The state of healthcare in the 26 Counties in the south of Ireland will remain a major political question in the next period. Ireland is the only country in western Europe that does not offer universal primary care. A typical visit to the GP is €52, to A&E is €100, and you can expect to fork out €80 to spend
a night in hospital (up to €800 a year). The two-tiered healthcare system of public and private health is deeply entrenched and blurred in such a way that public sector beds are routinely used for private patients. In May 2023 over 830,000 people were on waiting lists for hospital treatment.
Last year the doctors’ membership body and union Irish Medical Association spoke out about the ‘worsening crisis’ of overcrowding in hospitals. The crisis expresses itself within emergency departments but is underpinned by 900 vacant consultant posts across the country and fewer hospital beds and step-down facilities than 20 years ago despite a growing and aging population. Public 24-hour emergency departments have been closed over recent years.
In January thousands of people participated in protests against the overcrowding and underfunding of services in cities across Ireland. In the same month, there were record daily numbers of patients waiting on trolleys for hospital beds. There are countless incidents of patients being left on trollies for days due to overcrowding: a suspected stroke victim spent 36 hours on one without being admitted to a ward; people are routinely being left in hallways while they throw up, soil themselves and die. Overcrowding increases the risk of infections spreading among patients.
A long history of Church power
Following the establishment of the Irish ‘Free State’ in 1922, the Catholic Church retained enormous control over state policy. The Church was able to retain its dominance over, in particular, health and social care and education. Many hospitals in the country were voluntary hospitals, administered by charities and religious groups such as the Sisters of Charity and Sisters of Mercy. The institutional abuse at the hands of these groups is well documented.
The Church fought tooth and nail against state intervention and welfare, including healthcare provision, for both ideological and material advantage. Following the Second World War and the establishment of the NHS in Britain, and in the midst of soaring child mortality rates, the newly formed Irish Department of Health recommended a modernisation of the healthcare system while making it free at the point of use for all mothers and children up to the age of 16. This reform, mild in comparison to healthcare reforms across Europe, caused huge controversy with the church, whose clergy moved swiftly to quash the proposal. They were supported by consultants and other medical professionals defending their private incomes.
Reform: from private to more private
After numerous defeats for public health provision, a Voluntary Health Insurance scheme was introduced by the state in 1957 to offer health insurance to those who could afford it. It laid the basis for the development of the two-tiered system of public and private healthcare that exists today. Today, publicly owned and funded hospitals are run by the Health Service Executive (HSE), voluntary hospitals continue to be owned by religious or charity groups – but are publicly funded – and for-profit private hospitals are privately owned and funded. There are 47 public hospitals, 22 voluntary hospitals and 19 private hospitals.
Religious control remains deeply rooted: Catholic entities own seven of the largest ‘public’ hospitals in Ireland and receive more than €1bn in state funding every year, while 12 of Ireland’s 18 private hospitals follow Catholic ‘ethos’ (Peter Boylan, The Irish Times, November 2022). Sisters of Mercy are quite clear that their conception of Catholic ‘ethos’ translates to preventing women from accessing vital medicines and procedures with bans on IVF, abortion, the morning-after pill and sterilisation. Such policies also limit scientific research in realms including gene editing, which is used to look for the cure of hereditary diseases such as cystic fibrosis (The Irish Times, November 2022).
While the state financially sustains this practice, it has systematically undermined public healthcare and opened the door to for-profit providers. In 2019 Dr Julien Mercille of the University College Dublin revealed that more than 1,000 public sector hospital beds had been closed over the preceding 40 years, while in the same period more than 1,000 private for-profit hospital beds had been opened. Routinely cutting real-term public health spending during that period, the state effectively subsidised for-profit healthcare with tax-relief and by allowing publicly employed consultants to use public hospital beds for their private patients at prices that did not cover the costs of the beds.
While anybody admitted to a public hospital must be treated, most of the population is forced to pay for their access to healthcare. Free healthcare via Medical Cards is only available for those in receipt of welfare payments and low earners – 68% of the population do not qualify. Between 2008 and 2014 nearly €500m of the cost of some aspects of healthcare was transferred from the state onto people (Bridget Johnston, Health Policy, October 2019).
Outcry against the absurdity, inefficiency and corruptness of Ireland’s jumbled system has meant it has become politically necessary for parliamentary parties to support free, universal health and social care. The Fine Gael minority government in 2018 launched its ten-year plan for reforming health and social care services. Slaintecare: a ‘vision of one universal health service for all’.
In practice, this has taken the form of outsourcing to the private sector. One such example was the €77m earmarked for the HSE 2022 Winter Plan, of which €20m was to be spent on a series of agreements with private hospitals: ‘so over 15% of the funding in this plan is going to be handed over to private corporations’ (Eirigi, January 2022). Public hospitals continue to lack funding and staff.
The state can wax poetic on universal health care, but so long as public services remain chronically understaffed and underfunded, and private health companies are able to offer quicker results, it will remain a pipe dream.
Ria Aibhilin
FIGHT RACISM! FIGHT IMPERIALISM! 296 October/November 2023
