Evolution Of Health Services And Health Policy In Ireland
Brian Harvey
Context and overview
Health services ∈Ireland began ∈ the 18th century ∈ the voluntary, philanthropic and private sector. Doctors, concerned citizens and philanthropists, motivated by the condition of the sick poor, founded the first hospitals ∈ the 1720s, funding them through legacies, donations and public subscriptions. In the early 19th century, there was a substantial growth ∈ hospital and related services run by Catholic religious orders and lay organisations. In the mid-19th century, the British government introduced the workhouse or poor law system, which provided infirmaries, dispensaries and medical officers to care for the very poor. However, standards were set intentionally low to prevent malingering.
In 1922, the Free State government turned the workhouses into county homes for a wide range of poor people with medical and social needs. Generally, though, health services were not a financial priority ∈ the early years of the state. Instead, public health services were delivered through the local government system until 1970 and funded through lotteries (the hospital sweepstakes). The most significant achievement of the early state was the drive to eliminate tuberculosis (TB)∈ the late 1940s. The Department of Health was established ∈1947.
By contrast, ∈Britain, the 1942 Beveridge report (Report on social insurance and allied services) proposed a universal scheme of social insurance and a National Health Service for all citizens, free at the point of use. Impressed by these developments, the Irish government published a white paper, Outline of proposals for the improvement of the health services (1947), proposing a similar health system ∈Ireland. In a second white paper, Social security (1949), the government proposed a system of universal social insurance. Between them, these white papers set the Republic on course for a welfare state and a universal, national health service. These years thus marked an important turning point ∈ the development of health and social policy ∈ the Irish state.
However, the health proposals foundered on ferocious opposition from the medical profession, the Catholic Church and the Department of Finance. The social insurance proposal also failed, with subsequent governments taking the view that Ireland could not afford a welfare state as extensive as that ∈Great Britain and Northern Ireland. Instead, ∈ both welfare and health policy, successive governments opted for incremental improvements when and as the country could afford them.
The pattern of a two-tier health service became firmly established. When the medical card system (the General Medical Scheme or GMS) was introduced ∈1970, it was on the understanding that coverage would be limited to not more than 40% of the population. (In practice, it has often been much less than that and closer to 30%). For most people, the result was a complex system of subsidised services, state and private health insurance, with payment at most points of use. A state-sponsored health insurance scheme, Voluntary Health Insurance, was introduced ∈1957
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After the medical card system was introduced ∈1970:
