Year 1 Report on Mapping the Pathways to Universal Healthcare projectIntroduction The Health Research Board Mapping the Pathways to Universal Healthcare project began in October 2014. The initial project plan committed to submitting a year one report on assessing and measuring the size of gap, recent progress and trends on universal healthcare in Ireland.

Specifically component one of the project set out to:

To assess the gap between the current Irish health system in terms of access and provision and the realisation of universal health care, using, evaluating and adapting WHO definitions and concept by

1. Specification of targets and indicators for the WHO dimensions of universal health coverage (package, coverage and user price/charge). Draft bundle of indicators by month 6;

Progress on this work in year one: Initial work of the project reviewed the international literature on WHO definitions and concepts of universal healthcare. This involved gathering all relevant national and international documents which are stored in a database for project use. Most relevant documents are published on our project website International UHC documents and National UHC documents.

This work took the form of ‘A working paper on concepts of UHC and potential indicators for benchmarking Ireland (and other high income countries’) progress towards UHC’ drafted by project team members Sara Burke, Sarah Barry and Steve Thomas (appendix 1). It was presented to an international team meeting in February 2015 (including the European Observatory on Health Systems), to our advisory group in June 2015 and at our seminar in September 2015.

While concepts and definitions are clear, there is little relevant literature on indicators for UHC in high income countries. Most of the literature is devoted to low and middle income countries and many of the indicators are focused on Millennium development goals.

The WHO conceptual universal health coverage around three distinct components – I. The population – who is covered

II. The services – which services are covered and of what qualityIII. The costs – what do people have to pay out of pocket for and does this cause

financial hardship.

More recent WHO work in a higher income country context suggests a focus on I. Financial risk protection

II. Health service coverage aIII. Equity.

Following discussions at our international team meeting and local advisory group, it was decided to collect indicators for Ireland under the following headline areas:

1

I. A full package of care matching needII. Financial protection

III. Coverage for all IV. Resources for UHC (including financial and human resources and V. Quality of care.

A five dimensional framework for analysis was developed around these areas – see page 8 of working paper.

2. Assessment from relevant policy documents whether the commitment to UHI and free GP care in the Programme for Government actually matches the WHO concept of universal health coverage as outlined by WHO and the experience of other countries that claim the achievement of universal health care. Brief report by month 9.

This work was progressed in year one when the initial assessment work was done on concepts and definitions of UHC. It was also presented to the international team for discussion, to the local advisory group and based on feedback amended and presented at the year one seminar. Instead of producing a brief report on this for year one, it was drafted a journal articles for Health Policy and published in December 2015 (see appendix 2).

3. Measure Ireland’s performance using the key indicators, assess recent progress or deterioration of these indicators and identify the size of the task remaining. Present gap analysis report to Local Advisory Committee (LAC), month 8, and at end year 1 workshop;

As stated above the conceptual work focused on five dimensions, for each of these indicators were suggested, often based on what was possible to collect rather than what was best. These were presented at our first annual seminar and initial indicators collected are on our website.

Significant work was done in Year 1 on financial protection as part of a new WHO Europe focus on universal healthcare and financial protection in a high income context. Financial protection is traditionally measured using two indicators associated with the use of health services: impoverishing and catastrophic out-of-pocket payments. Both indicators estimate the number of households in which out-of-pocket payments for health care exceed a predefined threshold. In both cases, it is not the absolute amount of out-of-pocket spending that is important, but rather the impact that it has on household living standards.

We have carried out analysis using the WHO Europe new methodology for measuring Financial Protection with 2009/10 National Household Budget Survey. The findings were presented at our year one seminar where both the international and national research was presented. These findings will be updated and published by the WHO and the TCD team in 2017 when new 2015/6 data is available.

4. These indicators will be updated online and in policy briefs for the duration of the project.

As stated above, they are now on the project website and regularly updated.

2

Appendix 1

DRAFT working paper on concepts of Universal Health Care (UHC) and potential indicators for benchmarking Ireland’s (and other high income

countries’) progress towards UHC

June 2015

Sara Burke, Sarah Barry, Steve Thomas

Universal Health Coverage/Care

Universal health coverage/care has its origins in the WHO 1978 Declaration of Alma Alta which stated:

Primary health care is essential health care… made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development... It forms an integral part both of the country's health system, of which it is the central function and main focus, and of the overall social and economic development of the community (WHO 1978).

Such thinking has now largely evolved into Universal Health Coverage. According to the WHO, the ‘goal of universal coverage is for everyone to obtain the services they need at a cost that is affordable to themselves and the nation as a whole’ (WHO 2013: 7).

A recent World Bank report defined ‘the goals of universal health coverage are to ensure that all people can access quality health services, to safe guard all people from public health risk, and to protect all people from impoverishment due to illness, whether from out-of-pocket payments for health care or loss of income when a household member falls sick (The World Bank 2013): 10).

In 2005, all WHO member states including Ireland signed up to achieve universal health coverage. The UN General Assembly in 2012 and the WHO 2013 World Health Report reiterated the 2005 commitment to Universal Health Coverage (WHO 2005, WHO 2010, WHO 2013, WHO 2013). According to the WHO and UN, Universal Health Coverage achieves better health outcomes for individuals and whole populations because accessing services is not inhibited by cost (WHO 2010, WHO 2013, WHO 2013).

