New WHO study shows how Ireland can reduce health-related financial hardship and unmet need by delivering universal access to health care
WHO
In 2017, the Government of Ireland set out a ten-year plan for health reform, known as Sláintecare, to deliver universal access to health services in Ireland. A new WHO study shows how important it is for Ireland to implement the Sláintecare reforms to strengthen equitable access to health care and financial protection, building on steps already taken in response to COVID-19.
Ireland uses income, age and health status to determine eligibility for publicly financed health services. This unusually complex approach has led to notable gaps in coverage and inequalities in access to essential health services. For example, Ireland is the only country in western Europe that does not offer universal access to primary care. It also has a large market for private health insurance, which mainly benefits richer people.
WHO’s analysis of survey data from 2009–2010 and 2015–2016 finds that although catastrophic spending on health in Ireland is low on average, reflecting one of the lowest levels of out-of-pocket payments in Europe, it has increased over time. Ireland’s low incidence of catastrophic spending can be attributed to the absence of high user charges for the poorest third of the population and some protection mechanisms for people who have to pay user charges. It may also reflect unmet need for health care owing to financial barriers to access and some of the longest waiting times for specialist inpatient care in the European Union.
The WHO report’s lead author, Dr Bridget Johnston from the Centre for Health Policy and Management at Trinity College Dublin, said, “This research is the first of its kind in Ireland. It shows how even low user charges are a barrier to access and lead to financial hardship for some households. Although the health system successfully protects many, there are clear gaps in coverage for the poorest people.”
Financial protection undermined by austerity
Gaps in coverage grew following the 2008 financial crisis in response to cuts in public spending on health, cuts to the health workforce, the introduction of user charges for outpatient prescriptions for the poorest third of the population in 2010 and higher user charges and lower dental benefits for all households (2009–2014). These cuts and user charges are associated with increases in catastrophic health spending and unmet need for health and dental care, particularly among poor households.
Private health insurance premiums are a financial burden
Private health insurance covers around half of the population, fuelled by long waiting times and substantial tax subsidies. Although it reduces exposure to some out-of-pocket payments – mainly for elective specialist care – it represents a significant financial burden for many people, accounting for around 3% of a household’s budget on average, in addition to the 2% that households already spend through out-of-pocket payments. As other studies have shown, private health insurance also undermines equity and efficiency in the health system by allowing a large share of the population to access health care on the basis of ability to pay rather than need.
Building on the response to COVID-19
In working to control the COVID-19 outbreak, the government has taken steps that address longstanding inequalities in access to health care – for example, providing universal access to testing, diagnosis and treatment for COVID-19 without charge and extending free teleconsultations for all COVID-related symptoms to the whole population. In addition, public sector contracting of private hospitals to treat people with COVID-19 could offer a model for enhancing capacity and lowering waiting times in the future.
Ireland’s new government can now build on these achievements by introducing universal entitlement to health care, including publicly financed dental and general practitioner care. Progressive steps towards universal health care include exempting poor households from prescription charges; linking the annual cap on prescription charges to income; introducing waiting-time guarantees for public hospital services to reduce the need for people to pay out-of-pocket for specialist care or to purchase private health insurance; and introducing measures to limit the negative spillover effects of a large private health insurance market. Many of these steps are in keeping with the principles of the Sláintecare report, including that care should be provided free at the point of delivery, based entirely on clinical need.
