Beyond Arm’s Length

A qualitative analysis of a semi-autonomous agency's accountability practices in decision-making about conflicting public values
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Runtime: 2019-2023
Client: National Health Care Institute (Zorginstituut Nederland)

Project description

Since the 1980s, central governments across the globe have increasingly created semi-autonomous agencies operating at distance of their so-called ‘arm’s length’. These agencies are expected to realize enhanced public service delivery closer to citizens. Besides the pressure to realize these high expectations, they operate in a challenging position in-between the state, organized interests and individual citizens. Since agencies cannot be directly held accountable by individual citizens, they are expected to compensate for this ‘public accountability deficit’ by rendering account to these three actors through other public accountability practices. 

This expectation is particularly pressing when they make substantive decisions about salient issues in which conflicting public values are at stake. This book provides an in-depth qualitative analysis of the Dutch National Health Care Institute (Zorginstituut Nederland, ZiN) and thereby shows how public accountability can play a role in decision-making about conflicting public values by a semi-autonomous agency. The book shows that, in deciding on these values, the agency engages in three forms of public accountability. It shows that, although these multiple accountability forms and their strategic interaction have several advantages, they can also impede efficient decision-making in the public interest. The four conducted studies make clear that engaging in multiple accountability increases the complexity of the agency’s daily work.

This complexity has resulted in uncertainty about the agency’s role in the Dutch healthcare system of regulated competition. The book further sheds light on the current endeavors of the agency and other institutional actors in Dutch health policy to work their way out of this complexity and reflects on the international trend of ‘agencification’. 


Jolien van de Sande (PhD Candidate), Dr. Bert de Graaff, Prof. dr. Antoinette de Bont.

PhD defence (embargo version)


For the full version, please contact Dr. Jolien van de Sande at

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