WHO uses a cube to demonstrate the three facets of Universal Health Coverage (UHC) as specified below, also sometimes referred to as the breadth, depth and height of coverage. See figure 1 below. Nevertheless, it is unclear whether these three dimensions do justice to the rich concept of UHC and this is a matter that the authors return to later.

3

Figure 1: Dimensions of Universal Health Coverage, WHO

Indicators for Universal Health Care in the Existing Literature

There is much reference to the need for research and to develop indicators of UHC in WHO documents since 2010, but few if any of them give potential examples for high income countries, apart from the headline areas of 1) financial risk protection and 2) health service coverage and 3) equity. The fact that there are few examples of indicators for high income countries may suggest that there is little clarity around what UHC means in a high income context. Without clear definitions, it is difficult to know what is to be measured.

The WHO/World Bank further recommend country specific monitoring of UHC reflecting each country’s unique epidemiological and demographic profile as well as population demands, the type of health system and levels of economic development. While there is wisdom in this approach to making indicators useful in a specific context, it avoids the issue of precise definition. Their selection criteria recommended are:

Relevance – Do the indicators measure conditions of priority health needs? Is the service cost-effective? Is the service a source of major health care expenditure?

Quality – Do the indicators measure effective or quality-adjusted coverage? Availability – Are the indicators regularly, reliably, and comparably measured (i.e.

numerators/denominators/equity stratification) with existing instruments (e.g. household surveys or health facility information systems)? (WHO/The World Bank 2013).

Where the WHO/World Bank do develop indicators they tend to be derived from the Millennium Development Goals and are largely irrelevant to high income countries.

4

Unpacking the elements of UHC and potential indicators

In the following sections the authors unpack a much fuller definition of UHC pointing to areas where indicators are needed if progress is to be measured before relating such measures to the Irish context.

1. A full package of care matching need

A key question for any country attempting to implement UHC is exactly what care should be supplied. If there is to be universal access for a population to health care, what entitlement does that bring? Clearly universal access to long waiting lists for poor quality care, resourced by understaffed facilities and demotivated staff, is not an achievement worth celebrating.

The definitions from WHO and the World Bank imply “a full spectrum of quality health care” for all in need. This is a rich concept and there are several elements to this which need to be unpacked.

First the needs of the population have to be understood. This requires both an understanding of the demographic profile and the most prevalent conditions and the services which are required to match the needs. This in turn necessitates a supply capacity appropriately resourced (finances, human resources and physical infrastructure) which reflects and is responsive to need. Hence the system has to have the right capacity in place. (This is dealt with in section below on resources).

Second, the care provided must be appropriate, proportionate and according to clinical protocol/best evidence and provided by the right health professionals.

Third, the appropriate placement and location of care is critical. Universal access will mean that there are no geographic blackspots in coverage for a particular service or that the time for accessing critical services is broadly even across the country and within an acceptable range.

Fourth, the presence of waiting lists indicates a mismatch between supply and demand. The majority of people on waiting lists deteriorate and long waiting lists lead to increased morbidity and mortality and are not a feature of UHC. If care is needed, delaying care by placing people on an extended waiting list does not appear to square with a needs based approach for all. Careful targets are required for maximally acceptable waiting lists. In order to measure this mismatch between supply and demand, the best and worst waiting lists per specialty and hospitals can be looked at for OPD, daycase and inpatient treatment. It would also be useful to look at access to primary and community services.

To measure the ‘full package of quality care according to need’ requires good, timely data on

Demographics – pop size, age profile, health status, mortality, morbidity, burden of disease Measuring ‘appropriate, proportionate care according to clinical need’ is not straight

forward especially given the early stage of clinical protocols and integrated care pathways in Ireland. The pathway of a patient through a health system and the coordination between different facilities and services is telling of health system performance. UHC is not a guarantee of all care at all levels but the most appropriate care at the appropriate level. It must also stipulate something about the ease of transfers between one part of the system and another when medically appropriate. Possible indicators include the existence and or use of clinical protocols in specific clinical care programmes.

5

This year the HSE has committed to Integrated Care Programmes for Patient Flow; Children; Maternity Services; Older People; and the prevention and management of chronic diseases.Monitoring these could be possible indicators of appropriate and proportionate care according to clinical need (HSE 2014).

Geographical access to healthcare – is measuring geographical distance to certain facilities eg GPs, ED, trauma centre, stroke care, cancer services, differences in ambulance response times?

Matching supply and demand – waiting lists are an indicator of demand outstripping supply but are largely based on hospital care due to data availability, however, measuring access to primary and community care services is equally important and may begin to be possible as the HSE has started collecting indicators on these.

