Analysis: here are 4 reasons why proposed healthcare reforms are often not implemented at all
By Sheelah Connolly, ESRI
In Ireland, a significant proportion of Government expenditure goes to providing and financing health and social care services. In Budget 2024, €22.5 billion was allocated to the healthcare sector, representing 21% of total public expenditure.
But despite this large and growing expenditures, some groups of people continue to experience barriers when accessing a range of healthcare services. Charges to see the GP for those without a medical or GP-visit card are high and vary across the country.
Waiting times for publicly funded hospital-based services are long and compare unfavourable with other OECD countries. An inadequate supply of a range of community-based services for those with various health and social care needs means that such care often falls to families, has to be purchased privately or is gone without.
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From RTÉ Radio 1's News At One, almost half the population have private health insurance
These are not new issues in the Irish health and social care sector. Indeed, successive governments have not only recognised these issues, but also, in many cases proposed reforms to deal with them. The most recent of these – Sláintecare – seeks to achieve a healthcare system where access is based on need rather than ability to pay. However, proposed reforms are often only partially implemented or not implemented at all and there are a number of reasons we can identify for this.
Resistance from stakeholders
There are a number of potential stakeholder groups within the healthcare sector for which the status quo might be preferable to significant reform of the system. These include members of the public, healthcare providers and healthcare officials as well as other interested groups.
Back in 1951, an alliance of Church and doctors prevented the introduction of a proposed 'Mother and Child' scheme which would have offered free primary care to children, and free care to mothers before and after birth. More recently, objections were raised by members of the public and medical professionals about the removal of private maternity care from public hospitals (a key feature of the Sláintecare proposals) with some arguing that this would reduce choice for patients given the lack of private maternity hospitals.
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From RTÉ Archives, Dr Noel Browne speaks about the Mother-and-Child Scheme in September 1950
Competing demands for limited resources
Sometimes the resources necessary for the implementation of reforms are deemed to be not available or are allocated to other uses. Due to significant cuts in the healthcare budget between 2009 and 2013, the automatic entitlement for a medical card for those aged 70 and over was removed, thereby undoing previous measures which had attempted to improve access to health care.
In 2015, the Government's commitment to the development of a universal healthcare system funded by universal health insurance was abandoned, in part, due to concern about the cost implications of the proposed reforms. More recently, during the Covid-19 pandemic, it was necessary to divert resources (including financial and workforce) toward the immediate threat associated with the pandemic with many of the Sláintecare reform proposals put on hold.
A lack of proper planning
A lack of consideration on how proposed reforms would operate in practice can also contribute to policies not being implemented. Within the Sláintecare proposals, there is some ambiguity about whether universal healthcare implies access to care that is free at the point of use or whether user charges would remain a feature of the system. Without a clear description of what the policy will mean in practice, it is impossible to identify how the proposals would operate, the cost implications for both the exchequer and the individual, as well as the potential impact on demand for services and consequently the need for additional workforce.
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From RTÉ Radio 1's Morning Ireland, health economist Dr Brian Turner from UCC on the challenges currently facing the HSE
Politics
The nature of our political cycle can also contribute to reform proposals not being implemented. Often, policy makers are not accountable for the outcomes of their policy initiatives as they have moved on from the position they held when the reforms were developed. This can lead to the development of reform proposals as quickly as possible, rather than thinking about how things might work out in practice.
Even when policy makers remain in position and could therefore be held accountable for the non-implementation of reforms, a lack of clarity about how the reform proposals might operate in practice can provide an opportunity for policy makers to avoid criticism as it may be difficult to identify if, and to what extent, the reform proposals have been implemented.
While the development of policies can be complex and time consuming, even more challenging is ensuring that policies are implemented in full. Successful implementation requires ongoing collaboration with relevant stakeholders and identifying appropriate policy approaches after the problem has been defined, the options evaluated, and consultation undertaken. The first step in the development of any new reform proposals should be an assessment of why previous policy proposals have failed.
Dr Sheelah Connolly is a Senior Research Officer in the Social Research division and joint Research Area Coordinator for Health and Quality of life research at the ESRI. She is an Adjunct Professor in Economics at Trinity College Dublin.
The views expressed here are those of the author and do not represent or reflect the views of RTÉ
