FROM the many issues which can be raised on the doorstep with party canvassers, health is the one topic close to the heart of nearly every voter.
Answers to questions about waiting lists, medical cards, health insurance, the threatened closure of a hospital or cancer treatment should be on the tip of the tongue of any experienced vote catcher.
Recently, it would seem there has been little more to the health issue in the Republic than the hepatitis C scandal and healthcare workers threatening to strike. However, an election brings the general issues back into focus, with promises designed to ease one of the most basic of public fears what will happen if one gets sick?
Over 20 per cent of government spending goes on health services and health care costs will continue to rise due to an ageing population. This year, £2.6 billion will be spent on the public health service.
Earlier this week, the report by the Organisation for Economic Cooperation and Development warned of the need to control spending, particularly on doctors' pay and drugs. It called for a clearer delineation between private and public healthcare.
A common feature of party pledges is an extension of the GMS (i.e. the service provided for medical card holders). Fine Gael says it will extend eligibility to those over 75 years, regardless of income. While Democratic Left proposes a medical card for the entire population in the longterm, in the shorter term it favours the inclusion of all children under seven years and doubling of eligibility limits for all over 65.
Fianna Fail says it is also reviewing the medical card scheme, particularly eligibility for large families which are just above the current threshold; extending it to include young children and doubling the eligibility limits for pensioners.
Any of these proposals, if introduced, would be costly. At present, 36 per cent of the population have medical cards and an extension pushing that to over 40 per cent triggers an automatic review of the GMS agreement with GPs, according to Dr Tony Hynes, vice president of the Irish Medical Organisation. Doctors argue that such extensions entitle them to higher capitation fees.
The PDs say that, over the last five years, the cost of running the health service has increased by almost £1 billion. Since 1992, it has risen by 50 per cent, more than five times the rate of inflation. They say that, despite these huge additional resources, there has not been a 50 per cent improvement in service and there are still major deficiencies.
However, at the announcement of the Fine Gael health manifesto, the Minister for Health, Mr Noonan, said it was not possible to cut public expenditure significantly, as the PDs have planned, without cutting health care.
He said not only would future progress be stopped but existing programmes would be cut as the budget needed to be increased by 8 per cent each year to keep up with medical inflation, as opposed to the net increase of 2 per cent proposed by the PDs.
One issue almost guaranteed to interest the electorate is hospital waiting lists. The parties have made various pledges, all geared towards cutting these figures. Yet almost £50 million has been spent on waiting list initiatives over the past five years and there are still 27,000 people awaiting treatment, a quarter waiting for hip, knee or other orthopedic treatments for up to one year or more.
Figures for waiting lists are approximates as Mr Noonan has not yet published the figures to the end of March. They will not be available until after the election in mid June.
The president of the Irish Hospital Consultants Association (IHCA), Dr James Masterson, said there could be no solution to hospital waiting lists until the structural problems in the health services were resolved.
"The public should be very sceptical of claims and promises on waiting list reductions made during the general election. The initiatives are nothing more than a palliative which allow waiting lists to drop down to a certain level before they inexorably start to rise again," said Dr Masterson.
He said they would not drop below the current level - "no matter how much money is thrown at them" - until the large number of hospital beds which have been progressively taken out of the health system were restored. The structural problems of hospital financing which saw the routine closure of hundreds of beds for several month of the summer had also to be addressed.
In the summer of 1996, there were some 800 summer bed closures in acute and general hospitals. It is not known how many will close this summer. The average number of beds available in acute hospitals has fallen from 14,000 in 1989 to an expected 10,000 at the end of next year.
Of the smaller general hospitals, it appears the parties have taken a collective decision to avoid this contentious issue. However, politicians do not appear to have examined the implications of this and how keeping them open will affect funding of specialist units.
New ways will have to be found to organise, fund and manage these hospitals. More effort will have to be made to develop primary care and encourage more communication between GPs and hospital specialists for the benefit of the patient and the health budget.
A plan for the development of the health services has been sent to each political party by the recently established Irish Patients Association. It says its aims are in keeping with the aims of the Department's policy document, Shaping a Healthier Future.
The new Minister for Health will have to be aware of the growing demand for a better service, better communication with patients and the need for measurable health gain. As the Green Party points out, prevention is better than cure. It says more money must be spent on health promotion, currently at 0.2 per cent of the health budget.
Fianna Fail appears to recognise the need for change in this area and says, in the aftermath of the hepatitis C scandal, there is a clear need to introduce systems to make the health services more open and consumer orientated. The party has promised a customer focused healthcare service with a health ombudsman and a patients' complaints procedure.
These are badly needed, according to Mr Stephen McMahon, of the Irish Patients Association, who called for a centrally funded body with responsibility for patients' rights.
"We have uncovered a huge unmet need of patients and their families in Irish health care; that is the need for independent support and information, a guardian of their rights, a channel for their views and a voice for their expectations.
"We believe that we can meet that need but only from a firmly supported basis and possibly from a statutory one. This gap in health care should no longer remain unfilled and we want all parties to make a commitment to change in this area.