Available indicators for the package of care Source

1 Population size CSO2 Population growth and trends (whole pop over 65s) CSO 3 Perceived health status

4 Morbidity5 Prevalence of chronic diseases6 Life expectancy ( & over 65s)7 Mortality rates 8 Numbers of clinical protocols developed 9 Numbers of clinical protocols implemented 10 Distance to local GP – rural areas, urban deprivation areas 11 Comparing ambulance response times 12 Waiting times for initial outpatient appointment (best and worst

by specialist and hospital/group location? HSE PR 13 Waiting times for day case treatment – adults (best & worst) HSE PR & NTPF/SDU 14 Waiting times for day case treatment – children (best & worst) HSE PR & NTPF/SDU 15 Waiting times for inpatient treatment – adults (best & worst) HSE PR & NTPF/SDU 16 Waiting times for inpatient treatment – children (best & worst) HSE PR & NTPF/SDU 17 Nos waiting for ED admission (best & worst) Trolley watch 18 Nos waiting for ED admission - over 9 hours (best & worst) SDU/Trolley GAR19 Nos waiting for ED admission - over 24 hours (best & worst) SDU/Trolley GAR20 Waiting times to access Child and Adolescent Mental Health

Team HSE21 Primary care – longest waiting time for eye care, psychology HSE22 Primary care – longest waiting time for child orthodontics HSE23 Primary care – longest waiting time for podiatry, audiology HSE24 Primary care – longest waiting time for dietetics, nursing HSE21 Percentage of physiotherapy referrals seen for assessment in less

than 12 month & treatment in less than 2 years1

2. Indicators for financial protection

UHC clearly implies that households should not be impoverished by out of pocket payments for healthcare or face catastrophic out of pocket payments for their health care (WHO 2014). Nevertheless, it also seems from the World Bank paper that UHC actually implies no direct payment 1 These primary care indicators (17-21) are being collected in 2015 for the first time

6

for health care which means in all probability no out of pocket payments for health care access2. User fees themselves tend to produce inequity of access as some households will be put off seeking care by the financial barriers. They are also a poor mode of rationing, a blunt instrument, in that they prevent as much necessary as unnecessary use.

The two main forms of private spend on healthcare in Ireland are out-of-pocket payments to see a health professional and for drugs and premia paid for private health insurance. Given the shift in health expenditure in Ireland over recent years from the State onto people, evident in new and increased charges for hospital care and drugs, as well as the shifting landscape in terms of numbers covered by private health insurance and paying for GP care, it is worth monitoring these specific spends to see if they impact on financial protection or not over time (Thomas 2014).

Indicators for financial protection Source 1 Public private spend OECD/WHO2 Private health insurance spend HIAI/HBS3 Out of pocket spend OECD/WHO4 Incidence of catastrophic health expenditure HBS/EU SILC/QNHS 5 Incidence of impoverishment from health expenditure HBS/EU SILC/QNHS 6 € spent on drug charges for GMS (medical card holders) HSE PCRS data 7 € spent on drug payment scheme HSE PCRS data 8 € spent on public hospital bed charges HSE PR activity & income data9 € spent on ED charge HSE PR activity & income data

3. Coverage for All

It is important that the entitlement to care without financial barrier extends across all sections of the population regardless of age, gender, household income or any other socio-economic variable. It is also important that the differential ability to pay of some households does not translate into them getting access to faster or better medical care than those who cannot to pay. Therefore measuring and monitoring over time the numbers included in the medical card scheme (GMS), free GP care, those covered by private health insurance and universal schemes within the public health system are good indicators of coverage.

Indicators for coverage Source1 GMS (Medical card) coverage HSE PR & PCRS data 2 Free GP care HSE PR & PCRS data 3 Private health insurance coverage HIAI 4 Maternity & infant care scheme HSE5 Immunisation rates HSE6 Screening rates (breast cancer, cervical, bowel) HSE

4. Resources available for UHC

Given scarcity of resources is an endemic feature of all health systems, it is important to consider how this is best managed. Not all services should be provided at all facilities free of charge without gatekeeping (e.g. access to outpatient specialist appointments requires GP referral in the public

2 Nevertheless, an exception to this may be the stacking of user fees to support appropriate referral patterns, gate-keeping and appropriate pathways through the health system. In this case, user charges can be an effective incentive to help ensure UHC. See later discussion.

7

system). Therefore key decisions need to be made if UHC is to become a reality or at least to become a nearer reality. Furthermore, user fees or market based rationing is generally considered to be ruled out with a UHC based approach because of the risk of differential access or just barriers to access for some. Still, resource scarcity means that other forms of rationing will need to be implemented.

Public Funding

Optimal resource use and allocation is key for many resource scarce environments, but it is not sufficient. Even with maximum efficiency some underfunded systems will be far from achieving UHC. Furthermore, some systems need to have more resources to work effectively than others. What are those minimally acceptable funding levels? This may well be a context specific question, determined by the type of health system adopted or the historical path dependency of the economy and health policy. Nevertheless, what is clear is that after an era of austerity many health systems have been pushed further away from a secure foundation of sufficient finances for UHC.

Given the scramble for scarce resources and the need to maximise returns, deciding on which care to provide and what the best way is to deliver that care must be subject to economic appraisal. This analysis of the efficiency of health care resource use will help utilise resources to achieve care goals and deliver on UHC. Where relevant, thresholds values for new technologies or drugs will be important. Where services are already provided it is often evident which is the lowest cost setting and where not then research can help inform cost-effective delivery of care. Currently HTAs are carried out on new drugs especially expensive and high-tech drugs, but there is not system for retrospective HTAs or applying them to treatment interventions as well as drugs. Measuring the numbers of HTAs and government or health system adherence to them may be one way of beginning to assess progress in this area.

Recent work on the Irish health system shows that efficiencies were a hallmark of the early recessionary period and helped absorb resource cuts in hospitals but over time further efficiencies proved harder to realise and further budgetary cuts damaged health care (Burke 2014). In a similar way, UHC requires both sufficient resources and their effective and efficient use. Effective pathways and effective gatekeeping are not only good clinical practice but also mean that resources are used effectively and not wasted on inefficient services. This is an important foundation for moving towards UHC and relates to the clinical and integrated pathways referred to in section 1.

Human resources

The majority of healthcare funding is spent on labour costs. Historically the Irish health system has had fewer physicians and health care professionals than other high income countries. During the economic crisis in Ireland, there were significant cuts to health staffing levels. Implementing UHC has significant staffing implications. Indicators will be collected across similar high income countries so that comparatively analysis can be carried out.

Comparative indicators of resources Source1 Overall national health budget DPER/Revised estimates2 Public private spending OECD/WHO/CSO NHA?3 Public health system staffing HSE4 Staffing by category eg PCC? HSE5 Nos of GPs ICGP/IMC?6 Nos of GPs private only ICGP/IMC?7 Numbers of private hospital staff IHAI

8

8 Numbers of healthcare staff working in private sector IHAI + therapy bodies, IHCA, IMO9 New & existing treatments and drugs NCPE10 Adherence to HTA recommendations

5. Quality of care

Quality of care is central to UHC as there is no point having access to poor care. There is a growing body of knowledge internationally on quality indicators – a OECD review suggests the following dimensions are included:

Effectiveness – the degree a health system (or parts of it) are achieving desirable outcomes; Safety – the degree to which health professionals avoid, prevent and ameliorate outcomes

or injuries from healthcare processes; Responsiveness or patient centeredness – the degree that a system functions by putting the

patient/service user at the centre of its delivery of healthcare often measured as patient experience;

Accessibility – the ease with which health services are reached. Access can be physical, financial or psychological;

Equity (which is closely related to access) is used as a metric to assess health system financing and outcomes – and measures the extent that a health system distributes healthcare and its benefits to people;

Efficiency – the optimal use of available resources – the system’s ability to function at lower costs with desirable results. The OECD refers to macro and micro efficiency – macro efficiency is the overall health spend (public and private) at the ‘right’ level. Micro efficiency refers to value for money, a health system which is as productive as possible (Kelley 2006).

Many of these ‘quality’ indicators cross other aspects of the concepts of UHC considered in this paper. The Irish health system has had a poor track record of measuring quality and outcomes but is beginning to do so now. Below are indicators published in the Department of Health’s first ‘National Healthcare Quality Reporting System’ (Department of Health 2015).

Indicators of quality of care Source1 Hospital readmission rates HSE2 Unmet need SILC3 The rate of C Diff in public hospitals DoH4 MRSA rates in public hospitals DoH5 C-section rate? HIPE6 In-hospital wait time for hip fractures HIPE7 In-hospital mortality following ischaemic stroke HIPE8 In-hospital mortality following acute myocardial infarction HIPE9 Asthma hospitalisation rate HIPE 10 Diabetes hospitalisation rate HIPE11 COPD hospitalisation rate HIPE

Figure 2: Potential framework for analysis of five dimensions of UHC in an Irish/high income context

9

10

REFERENCES

Burke, S., Thomas, S, Barry, S, Keegan, C. (2014). "Indicators of Health System Coverage and Activvity in Ireland during the economic crisis, 2008 - 2014 - From 'more with less' to 'less with less'" Health Policy(117): 275-278.

Department of Health (2015). Healthcare quality indicators in the Irish health system. Dublin, Department of Health.

HSE (2014). HSE National Service Plan 2015 Dublin, HSE.

Kelley, E., Hurst, J. (2006). Health Care Quality Indicators Project Conceptual Framework Paper. Paris, OECD.

Thomas, S., Burke, S, Barry, S. (2014). "The Irish health-care system and austerity: sharing the pain." The Lancet 383 (3 May 2014).

WHO (1978). Declaration of Alma-Ata. International Conference on Primary Health Care, Alma-Ata, USSR, 6-12 September 1978, WHO.

WHO (2005). World Health Organisation 58th World Health Assmebly Resolution WHA58.33 Sustainalbe Health Financing, Universal Coverage and Social Health Insurance Geneva, WHO.

WHO (2010). The World Health Report: Health System Financing and the Path to Universal Coverage. Geneva, WHO.

WHO (2013). Arguing for Universal Health Coverage. Geneva, WHO.

WHO (2013). Research for universal health coverage: World health report 2013. Geneva, WHO.

