Healthcare demands equality - Village Magazine

36 December-January 2014

EALTH is life-deﬁning. We all experience ill-

health during our lives and need health services.

Health inequalities are reﬂective of injustice and

inequality in society. Austerity has exacerbated this

injustice and deepened these inequalities in Ireland.

Three studies have recently been published which

examine the impact of austerity on access to health

services and the impact of geography on cancer survival

rates. A common thread through the research studies

is inequality – of access to health services and of health

outcomes in cancer survival rates. Health inequali-

ties refer to the diﬀerences in the experiences of health

among diﬀerent sections of the population. Although

some people will live longer healthier lives due to genetic

or hereditary factors, health inequalities refer to ine-

qualities which are unnecessary, unjust and avoidable,

and could be addressed through public policies.

The European Foundation for the Improvement of

Living and Working Conditions research on ‘Access to

Healthcare in Times of Crisis’ found that the economic

crisis has had a negative impact across Europe on access

to healthcare services not only because of budget cuts,

but also because access to healthcare for households

has been reduced when their disposable income has

declined, creating new barriers to diminished health

services. In Ireland, the ESRI budgetary analysis has

previously illustrated the disproportionate eﬀect of

successive austerity budgets on low-income families,

which are also particularly dependent on the public

health system and therefore most aﬀected by cuts in

health services. The situation in Ireland thus presents

a particularly acute case in the European context.

The funding of the Health Services Executive (HSE)

was reduced by €3.3 billion (22%) over a four-year

period, 2009-2013. Health staﬀ levels have been cut

by approximately 10% since the 2007 peak. The health

system was able to ‘do more with less’ to a certain extent

in the early years of the cutbacks. However, in more

recent years it has been more a case of ‘doing less with

less’. This is evidenced by the growing numbers of peo-

ple on trolleys in emergency departments, increased

waiting times for public appointments, and the removal

of medical cards from signiﬁcant numbers of people.

Alongside this there has been a growing trend towards

cost-shifting by Government to individuals and fami-

lies through the introduction of, or increase in, charges

and thresholds for reimbursements (illustrated in Chart

1). In 2013, cost-shifting meant that on average every

person in Ireland was paying about €100 in additional

costs for care and prescribed drugs (Lancet, 2014). This

cost-shifting further worsens the inequities in access to

health services by low income families.

Fund it better

and distribute it

on basis of need

only, not wealth

Healthcare demands equality

SINÉAD PENTONY

December-January 2014 37

Budget 2015 included a slight improvement in

Government funding for health, which was increased by

just over €300 million. This brought the health budget

up to €13.1 billion. While this modest augmentation

is to be welcomed, Ireland has a growing and ageing

population and the additional resources are likely to be

eaten up by increased demand for existing services. This

leaves little or no scope to extend and improve health

services.

The latest OECD data show that Ireland’s total health

spend was 8.9% of GDP in 2012. This was the second

lowest in the EU (15), which had an average total spend

on health of 9.9% of GDP.

It is also necessary to remember that private money

from health-insurance premiums and out-of-pocket

spending on various health-related charges make up

a lot of our total health spending. On average, public

spending on health in the EU accounts for 75% of all

spending on health. In Ireland, this ﬁgure is 68%, and

we rely more on private sources of funding than most

other EU countries.

This mix of public and private resourcing of health

services has resulted in a dual system which means that

health services can be assigned on the basis of medi-

cal resources (i.e. health insurance) and not medical

need.

A funding model that supports a single-tier health-

care system capable of providing universal access is

long overdue. The Government had planned to reform

the funding of health services and address the inequi-

ties in the system through Universal Health Insurance

(UHI). While it is questionable whether these goals could

have been achieved through the model proposed by the

Government, its planned introduction has now been

shelved indeﬁnitely. It appears that the Government has

gone back to the drawing board in seeking to develop a

sustainable funding model.

In the meantime, low-income individuals and fami-

lies with limited means will continue to face barriers

to access to health services, while others continue to

skip the queue and receive treatment and care in a

timely manner. For some reason it has been accepted

that treating patients on the basis of their ability to

pay instead of medical need is acceptable in Ireland.

Perverse incentives are hard-wired into the health

system and will only be addressed through root and

branch reform.

The current system of healthcare is a contributing

factor to the prevalence of health inequalities, and

research projects from the National Cancer Registry

(NCR) and NUI Maynooth clearly illustrate the eﬀect

this is having on cancer patients living in deprived com-

munities. There have been many advances in the early

diagnosis and eﬀective treatment of cancer in recent

years; however, these improvements do not always

reach the population in the same way.

The NCR research shows that people living in

deprived areas experience a poorer survival from can-

cer than those who live in more aﬄuent parts of the

country and it found that breast-cancer patients from

the most deprived areas were about 30 per cent more

likely to die from their cancer than patients from the

Source: Thomas, Burke, Barry, ‘The Irish Healthcare System and Austerity: Sharing the Pain’.

The Lancet

, 2014, 383 (9928):1545

Source: Wilkinson, R. and Pickett, K, ‘A Convenient Truth: A better society for us and the

planet’. Fabian Society and F’riedrich Ebert Stiftung (2014).

Chart 1: Estimates of cost-shifting from Government to household 2008-2013

Chart 2: Life expectancy is strongly related to income within rich countries

38 December-January 2014

least deprived areas.

Those from more deprived backgrounds were more

likely to present late with advanced stage cancers and

were more likely to present with symptoms rather

than present on foot of screening. The research found

death rates from cancer in some of the poorest parts of

Dublin were more than twice as high as in more aﬄu-

ent areas.

The NUI Maynooth research found that some of these

disparities are due to the diﬃculties getting access to

healthcare for the poorest in society. In North Dublin,

for example, there is one GP for every 2,500 people.

Nationally the ﬁgure is 1:1,600. Issues relating to the

provision of primary care services are not restricted

to towns and cities. The village of Feckle in Co Clare

has no GP and it made the national headlines recently

when the community oﬀered a rent-free surgery to any

GP willing to move to the village.

The equitable provision of, and access to, health

services is essential for the elimination of health ine-

qualities. There has been some progress at policy level

with the reduction of health inequalities established

as one of four goals in the Government’s public-health

strategy ‘Healthy Ireland’. However, there is no clear

plan on how this goal is going to be achieved, no budget

allocation and no targets.

The provision of, and access to health services, is only

part of the solution. The main factors inﬂuencing health

include environment (where we live), education, income

and life opportunities. For real improvements in health

and wellbeing we need a more equal society. Wilkinson

and Pickett (2014) draw particular attention to the very

close relationship between life expectancy and income

within societies. This relationship is almost perfectly

graded across society, as health improves with each

step up the socio-economic scale (see Chart 2). This is

the pattern of health inequalities which can be seen in

almost any society when health is shown in relation to

income, education or any other indicator of socioeco-

nomic status.

Reducing and ultimately eliminating health inequal-

ities therefore requires a more equal distribution of

wealth, income and resources. This implies investment

in public services (including health) and the develop-

ment of a funding model tahat ensures public-health

services are accessed on the basis of medical need.

Health is a fundamental human right which can be pro-

tected as part of a wider set of economic, social and

cultural rights in Irish law.

Enshrining these rights in Irish law would copper-

fasten their protection and contribute to a more just,

inclusive and equal society. •

OPINION PENTONY

Eliminating health

inequalities requires

more equal distribution

of wealth, income

and resources, and

public-health services

distributed on the basis

of medical need

“

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