American politics can't seem to agree on much lately. But when Donald Trump rode the Rust Belt to the presidency in 2016 with a pledge to rebuild factories, he tapped into something durable. Joe Biden then doubled down on reindustrialization, albeit softening some of Mr. Trump's harshest rhetoric. This isn't a uniquely American phenomenon, either. Governments across the world are rediscovering industrial policy after a frigid neoliberal winter.

The smokestacks themselves aren't the point. The real motivation is good jobs. Industrial roles once anchored a broad middle class with a rare combination of decent pay, upward mobility, and autonomy. But the United States has lost roughly seven million of these jobs since 1980, a trend observed across almost every advanced economy. Clerical and routine white-collar work, once another path to the middle class, has also dried up.

What remains is a hollowed-out labor market split between high-paid professionals and low-wage service workers. As a result, less than half of American jobs meet basic quality criteria. With shrinking middle classes and stagnant real wages, the rest of the developed world offers a similarly bleak picture. Reshoring therefore carries obvious bipartisan appeal. But given the rise of global value chains, automation, and capital-intensive production, a manufacturing revival would generate fewer jobs and far less upward mobility than its advocates claim.

The more promising path forward is improving the jobs most people already do. In advanced economies, nearly three out of four workers are employed in services, with the sector accounting for nearly all recent job growth. Unfortunately, increasing productivity in services is notoriously difficult. Though digital technologies have produced some important gains in retail and hospitality, the challenge isn't just productivity. For instance, home and health care are among the fastest-growing US industries, but both are plagued by poor morale and high turnover. Many have resigned themselves to this being the nature of service work.

The Buurtzorg model

In 2006, Dutch nurse Jos de Blok set out to prove otherwise. Disillusioned with the state of Dutch home care, de Blok founded Buurtzorg. Anchored by a core belief in "humanity over bureaucracy," the non-profit organizes nurses into small teams, each covering 40–60 patients within a given neighborhood. Teams split when they grow too large and merge with neighbors when they shrink.

In contrast to the hospitals and large agencies that typically manage home nursing, Buurtzorg grants its teams full autonomy with little overhead. Without middle management, nurses rotate through administrative roles. One nurse might act as a designated planner who drafts schedules, whereas another may serve as a mentor who onboards new colleagues. 

On the clinical side, nurses wear just as many hats. Instead of splitting responsibilities among many specialists with varying degrees of training, Buurtzorg nurses administer comprehensive care. Duties range from medical treatments such as injections to supportive services like bathing and dressing.

However, this lack of hierarchy invites concerns about gridlock. Buurtzorg addresses this by making decisions based on consent rather than consensus or majority vote. In short, proposals are adopted unless someone has a principled objection. Nurses cannot veto decisions simply because they would prefer an alternative, and adopted proposals are always understood to be revisable at any time.

Teams aren't entirely without support, either. A lean back office handles some administrative tasks such as finance, payroll, and contract paperwork. Buurtzorg also retains a small number of regional coaches to offer mentorship and advice. At the same time, coaches refrain from solving problems directly to avoid stepping into a more managerial role.

Though Buurtzorg's model is unique, de Blok gestures to their IT system as the foundation of the organization's success. The platform, known as BuurtzorgWeb, integrates all clinical and business operations under one centralized system. Maintained by the back office, the website enables nurses to focus on patient care by streamlining online scheduling, time reporting, and other essential administrative tasks. 

On the clinical side, BuurtzorgWeb structures patient records around the Omaha System, a standardized framework that categorizes patient problems and links each to specific interventions and measurable outcomes. But the motive isn't just bureaucratic record-keeping. Standardization also gives Buurtzorg's many autonomous teams a common language, decreasing friction when patients move between teams and making it easier for nurses to draw on each other's work. In fact, learning from other teams is so central to the organization's culture that BuurtzorgWeb features a forum described by de Blok as a type of internal Facebook.

Successes and growth

Now two decades in, Buurtzorg's track record is strong. Overhead costs sit around 8 percent, which is over three times lower than comparable firms. Those savings flow to workers, with nurses paid at a salary level one step above their certification. 

Low overhead isn't the only driver of higher pay, though. Buurtzorg's high-trust, informal culture seems to make nurses more productive—and more entrepreneurial. Any team with an idea is encouraged to start a project. When an 87-year-old patient complained about the lack of races for people requiring walkers, one nurse piloted a now-widespread national walker race. Another team's idea eventually spawned Buurtdienst, a Buurtzorg-like organization for domestic help that has since grown to nearly 4,000 employees. Zooming out, Buurtzorg had over 100 live projects less than a decade after it was founded. 

All of this seems to feed back into retention and morale, with absenteeism and turnover up to two-thirds lower than sector averages. Unsurprisingly, the non-profit was named the best employer in the Netherlands five times in seven years.