WHO/The World Bank (2013). Monitoring Progress towards Universal Health Coverage at Country and Global Levels: A Framework. Joint WHO/World Bank Group Discussion Paper, December 2013, WHO/The World Bank.

World Bank (2013). Global conference on universal health coverage for inclusive and sustainable growth : a global synthesis report. . Washington DC, World Bank.

11

Appendix 2

From universal health insurance to universal healthcare? The shifting health policy landscape in Ireland since the economic crisis ☆

Sara Ann Burke , , Charles Normand 1 , , Sarah Barry 1 , , Steve Thomas 1 ,

Show morehttp://dx.doi.org/10.1016/j.healthpol.2015.12.001Get rights and contentOpen Access funded by European Observatory on Health Systems and PoliciesUnder a Creative Commons license Open Access

Highlights•The Irish government has failed to implement its 2011 commitment of universal primary care by 2015.•The 2011 universal health insurance model has been abandoned.•In 2015, there was a shift in focus to universal healthcare without any specifics as to how to achieve universalism.•The Irish health system was less universal in 2015 than in 2011.

AbstractIreland experienced one of the most severe economic crises of any OECD country. In 2011, a new government came to power amidst unprecedented health budget cuts.Despite a retrenchment in the ability of health resources to meet growing need, the government promised a universal, single-tiered health system, with access based solely on medical need. Key to this was introducing universal free GP care by 2015 and Universal Health Insurance from 2016 onwards.Delays in delivering universal access and a new health minister in 2014 resulted in a shift in language from ‘universal health insurance’ to ‘universal healthcare’. During 2014 and 2015, there was an absence of clarity on what government meant by universal healthcare and divergence in policy measures from their initial intent of universalism.Despite the rhetoric of universal healthcare, years of austerity resulted in poorer access to essential healthcare and little extension of population coverage. The Irish health system is at a critical juncture in 2015, veering between a potential path to universal healthcare and a system, overwhelmed by years of austerity, which maintains the status quo.This papers assesses the gap between policy intent and practice and the difficulties in implementing major health system reform especially while emerging from an economic crisis.Keywords

Universal health insurance; Universal healthcare; Ireland; Health system; Health policy implementation;

12

Financial crisis; Equity

1. IntroductionThis paper traces the evolution of universalism in Irish health policy in recent years in order to assess the gap between policy intent and practice. Ireland has never had a system of universal health coverage universal health coverage as defined by the World Health Organization (WHO):a situation where all people who need health services (prevention, promotion, treatment, rehabilitation, and palliative) receive them, without undue financial hardship [1].Universal health coverage consists of three dimensions:i)Breadth: coverage for the entire population.ii)Scope: coverage of the full spectrum of quality health services according to need; andiii)Depth: coverage of the full costs of health services (no user charges) [1].In March 2011, a new government was elected in Ireland soon after the country had entered an international bail-out. The two parties that formed the coalition government in 2011, campaigned for power on a platform of introducing:a universal single-tiered health service, which guarantees access based on need, not income… through Universal Health Insurance. Universal Primary Care will remove fees for GP care and will be introduced within the government's first term in office.’ [2].This was the first time in Irish history, when a government committed to end the two-tier system of access to healthcare, which gives preferential access to hospital care to those who have private health insurance [3]. In Ireland, ‘two-tier’ refers to the fact that people who can pay privately or have private health insurance (PHI) can get a diagnosis quicker and can secure faster hospital treatment, even in public hospitals, because they can afford the monthly premiums [4]. About 45% of the population have PHI but it contributes only about 9% of all health spending [5]. Those who cannot afford private health insurance must often face long waiting lists [6]. Details of the complicated nature of coverage in the Irish health care system are explained in Fig. 1.

Fig. 1. Coverage for care in Ireland, 2015.Figure optionsAbout two fifths (37%) of the population have medical cards under the General Medical Services (GMS) scheme, which are means tested and allocated on the basis of low income. These cards enable poorer people to access GP and hospital care without charge and medicines at a low cost. In addition, a GP visit (GPV) card is available, which entitles those without GMS but still on low incomes or at certain age to GP visits without charge. The rest of the population have to pay on average €52.50 for each GP visit and up to €144 a month for prescription drugs [7]. They also pay €100 for presenting at an Emergency Department without a GP referral and €75 per day for public hospital treatment, capped at €750 per year [7].A recent analysis of the Irish health system foundIreland is the only EU health system that does not offer universal coverage for primary care… Ireland is an extreme outlier among EU countries when it comes to user charges… A recent assessment of coverage… found that gaps in population and cost coverage distinguished Ireland from other European countries [8].2. Tracing universalism in the Irish health policy process 2011–2015The 2011 coalition government was elected with a significant majority, however its popularity declined as it had to continue to implement austerity measures introduced under the 2010 troika bail-out. This included cuts to health [6]. Until 2011, there was a distinct absence of any intent of

13

universalism in Irish health policy with only a minimal focus even on equity. Key policy moments are detailed in Table 1.Table 1.Policy measures tracing universalism in Irish health policy 2001–2015.

Year Measure Impact

2001

National health strategy published: ‘Quality and Fairness – A Health System for You’. No focus on universalism.Medical cards introduced for all over 70-year-olds.

