Current Affairs: In 2002, the Republic of Ireland spent nearly a quarter of its government revenue on the health system. As Maev-Ann Wren tells us in her new book, public health spending in the country was well below the European average for decades, having reached its nadir in 1989 after the fiscal crisis of the late 1980s, writes Tom Garvin.
In 2001, health spending actually exceeded the EU average for the first time, both in terms of spending per head and as a percentage of GNP. However, under-investment and inappropriate investment in the past still marked the system. Irrationalities abound in the system, and the effects of past political conflicts over the production of healthcare have left deep marks on it. Most conspicuously, Ireland's two-tier system of healthcare, consisting of a pay-as-you-go system for the well-off and what amounts to a queuing system for poorer people, still exists, despite attempts by various ministers for health over the years to abolish or at least ameliorate it. The two-tier system is grossly unfair and evidently inegalitarian. Worse, it seems to involve ensuring that poorer people in our society get inferior healthcare and get it far less promptly than those who can pay to "jump the queue", as the author accurately puts it.
Another aspect of the system is its decentralised and fragmented character, caused by the intensely localist structure of the Irish political system. Every county wishes to hold on to its medical facilities, even though modern healthcare dictates a pattern of fewer, larger and better-equipped hospitals in central locations. As long ago as 1975, there were 54 general hospitals in the Republic, and Brendan Corish proposed to reduce the numbers to 33. Fianna Fáil swept to office in 1977, and the targeted hospitals survived, even though they were "poorly resourced and staffed".
To put this in perspective, back in 1968, the FitzGerald Report recommended a mere four regional and 12 general hospitals for the entire country. Little has changed in this respect since the late 1970s.
Yet another feature of the Irish political system is responsible historically for the situation: the extreme vulnerability of Irish politicians and governments to veto groups. In the past, these veto groups most famously included the Catholic Church, the trade unions, the farmers' lobbies and various professional organisations. Every Irish government minister apparently has someone out to stop him doing something. In the case of health, the Church's control over aspects of the health system was originally fuelled by obsession with sexual behaviour and the physiology of childbirth. The Church's leaders had, 50 years ago, also what could be unkindly termed an exaggerated respect for the learned professions, and in particular for the opinions of the Irish Medical Association of the time. The result was, of course, the notorious mother and child legislation clash of 1951. A long-term result of that episode was the enforcement of the doctors' and consultants' interests at the expense of the establishment of an egalitarian and universal healthcare system, whether financed by insurance or public funds, or some intricate combination of both plus private payment, as in some countries. The two-tier system is the child of history and the survival of interest group veto, as are so many other irrationalities and anomalies in Irish public service systems, ranging from transportation to town planning.
Wren tells her horror story with great verve. She does not demonise pivotal individuals, but maps out the perverse results which the efforts of private individuals set against each other have, mainly unintentionally, brought about. The author even gives us some good guys: Noel Browne, Muiris FitzGerald in a later generation, and, I am glad to see, my own old friend and personal hero, James Deeny, who set up much of the original health system after 1944. Wren is long on diagnosis, but like most of the rest of us, somewhat shorter on how to fix it. Like this writer, she is agnostic as to modes of financing the system, but feels the present system doesn't work, is irrational and unfair and bad value for money. She identifies in particular a "political vacuum":
. . . the avoidance of difficult decisions in areas such as hospital reorganisation, the unwillingness to confront hospital consultants, the glaring contradictions in health policy caused by the interventions of the Minister for Finance, the inconsistencies in the health strategy, the absence of explicit values and of vision. To reform Irish healthcare, incrementalism will not suffice. That got us into this fine mess.
James Deeny once remarked genially that you are stuck with the present trained cadre of medical personnel: "You cannot take them out and shoot them." Perhaps occasionally he felt like doing so. Wren herself seems somewhat pessimistic about the prospect for root-and-branch reform, and gives us a fascinating and disturbing explanation rooted in political culture for the apparent defeatism of the Irish political establishment in situations like this: an old and deeply rooted pessimism about Irish society that resurfaces when times get harder. The folk memory of failure is still around in a society that on the surface seems so successful and to have broken out of its historical trap of under-development and subservience. This defeatism is still discouraging us from rebuilding the health service on rational principles in an era in which the Republic has become one of the richest countries in the world, she argues.
There is something in this, but what strikes me about Wren's story is not only the activities of veto groups, but also the opportunism of so many of the decisions that have been made, commonly driven not only by the special interests of consultants but by the electorate, an electorate reacting more to local and short-term considerations than to an admittedly rather intangible greater interest, that of the nation as a whole. We have seen the enemy and he is us.
Tom Garvin is Professor of Politics in University College Dublin and a member of the Royal Irish Academy. His books include 1922: The Birth of Irish Democracy (Dublin: 1996). He is at present completing a study of Irish developmental politics during the period 1937-1967
Unhealthy State: Anatomy of a Sick Society. By Maev-Ann Wren, New Island, 445 pp, €17.99