs -RRB- to the package -LSB- 5 -RSB- . Especially in the case of pharmaceuticals dispensed outside the hospitals the role of cost-effectiveness as criterion for reimbursement is quite prominent . If the manufacturer can demonstrate greater effectiveness than existing drugs and wants a premium price , he must submit a pharmacoeconomic dossier and figures allowing the Health Care Insurance Board to base its policy on information on -LRB- cost - -RRB- effectiveness . Furthermore , many technology assessment studies have been financed from a special fund managed by the Health Care Insurance Board and later by the National Medical Research Council that have produced valuable information on the cost-effectiveness of new diagnostic and therapeutic procedures . Although not legally required , this information has been used to define the benefit package or for the development of practice guidelines . Further criteria have emerged as constant factors in decision making : severity of illness , individual vs. collective responsibility , affordability , and leakage -LRB- the probability of use outside a targeted patient group -RRB- -LSB- 6 -RSB- . Although initially consistent use of these criteria may have been doubted , gradually patterns emerged . Severity of illness , for example , played a role in deciding to finance the lung transplantation program although it was demonstrated to have a high cost-effectiveness ratio -LSB- 7 -RSB- . In relation to budget impact it also played a role in the decision not to fund PDE-5 inhibitors in the treatment of erectile dysfunction . Responsibility and affordability have played a role in deciding to restrict the reimbursement of pills for minor illnesses and dentistry . Leakage played a role in the decision to limit funding of some medicines -LRB- e.g. , clopidogrel -RRB- to specific patient group . The increased understanding of the balance between the criteria is also recognized by policy makers . The role of practice guidelines An important way to influence the providing of service is through practice guidelines . There are many disciplinary and interdisciplinary practice guidelines for both primary and secondary care , some of which are also based on economic evidence . In The Netherlands a government program supported the development of practice guidelines in 1998 -- 2002 which led to 31 consensus guidelines for medical practice addressing 23 disorders across seven disease groups as defined by the International Classification of Diseases . One example is the guideline for the use of cholesterol-lowering drugs in primary and secondary prevention which sets rules for the prescription of statins according to the patient 's personal risk profile . Future prospects An important development is the change in hospital financing , involving description of the benefit package in terms of DBCs which are or are not reimbursed . Currently it is being discussed how the definition of DBCs can be more detailed to include specific regulations on the technologies to be used within a certain treatment . A so-called `` maintenance organization for DBCs '' is set up to -LRB- re -RRB- define DBCs . The reforms of 2006 are intended to reduce government control in the health care sector and provide incentives to patients and insurers for cost consciousness . Health care should follow the preferences of consumers . It follows that entitlements are formulated in functional form rather than as specific facilities or services . It is still not clear whether local actors will assume a role in defining the basket , and whether the government will centralize decisions .

O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O 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O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O 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