Led to multiple changes in public health system structures, rather than impacting on access or quality issues.From 2002, all over 70-yr-olds entitled to medical cards (GMS)

2005GP visit card (GPV) introduced Very low uptake, fewer than 150,000

GP visit cards by 2014

2008Economic crises. 1st emergency budget October 2008

Removal of GMS for over-70s. Increased hospital charges.

2009Two supplementary budgets and health budget cuts

Increased & new charges, HSE budget & staff cuts. Salary cuts

2010 Ireland enters bailout Troika in charge. More cuts

2011

Change of government. ‘Programme for Government’ commits to Free GP care & Universal Health Insurance

Huge programme of health system reform promised, HSE to be abolished

2012‘Future Health’ published, ‘roadmap’ for reform

Plan for reform. Free GP care delayed, UHI by 2016

2014White Paper on Universal Health Insurance (UHI)

No clarity on who would be covered for what or cost of UHI

2014

Change in minister after poor local & European election results & decline in numbers with medical cards

Shift in policy from UHI to universal healthcare (UHC). Criteria for medical cards loosened. HSE not to be abolished.

2015

Small increase in health budget, the 1st increase in six yearsIntroduction of Life-Time Community Rating

Free GP care for under 6s & over 70s.Penalties introduced for those who take out PHI over age 35UHI costings published showing model ‘unaffordable’

Table optionsThe predominant influence on health policy choices from 2009 to 2014 was the prolonged austerity leading to continuous cuts to staff and budgets alongside an increasing demand for care [6]. In the midst of this, the 2011 Programme for Government committed to a single-tiered health service through universal GP care and universal health insurance (UHI) [2].Future Health, published in 2012, was the government's ‘roadmap to reform’ for implementing the Programme for Government [9]. It reinforced the above commitments, with ‘major healthcare reforms that will be introduced by 2015, prior to the launch of Universal Health Insurance in 2016’ [9].‘The Path to Universal Healthcare – The White Paper on Universal Health Insurance’, the legislative basis for the introduction of UHI – was published in April 2014 [10]. It proposed a ‘multi-payer’ model of compulsory private health insurance, with for-profit insurance companies operating in competition and delayed its implementation until 2019. However, the new system was also to be a hybrid model as an unspecified amount of health care was to remain tax-funded [10]. The promise of universal free GP care and UHI which would deliver universal access to hospital care demonstrated the intent and ambition of universalism.

14

In May 2014, the government parties lost many seats in local and European elections and the loss of GMS medical cards related to improved economic conditions and tighter eligibility rules was cited as the strongest reason for this [11]. Two months after these poor election results, a cabinet reshuffle resulted in a new health minister, Leo Varadkar. Speaking on the issue of medical cards in October 2014, Minister Varadkar saidthe more that I have studied the issue of eligibility for medical cards, the more I have become convinced that the only solution is universal healthcare. No matter what means-test you apply, whether financial or medical, there will always be anomalies and there will always be people just above the threshold [12].In January 2015 Minister Varadkar, published his list of 85 priorities, which clearly indicate that the UHI policy is delayed and possibly abandoned [15]. Included under the banner of Universal Healthcare (UHC) were:•Make the first concrete steps to universal healthcare by extending GP services without fees to the under-6s and over-70s.•Complete the initial costing analysis [of UHI] and revert to Government with roadmap.•Implement a package of measures to increase the number of people with health insurance [13].The two central planks of universalism in the 2011 Programme for Government were the introduction of universal free GP care by 2015 and universal health insurance after 2016 [2].2.1. Universal free GP careThe Programme for Government stated that universal free GP care would be introduced on a staged basis within the government's first term, starting with the sickest in 2012. However, this approach was stalled by ‘legislative difficulties’ and key milestones were not met. In 2014, government decided to introduce free GP care on age basis, to under six-year-olds and to over 70-year-olds.In July 2015, GP visits cards were extended to all under six year olds and over 70 year olds. Budget 2016 announced in October 2015, pledged to extend free GP care to all under 12 years olds in 2016.2.2. Universal health insuranceThere has been no progress implementing universal health insurance since the publication of the UHI White Paper in 2014. In November 2015, long-awaited costings of the proposed UHI model were published which found that it would cost between €666 million and €2 billion more than current health spend [5]. The health minister concluded that this particular model is not viable stating it was ‘not affordable now nor ever’ [14].In the meantime, on 1 May 2015, ‘life-time community rating’ was introduced, which brought into effect ‘late entry loadings’ for those who take out PHI over age 35. The purpose is to encourage people to purchase PHI at a younger age with the intent of making the health insurance market more sustainable by spreading the costs of care across the population. However, there is concern that in the absence of a UHI plan, life-time community rating exacerbates existing inequalities by maintaining two-tier access to hospital care and making it more expensive for poorer over-35-year-olds to take out health insurance.3. What has happened with coverage since 2011Fig. 2 details proxy indicators of coverage for the Irish health system between 2008 and July 2015. It shows little actual change in the proportion of the population with GMS medical cards, GP visit cards and private health insurance coverage between 2011 and 2015, despite the intent of universalism in the proposed reforms.

