Translating Dutch: challenges and opportunities in reforming health financing in Ireland

The Influence of Socioeconomic Status on the Choice of Patterns and Methods of Health Financing in Jambi Province

Healthcare financing plays role in improving the quality of health services, with an aim to examine the effect of family socioeconomic status on the patterns and methods of ability to purchase health services. A quantitative study with a survey approach used in this research that connects exogenous (family socioeconomic status) and endogenous variables (financing patterns and methods, ability to purchase health services), with total sample of 770 households. The technique used an accidental sampling in western and eastern regions of Jambi, with questionnaire instrument and analysis PLS-SEM’s second order. Based from this research, family socioeconomic status has a direct influence on the ability to purchase health services showing as the first hypothesis. The second hypothesis also proved direct influence on the ability to purchase health services. The third hypothesis was also proved like the first and second hypotheses. Methods of health financing mediated the correlation between family socioeconomic status and ability to purchase health services was accepted of fourth and fifth hypotheses. Therefore, the family’s socioeconomic status, patterns and methods of health financing have a direct influence on the ability to purchase health services. Meanwhile, there was an indirect effect of family socioeconomic status on the ability to purchase health services through health financing patterns and methods.

A European late starter: lessons from the history of reform in Irish health care

The Irish health care system is unusual within Europe in not providing universal, equitable access to either primary or acute hospital care. The majority of the population pays out-of-pocket fees to access primary health care. Due to long waits for public hospital care, many purchase private health insurance, which facilitates faster access to public and private hospital services. The system has been the subject of much criticism and repeated reform attempts. Proposals in 2011 to develop a universal health care system, funded by Universal Health Insurance, were abandoned in 2015 largely due to cost concerns. Despite this experience, there remains strong political support for developing a universal health care system. By applying an historical institutionalist approach, the paper develops an understanding of why Ireland has been a European outlier. The aim of the paper is to identify and discuss issues that may arise in introducing a universal healthcare system to Ireland informed by an understanding of previous unsuccessful reform proposals. Challenges in system design faced by a late-starter country like Ireland, including overcoming stakeholder resistance, achieving clarity in the definition of universality and avoiding barriers to access, may be shared by countries whose universal systems have been compromised in the period of austerity.

The 2011 proposal for Universal Health Insurance in Ireland: Potential implications for healthcare expenditure

The Irish healthcare system has long been criticised for a number of perceived weaknesses, including access to healthcare based on ability-to-pay rather than need. Consequently, in 2011, a newly elected government committed to the development of a universal, single-tier system based on need and financed through Universal Health Insurance (UHI). This article draws on the national and international evidence to identify the potential impact of the proposed model on healthcare expenditure in Ireland. Despite a pledge that health spending under UHI would be no greater than in the current predominantly tax-funded model, the available evidence is suggestive that the proposed model involving competing insurers would increase healthcare expenditure, in part due to an increase in administrative costs and profits. As a result the proposed model of UHI appears to be no longer on the political agenda. Although the Government has been criticised for abandoning its model of UHI, it has done so based on national and international evidence about the relatively high additional costs associated with this particular model.

"Managed competition" for Ireland? The single versus multiple payer debate

BACKGROUND

A persistent feature of international health policy debate is whether a single-payer or multiple-payer system can offer superior performance. In Ireland, a major reform proposal is the introduction of 'managed competition' based on the recent reforms in the Netherlands, which would replace many functions of Ireland's public payer with a system of competing health insurers from 2016. This article debates whether Ireland meets the preconditions for effective managed competition, and whether the government should implement the reform according to its stated timeline. We support our arguments by discussing the functioning of the Dutch and Irish systems.

DISCUSSION

Although Ireland currently lacks key preconditions for effective implementation, the Dutch experience demonstrates that some of these can be implemented over time, such as a more rigorous risk equalization system. A fundamental problem may be Ireland's sparse hospital distribution. This may increase the market power of hospitals and weaken insurers' ability to exclude inefficient or poor quality hospitals from contracts, leading to unwarranted spending growth. To mitigate this, the government proposes to introduce a system of price caps for hospital services.The Dutch system of competition is still in transition and it is premature to judge its success. The new system may have catalyzed increased transparency regarding clinical performance, but outcome measurement remains crude. A multi-payer environment creates some disincentives for quality improvement, one of which is free-riding by insurers on their rivals' quality investments. If a Dutch insurer invests in improving hospital quality, hospitals will probably offer equivalent quality to consumers enrolled with other insurance companies. This enhances equity, but may weaken incentives for improvement. Consequently the Irish government, rather than insurers, may need to assume responsibility for investing in clinical quality. Plans are in place to assure consumers of free choice of insurer, but a key concern is a potential shortfall of institutional capacity to regulate managed competition.

SUMMARY

Managed competition requires a long transition period and the requisite preconditions are not yet in place. The Irish government should refrain from introducing managed competition until sufficient preconditions are in place to allow effective performance.

A framework for assessing health system resilience in an economic crisis: Ireland as a test case

BACKGROUND

The financial crisis that hit the global economy in 2007 was unprecedented in the post war era. In general the crisis has created a difficult environment for health systems globally. The purpose of this paper is to develop a framework for assessing the resilience of health systems in terms of how they have adjusted to economic crisis. Resilience can be understood as the capacity of a system to absorb change but continue to retain essentially the same identity and function. The Irish health system is used as a case study to assess the usefulness of this framework.

METHODS

The authors identify three forms of resilience: financial, adaptive and transformatory. Indicators of performance are presented to allow for testing of the framework and measurement of system performance. Both quantitative and qualitative methods were used to yield data for the Irish case study. Quantitative data were collected from government documents and sources to understand the depth of the recession and the different dimensions of the response. Semi-structured interviews were conducted with key decision makers to understand the reasons for decisions made.

RESULTS

In the Irish case there is mixed evidence on resilience. Health funding was initially protected but was then followed by deep cuts as the crisis deepened. There is strong evidence for adaptive resilience, with the health system showing efficiency gains from the recession. Nevertheless, easy efficiencies have been made and continued austerity will mean cuts in entitlements and services. The prospects for building and maintaining transformatory resilience are unsure. While the direction of reform is clear, and has been preserved to date, it is not certain whether it will remain manageable given continued austerity, some loss of sovereignty and capacity limitations.

CONCLUSIONS

The three aspects of resilience proved a useful categorisation of performance measurement though there is overlap between them. Transformatory resilience may be more difficult to assess precisely. It would be useful to test out the framework against other country experiences and refine the measures and indicators. Further research on both the comparative resilience of different health systems and building resilience in preparation for crises is encouraged.