Sinn Fein set out need for all-Ireland health strategy

Féilim Ó hAdhmaill looks at Sinn Feín's new health policy for the island of Ireland

THE May launch of Sinn Fein's new health care policy for Ireland is to be welcomed by republicans and socialists.

The 45-page Health for All document covers a range of practical proposals based on the establishment of an all-Ireland system of socialised health-care provision.

It tackles both the limitations placed on health care provision posed by the border and the issues of health inequality and the lack of provision for those in poverty or disadvantage at a time when the Irish economy is among the strongest in the world.

At the core is a proposed new universal public health system that provides care to all, free at the point of delivery, on the basis of need alone and funded from general and progressive taxation.

A fundamental re-orientation of the health system is proposed, to adopt a central focus on prevention, health promotion and primary care. There is also an added commitment to eliminate the underlying social and structural causes of illhealth and premature death, such as poverty and inequality.

The programme includes a pursuit of social and economic equality in general and opposition to privatisation policies.

Of profound significance is the proposal to enshrine the right to health and the right to healthcare in a future all-Ireland Charter of Rights and a future united-Ireland constitution.

As a result, the right to healthcare would become fully enforceable right in Irish courts. Equality and human rights-proofing is also proposed for all health policy and as well as for other areas of law and policy.

To tackle the barriers to health caused by partition, a single, all-Ireland strategic health executive is proposed that will progressively subsume existing partitionist health bodies.

One consequence of partition has been the development of separate welfare systems. In the south, due to dominant centre-right politics and a past lack of economic development, the health service has traditionally depended on a mixture of public and private funding and provision, with a heavy emphasis on private insurance cover.

This has led to the development of a two-tier system of health care and gross inequalities in health based on socio-economic status and geographical location. An under-resourced and over-burdened public system exists side by side with a thriving government subsidised private health sector.

Currently one of the biggest problems is access to hospital beds. Since 1980 the number of acute hospitals beds in the health service has been cut by 5,500, despite an increasing population. This is despite the fact that health is the highest spending government department and the health budget consistently absorbs the equivalent of the entire income-tax take.

In the six counties, while most healthcare is free at the point of delivery, the health service has been undermined by budgetary constraints imposed by London and a privatisation strategy inherited from the Thatcher/Major era and continued under 'New Labour'.

One of the consequences of years of under-resourcing has been a lengthening of treatment waiting lists. It has been estimated that nearly 190,000 people - or about one person in nine - is now on a waiting list for care. In addition, there is a lack of bed capacity.

The six counties therefore continues to suffer from lack of provision and health inequalities.

Why is this the case? Would an Irish national health service do any better?

The six counties did of course benefit from the establishment of the new NHS in 1948, despite initial opposition, on cost grounds, from the unionist regime at Stormont. The newly elected British Labour government's aim was to provide a national health care service free at the point of access, available to all regardless of income or geographical location, paid for out of a progressive taxation system and providing most importantly, an optimum level of care.

The initial utopian hopes were that once a backlog of ill-health was cleared, the costs of the NHS would be containable, and a healthier nation would be much more economically efficient.

Of course this wasn't to to be. Costs continued to spiral. Partly because of the success of the NHS and better nutrition and public health, people lived longer.

However, it is not just demographic changes which have spurred costs in the NHS. The monopoly control of the production and sale of drugs by transnational corporations ensured that drug prices are set at an increasingly high level. It is this which forces some health trusts in Britain to deny new cancer drugs to patients in need, in order to keep within their budgets.

In fact, spending on pharmaceuticals grew on average 1.3 times faster per year than total health expenditure between 1992 and 2002.

When the Blair administration took office in 1997 the NHS budget was increased substantially. Today there are 85,000 more nurses than in 1997, and the NHS currently employs 1.3 million people. Despite this, complaints continue about waiting lists for elective surgery and lack of provision in rural areas.

There have been calls in the right-wing press for increased privatisation in the NHS over and above what is already taking place, especially with Private Finance Initiatives.

However, public funding and provision can be much more efficient, cost effective and equal than private provision. One study has shown that, of 89 procedures, 46 cost less in the NHS than in five other European health care systems with a sizeable element of private provision.

Nowadays it is generally accepted across the EU, in Britain and in Ireland that illhealth inequalities are linked to poverty. It is also recognised that, among developed countries, the greatest health inequalities exist in the US, which has the most privatised health care system of all.

But the US spends nearly twice as much of its GDP on health care than the average for OECD countries. Yet more than 45 million people in the USA are not covered by either private health insurance or the grossly inadequate public provision provided by Medicaid and Medicare schemes.

It has also been estimated that around 25 per cent of the health care budget in the USA is absorbed by administration. So not only does private provision promote inequality, it is also inefficient.

Despite the development of the NHS, inequalities have persisted.

A range of measures have been taken to remove these. From at least the mid- 1970s there have been efforts to promote primary care centres in areas of high socio-economic deprivation.

The persistence of a vibrant private sector operating both independently and within the NHS militates against such efforts. Nonetheless the most persistent inequalities are in the experience of ill health, which is usually not linked to inequality in access to treatment but due to poverty, poor environment and other public health issues. A wide range of reports from the Black report (1980) to the Acheson report (1998) have documented just this.

In recognition of this Sinn Feín's Bairbre de Bruin, in her brief period as minister for health in the Northern executive, although constrained by lack of control over the NHS budget, made an attempt to refocus attention on the north's problem of gross health inequalities in Investing for Health (2002). This accepted the link between economic and social deprivation and ill health and proposed wide ranging measures involving not just the promotion of health care and preventive health measures among sectors of society most at risk. It included a comprehensive approach to tackling poor housing, environment, unemployment, social and educational and community facilities.

The fall of the northern executive however, left control in the hands of unaccountable direct-rule British ministers who currently seem more concerned with public sector cuts and privatisation than in investing for health.

Would an Irish NHS fair any better?

A lot depends on commitment to the provision of a public service and a minimisation of private profiteering, an ending of duplication, especially via all Ireland strategic planning, and a new orientation to health care, concentrating on health promotion, primary care and the elimination of gross socio-economic inequalities.