15

Fig. 2. Proportion of the population with medical cards, GP visit cards & private health insurance.Figure options3.1. Breadth of coverageIn mid-2015, 37% of the population had a medical card on the basis of their low income, while 63% of the population did not [15]. The numbers of people with GMS medical cards grew from 1,694,063 million in 2011 to 1,866,223 in August 2013. Since then, there has been a decline, with 1,735,168 people covered in July 2015, however the proportion of the population covered remained static.Instead of introducing universal free GP care (as announced in the government program), government decided in 2014 to introduce free GP care on age basis. By July 2015, 5% of the population qualified for GP visit cards [16].PHI coverage peaked in 2008 at 51.6% of the population [17] and declined (largely as a result of the crisis) to 45% in 2014. Numbers with PHI coverage began to increase in the third quarter of 2014 [17]. An additional 74,000 people signed up for PHI before May 2015 when ‘life-time community rating’ was introduced.3.2. Scope of coverageDue of the complicated nature of the package of care in Ireland with differential access to different parts of the health system (as detailed in Fig. 1), it is very difficult to monitor the scope of coverage. However, recent waiting list data for access to initial outpatient specialist appointment and hospital treatment show more people waiting over three, six and twelve months for treatment in summer 2015 than there were in 2011 indicating a decline in scope [18].3.3. Depth of coverageEarlier research showed that the depth of coverage in Ireland narrowed with increasing numbers of user charges, even for those on medical cards between 2009 and 2014 [19]. For example, there was no charge for prescription drugs for GMS until 2010 when a 50 cent charge per item was introduced, this rose to €2.50 per item in 2013.

16

This research demonstrated a steady transfer of out-of-pocket payments from the State onto people between 2009 and 2014 [19]. By 2014, Irish people were paying €599 million more for drug and hospital charges than they were in 2007 [20]. Many of these increased costs for people were introduced pre-2011, some were introduced post-2011, for example the cost of drugs for non-medical card holders rose from €120 per month to €144 per month during the this period.The €599 million figure is an understatement as many out-of-pocket expenses are not caught by official data such as private spending on homecare or allied health professionals. These services are often not available to those without medical cards and if they are, have such long waiting lists that people pay privately for them if they can.4. DiscussionWhile there has been an intent of universalism in official government policy since 2011, the data presented here show little progress made on increasing the breadth, with decreasing depth and scope of coverage of coverage evident through increased user charges and numbers waiting for hospital diagnosis and treatment. The exception is the extension of free GP care to the youngest and oldest citizens in mid-2015 and a small increase in private health insurance in 2014/5.This failure to progress towards universalism can be explained by the unrelenting pressure on the health system as a result of budget cuts since 2009 and by the lack of clarity on the exact form of universalism espoused and the mechanisms to achieve it [6] and [7].The White Paper on UHI was notable in its absence of detail, with no clarity on the range of services to be covered and critically no detail on what it would cost the individual or the State [10]. This inevitably delayed implementation and finally led to its abandonment.Universal free GP care has become free GP care for younger and older people. Despite previous commitments to free GP care for all by 2015, Varadkar has stated that there are ‘different ways to cover adults who are not already covered for free access to primary care… refunding some of their health care costs through social insurance… could be examined’ [21]. This is different to universal free GP care at the point of delivery. The health minister's statement implies many adults will continue to pay for GP care. Universal free GP care was not achieved by 2015 as committed to in 2011.The lack of clarity on the mechanism and route to achieve UHI also meant that it failed to gain public or political support. The growing evidence from Holland (on which the initial Irish model of UHI was based) of increased costs and rationing caused public and political concern, while the Irish Department of Public Expenditure and Reform expressed specific opposition to it citing the cost implications for the exchequer and the public of the UHI model proposed [22]. By the time the White Paper on UHI was published, other newly-introduced government charges and taxes for water and property meant that politicians were very reluctant to impose further new taxes/insurance costs onto people, especially when the specific cost of the scheme were still not known, but predicted to be high. By November 2015, government's proposed model of UHI was abandoned as it was going to cost up to 11% more than current expenditure [5] and [14].It is interesting to observe the changing stance on universalism emerging from this analysis. There was no commitment to introducing universal health insurance in Varadkar's priorities in January 2015, instead universal healthcare was prioritized. The new minister consistently uses the language of universal healthcare and rarely mentions UHI. However, apart from the plans for free GP care, there is little clarity on the ‘steps to universal healthcare’ nor precisely what it entails.While the policy commitments in 2011, 2012 and 2014 clearly specified an intent of universalism, this dissipated in 2015. Writing in July 2015 the health minister stated ‘my definition of universal healthcare is wider access to safer – and higher quality – healthcare for more people’ [21]. Universalism by its very definition means ‘involving all’. Speaking to medical specialists in October 2015, Minister Varadkar redefined his take on ‘universal healthcare – by which I mean access to affordable healthcare for everyone in a timely manner’ [21]. Apparently, the health minister has a changing definition of universal healthcare and one which differs from the WHO definition mentioned above.

