Governing regional care networks and the AZWA work agenda

The AZWA, the Dutch supplementary health and social care agreement, builds on its predecessor, the integrated care agreement (IZA), and uses the same 38 regions. In each region one lead municipality applies for the funding on behalf of all municipalities and, together with the region’s lead health insurer, makes agreements with providers. The Association of Netherlands Municipalities (VNG) writes that this mandate structure has no formal legal form, such as a joint arrangement between municipalities; the municipalities decide among themselves, at regional level, how they reach decisions. The brief for the work agenda (version of 20 April 2026) puts the lead municipality and the insurer in charge of a regional work agenda setting out goals, priorities, who does what, and how parties will hold each other to account if plans stall. The agenda is first adopted at the IZA regional table and then by every municipal executive (the mayor and aldermen), before 15 November. Without a submitted work agenda, central government will not pay out the funding for 2026.

At the start of 2026 RIVM, the Dutch public health institute, measured for the third time how the collaboration is working in practice, using questionnaires completed by 320 of the 342 municipalities and 36 representatives of health insurers. More than 60 per cent of the IZA regions have no centralised form of governance; across all large networks of more than eight organisations the figure is 40 per cent. Lead municipalities give making agreements with the insurer a mark of 5.7 out of 10 and the sense of shared responsibility a 6.3; the insurers give the same items 6.9 and 7.4. According to RIVM, the collaboration has stabilised after last year’s decline, but joint decision-making and firm financial agreements are still seen as inadequate. The report warns that a new agreement may push the old arrangements into the background, and that funding with a three-year term is once again temporary.

The University of Groningen (RUG) and Hanze University of Applied Sciences looked at the networks themselves. From 2,302 projects screened, the researchers analysed 142 initiatives spanning several domains against 33 building blocks for lasting collaboration. The average is 2.93 out of 33 points, two thirds score three points at most, and not a single initiative falls into the ‘good’ category. Three building blocks are missing everywhere: a governance structure that can grow with the complexity, a plan for when key people leave, and systems that genuinely let data flow between organisations. Municipalities and insurers are involved in 41 per cent of the initiatives, and seven in ten sources are not public or only partly so, which according to the researchers means every region reinvents the wheel.

So the problems pile up. The agreement places obligations and a deadline on a network that rarely has a governing body, with a mandate that on paper rests with one municipality and in practice with every municipal executive. What is missing is what any ordinary organisation would miss first: who decides when there is friction.

How solid is this? The AZWA dates from August 2025 and the first measurements that say anything about it are from June 2026, two independent studies within a single week. Whether the work agendas lead to a governance structure after 15 November has not yet been measured.