140 CHAPTER 5 Our findings suggest that the Solid Start program contributes to the shift from traditional, fragmented care towards a more integrated, population health-based care system as described in literature (39). This approach involves an increased focus on prevention, recognition of the social determinants of health and improving equity in health and wellbeing (39). In line with literature about complex persistent problems, societal transitions, system changes and transformations (40-43), stakeholders mentioned that these developments take time and effort. Historically grown specializations and demarcations that once facilitated progress in healthcare now pose significant integration barriers due to separated cultures, structures and legislations. Nevertheless, it seems that Solid Start has created a nationwide movement to integrate medical and social services for early life within a relative short time (mid-2018 till 2021), with modest funding (€41 million allocated throughout the program’s duration) (15, 44) and without a system reform or refiguration. According to Barsties et al.’s transition research in Dutch obstetric care (8), social obstetrics is a new way of thinking, doing and organizing that challenges the incumbent regime that may provide a sustainable addition to the current system, instead of a disruptive transformation. The authors note that social obstetrics can be a starting point for further transformations in obstetrics and other societal systems. Several experts also suggest that systemic structures (e.g. financial structures, laws and regulations) must ultimately transform to achieve greater sustainability and long-term impact than possible through improvements within the current system (43, 45). The trajectory of such transformational processes is often unpredictable and nonlinear (46). Our findings reveal various practical and systemic barriers that impede stakeholder efforts to effect change, calling for systemic transformations as well. The path towards improvements in early life will be influenced by political decisions made in the Netherlands. In any case, stakeholders emphasized the importance to institutionalize Solid Start and ensure the program’s sustainability, to guarantee that the incremental changes result in lasting improvements. Drawing on stakeholders’ perspectives and previous literature, several factors can accelerate this transition. The first factor is structural and sustainable funding. Short-term grants should be considered a bridge towards stable financial arrangements for long-term integration and value-creation (45, 47). Meanwhile, sustainable arrangements with municipalities, healthcare insurers, and others should be considered to fund prevention and health promotion, which may require local experiments and legal enforcements. The second factor is adapting the scope of laws and regulations to facilitate Solid Start and cross-sectoral collaboration. The recent changes to the Public Health Act since July 1, 2022, for example, require municipalities to provide prenatal home visits by youth healthcare to parents-to-be in vulnerable situations. Stakeholders have requested additional changes, such as legally outlining preconception care and early detection of vulnerability. If such activities are regarded as core tasks due to laws and regulations, organizations and professionals may be less likely to drop Solid Start activities during crises such as COVID-19 and (expected) labour shortages. The need fits the wider call in the Netherlands to embed public health benchmarks in legislation to increase accountability, similar to environmental legislation (48).
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