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164 Economic crisis, health systems and health in Europe: country experience
the boom years meant that there was room for efficiency gains in the recession.
Essentially, built-in inefficiency provided a cushion for the hard fall of significant
budget cuts in health. The system is now certainly more efficient than at the
beginning of the crisis and is generally doing more with less (Thomson, Jowett
& Mladovsky, 2012). The recession, at least in the first few years, proved to be a
useful mechanism to reduce input costs (which were very high by international
standards) and to increase productivity by treating patients more cost-effectively
(e.g. increased day care in hospitals).
However, with further reductions in public health expenditure required over
the period 2013–2015, there are doubts over the capacity of the system to
absorb further cuts without damaging patient access and care (Thomson, Jowett
& Mladovsky, 2012). In addition, it is now clear that the cuts proposed in
each budget have proved increasingly hard to realize because of continued cost
pressures (e.g. in terms of expenditure on agency staff) and failure to implement
some key cost-reduction initiatives in the face of stakeholder pressure. Some
input prices still remain high by international standards (Thomson, Jowett
& Mladovsky, 2012; Brick, Gorecki & Nolan, 2013). It is also important
to remember that such cuts are occurring in the context of a system that is
experiencing significantly increased demands in the form of population ageing,
increased fertility and rising rates of chronic disease.
5.2 Content and process of change
Despite the significant cuts in public health expenditure that have occurred, a
crucial safety net for vulnerable groups has been maintained via the medical card
scheme. However, there have been recent changes to both the breadth and depth
of cover in the medical card scheme, and for those not covered by a medical card,
the scope and depth of public cover has been continually eroded (see Table 5.5).
The latter has occurred despite a recent report that found that Ireland is unusual
internationally in terms of the high level of user fees that are charged for public
health services (see Table 4.6 in Thomson, Jowett & Mladovsky, 2012).
In addition, in the context of a system that requires the majority of the
population to pay the full, unregulated, OOP cost for primary care services,
continued price inflation in doctors' and dentists' fees is a concern. Health
care affordability is likely to become an even greater issue in future, as average
annual disposable incomes continue to fall.
However, for the first time in the history of the Irish State, the principle of
“a universal, single-tier health service, which guarantees access to medical
care based on need, not income” (Government of Ireland, 2011a) is a core
component of official health policy. The Programme for Government notes that
everyone in Ireland will be able to obtain statutory benefits from an “insurer” of