17

5. ConclusionFor four years there was no purposeful action towards universal healthcare which was then followed by diverging policy measures, most evident in government introducing life-time community rating and rejection of their own UHI model in November 2015.A general election has to be held in Ireland by April 2016. The real issue for Irish citizens is whether government health policies have resulted in improved access to services and quality care for everybody. The analysis presented here indicates not.Ireland is at a critical juncture, veering between a potential path to universal healthcare and a system overwhelmed by seven years of austerity, which continues to maintain the status quo and a historical bias towards a two-tier unequal system of care. Although it is too soon to tell which direction Irish health policy takes, this research demonstrates the significant gap between the intent of policy and what actually happened. It also clearly shows the deficiencies of introducing major health system reform without clear objectives, costings and implementation mechanisms.AcknowledgementsThis paper is part of an Irish Health Research Board funded project, grant no HRA-2014-HSR-499. More https://medicine.tcd.ie/health-systems-research/.References

1.o [1] o WHO/The World Banko Monitoring Progress towards Universal Health Coverage at Country and Global

Levels: A Framework. Joint WHO/World Bank Group Discussion Paper, December 2013

o WHO/The World Bank (2013)o

2.o [2] o Government of Irelando Government for National Recovery 2011–2016o Fine Gael/Labour Party Dublin (2011)o

3.o [3] o A. Brick, A. Nolan, J. O’Reilly, S. Smitho Resource Allocation, Financing and Sustainability in Health Care. Evidence for the

Expert Group, vol. 1, Department of Health and Children/ESRI Dublin (2010)o

4.o [4] o S. Burkeo Irish apartheid healthcare inequality in Ireland, 1st ed.o (1st ed.)New Island, Dublin (2009)o

5.o [5] o M. Wren, S. Connoly, N. Cunninghamo An examination of the potential costs of universal health insurance in Irelando ESRI, Dublin (2015)o

6.o [6]

18

o S. Burke, S. Thomas, S. Barry, C. Keegano Indicators of health system coverage and activity in Ireland during the economic

crisis, 2008–2014 – from ‘more with less’ to ‘less with less’o Health Policy, 117 (2014), pp. 275–278o Article

| PDF (602 K) | View Record in Scopus | Citing articles (14)

7.o [7] o A. Nolan, S. Barry, S. Burke, S. Thomaso Observatory-WHO study on the impact of the financial crisis on health and health

systems in Europe. Case Study Irelando WHO European Observatory on Health Systems, London (2014)o

8.o [8] o S. Thomson, M. Jwett, P. Mladovskyo Health system responses to financial pressures in Ireland. Policy options in an

international contexto World Health Organisation, Copenhagen (2014)o

9.o [9] o Department of Healtho Future Health: A Strategic Framework for Reform of the Health Service 2012–2015,

Dublino (2012)o

10.o [10] o Department of Healtho The Pathway to Universal Healthcare: White Paper on Universal Health Insurance

D.o. Health, Editoro Department of Health, Dublin (2014)o

11.o [11] o RTE/B&Ao RTE/Behaviour & Attitudes European Election Exit Pollo RTE, Dublin (2014)o

12.o [12] o Department of Healtho Lynch & Varadkar announce ten key actions for Medical Card Systemo Department of Health, Dublin (2014)o

19

13.o [13] o Department of Healtho Profile table of priority areas, actions and deliverables for the period 2015 and

2017o Department of Health, Dublin (2015)o

14.o [14] o Department of Healtho Statement by Minister Varadkar following Cabinet discussion on UHIo Department of Health, Dublin (2015)o

15.o [15] o HSEo Healthcare Data Report April 2015o HSE, Dublin (2015)o

16.o [16] o HSEo HSE Monthly Performance Assurance Report, December 2014o HSE, Dublin (2014)o

17.o [17] o Health Insurance Authority of Ireland (HIAI)o Market Statistics for number of people with private health insurance inpatient

covero (2015) Available from: http://www.hia.ie/sites/default/files/Website%20Statistics

%20270315.pdf [cited 27.04.15]o

18.o [18] o NTPFo Inpatient/day case national waiting times by group/hospital as at 26/05/2015o NTPF, Dublin (2015)o

19.o [19] o S. Thomas, S. Burke, S. Barryo The Irish health-care system and austerity: sharing the paino The Lancet, 383 (May) (2014)o

20.o [20] o S. Burkeo Indicators of Universal Healthcare in Ireland in Mapping the Pathways to Universal

Healthcare in Ireland, First Seminar, 22 September 2015The Hub, Trinity College Dublin (2015)

20

o1.

o [21] o L. Varadkaro Universal healthcare a worthwhile and achievable goal, in Irish Timeso Irish Times, Dublin (2015)o

2.o [22] o D. Maloneyo Letter from David Maloney, Assistant Secretary, Department of Public Expenditure

and Reform to Department of Health, 12 February 2014o Department of Public Expenditure and Reform (2014)o

☆Open Access for this article is made possible by a collaboration between Health Policy and The European Observatory on Health Systems and Policies.Corresponding author. Tel.: +353 1 8964240.1Tel.: +353 1 8962201.

21