But Buurtzorg isn't just producing better jobs. It's producing better care. Whereas traditional home nursing sends different caregivers at different times on different days, just three or four Buurtzorg nurses cover each patient. This continuity has led patients to regain autonomy faster, spend less time in the hospital when admitted, and report satisfaction ratings 30 percent higher than comparable organizations. And despite higher hourly costs, the model is cheaper overall: a 2009 Ernst & Young study found that Buurtzorg nurses met patients' needs in under half the time allotted by the Dutch government. The same study estimated that if all Dutch home care adopted the model, the system would save around 2 billion Euros annually. These results have propelled Buurtzorg to cover nearly a fifth of Dutch home care. 

Scaling Buurtzorg hasn't come without friction, though. For instance, self-management requires nurses to overhaul their traditional mental models of the healthcare system. Support from coaches helps, but some nurses are unable to overcome their discomfort operating without a clear hierarchy. Many simply prefer working beside dedicated administrators and managers. Even nurses committed to the model face challenges that don't lend themselves to self-management, such as personnel issues. After spending over a year addressing a colleague's misconduct related to the COVID-19 pandemic, one nurse confessed that her team wasn't "educated to solve problems like that."

Buurtzorg also faced an uphill battle garnering credibility from the broader healthcare establishment. For instance, competitors alleged that Buurtzorg cherry-picked patients to inflate their metrics. A 2015 study largely invalidated such claims, but skepticism toward the new model persists among industry incumbents and some government ministers.

There's also the ever-present risk of bureaucratic creep. Early growth likely generated pressure to add management layers, but Buurtzorg resisted by investing in its IT platform and regional coaches instead. Still, much of this resistance traces back to de Blok himself, who has spent nearly two decades fending off the bureaucratic impulses that accompany scale.

Replicating abroad

An even bigger challenge than scaling Buurtzorg domestically has been exporting the model abroad. Take the United States, where Buurtzorg Minnesota launched in 2014 with four nurses. A decade later, it has shown no evidence of significant growth. The major challenge has been dealing with multiple different payers with distinct rules and procedures. Unlike their Dutch counterparts who bill a flat hourly rate for any service, the Minnesotan nurses had to navigate Medicare's 432 case-mix groups, 50 different state Medicaid programs, and the varying demands of private insurers. Such complexity made self-billing impractical for American nurses, driving up overhead costs. 

Several UK attempts at replicating Buurtzorg's model presented equally intimidating obstacles. Though the pilots suffered from a variety of pathologies, the most fundamental problem was structural: the NHS handles health care while local authorities manage social care, a division former Health Secretary Frank Dobson once called the "Berlin Wall." Buurtzorg's integrated model didn't map onto this split. Accordingly, most pilots struggled to gain traction and were eventually folded back into their parent organizations. 

Even with a conducive regulatory environment, international adopters must build from scratch what Dutch teams simply inherit. Buurtzorg's success is underpinned by comprehensive IT systems, networks of experienced coaches, and established relationships with local medical providers. Transforming existing organizations may provide such networks and resources. But this route may prove even more difficult, as bureaucrats are historically resistant to reforms that would make them obsolete. For instance, in the aforementioned UK pilots, some managers enforced rules that undermined the team's autonomy, such as requiring approval for routine equipment orders.

Unlike reindustrialization, which boasts a familiar toolkit of tariffs and subsidies, there's no historical policy playbook for addressing these obstacles. That doesn't mean governments are powerless, however. Countries could provide services such as IT platforms, access to coaching networks, and training programs to prepare nurses for self-management. In exchange, providers would make provisional commitments on turnover, pay, and patient outcomes.

Granted, none of this is likely to work without first simplifying regulatory regimes. For this, the UK should continue recent progress on bridging the divide between health and social care. With the US, simplified Medicare and Medicaid billing or an expedited waiver process for organizations like Buurtzorg Minnesota would go a long way. Such reforms would allow self-managing teams to function with fewer administrative burdens that would otherwise require significant overhead.

Finally, replicating Buurtzorg's model for inclusive job creation means extending its organizational principles beyond trained nurses. The Dutch implementation only hires nurses qualified at level 3 or above—equivalent to three years of vocational nursing training. While this contributes to Buurtzorg's efficiency, its core principles of autonomy and flat hierarchy do not require credentialed workers. In fact, international adaptations of Buurtzorg have extended teams to include vocational aides, housekeepers, and support workers.

Ultimately, reindustrialization offers a comforting sense of nostalgia for an economy that formerly delivered broad prosperity. Upgrading services demands something less glamorous but more effective: reimagining the jobs most people already have. Of course, it is unlikely that the Buurtzorg model will be applicable to every industry and country. And the obstacles to replication are intimidating, especially the sheer difficulty of building from scratch what Buurtzorg spent two decades developing. Yet governments willing to simplify billing regimes, bridge administrative divides, and invest in shared infrastructure could make self-management viable at scale. The harder question is whether they will, especially given what appears to be a rare bipartisan consensus pointed squarely at the factory. If nothing else, Buurtzorg demonstrates that the quality of today's service jobs isn't immutable, nor is it inherent.