2/2/17: What Euro Health Index 2016 Tells Us about Ireland's Health System?

Some pretty harsh ratings of the Irish Health system have been released by the Euro Health Consumer Index back at the end of January. Overall, based on data across 35 countries, including European Union member states, Norway, Iceland, Switzerland and the Balkan states (Montenegro, Albania, Serbia and FYR Macedonia), Irish health system ranks miserly 21st, scoring 689 points across 6 key macro-categories of assessment (or sub-disciplines).

The sub-disciplines on which assessments were based are:

1) Patient Rights and Information

2) Accessibility (waiting times of treatment)

3) Outcomes

4) Range and reach of services

5) Prevention

6) Pharmaceuticals

Ireland’s total score is statistically indistinguishable with a higher-ranked FYR of Macedonia (20th place), not exactly a known powerhouse of social or public services and Italy (ranked 22nd). With exception of Italy, Ireland’s ranking is the weakest amongst all high income countries present in the EU and in the sample overall. 

The issue of income and relationship between amounts spent on healthcare and the system performance is a complex one. And the report does attempt some analysis of this. However, it might be an interesting exercise to see, just how much better would Ireland’s system perform were we to adapt the best practices found across each sub-discipline amongst two subsets of the countries, both with vastly lower incomes than here. 

I undertake this exercise below under two scenarios. For each sub-discipline:

1) Scenario IRL “Peripheral” assumes that Ireland adopts the best practice found in the group of the euro ‘peripherals’ states (Greece, Ireland, Italy, Portugal and Spain); and 

2) Scenario IRL “Emerging” assumes that Ireland adopts the best practice found in the group of the sampled states that comprise emerging economies of East-Central Europe (Slovenia, Estonia, Croatia, FYR Macedonia, Slovakia, Serbia, Lithuania, Latvia, Hungary, Poland, Albania, Bulgaria, Montenegro and Romania).

Note: these are not exactly scientific exercises, so treat them as an indicative analysts, rather than an in-depth and conclusive. However, I did perform some simple statistical robustness checks on these findings and they do not appear to be complete ad hoc.

The two scenarios are co-plotted in the following charts alongside the actual Euro Health Consumer Index scores:

As shown in the last chart above, adopting best practices from the countries with vastly lower incomes (and, thus, lower per capita expenditures on healthcare - controlling for the argument that the issue with Irish system is lack of money) would have resulted in a vastly better performance of the system across the board. That is because with exception of just one sub-discipline (Pharmaceuticals), Ireland’s performance is substantially sub-par when compared to the lower income countries best practice experiences. 

The truth is: the Euro Health Consumer Index suggests that the real problem with Irish health system's abysmal performance is not necessarily solely down to the lack of money (although that too might be the case) but may be significantly down to the lack of will to adapt some of the better practices that are, apparently, available and accessible for lower income economies. Yet, despite this pretty simple to grasp observation, majority of Irish analysts and media continue to insist that improving Irish health system requires only one thing: more cash from the taxpayers. What's the margin of error on this argument, given Macedonia scores better on Health Index than Ireland? I would say it is huge.

18/11/2013: European Health: Cancer Survival Rates

Spot where our HSE comes compared to NHS...

Source: http://www.thecommentator.com/article/4359/if_polly_toynbee_cared_about_britons_health_she_d_campaign_to_scrap_the_nhs

Now see some other metrics: http://trueeconomics.blogspot.ie/2013/10/8102013-jokers-burning-money-public.html

Most detailed and most recent study of cancer rates: incidence and survival across Europe: http://www.iarc.fr/en/media-centre/iarcnews/pdf/Ferlay%20J_EJC_2013.pdf

26/9/2013: Framing Budget 2014: Village Magazine September 2013

This is an unedited version of my column in the Village Magazine, August-September 2013


With early Budget looming on the horizon, the circus of the 'austerity is overdone' politics has rolled into town. The Labour and the FG backbenchers are out in force trying desperately to salvage the little popular support they still might command in the streets. Not to be outdone, Fiana Fail, freshly converted into the Church of Socialistas has been unleashing torrents of newly-discovered social consciousness. Things are getting so hot on the anti-austerian' speaking circuit that Siptu was able to get even Jack O'Connor a gig. Their star performer was last seen thundering at the MacGill Summer School a potent brew of outlandishly misinformed comparatives between the European and the American policies for dealing with the Great Recession and calls on the imaginary Government to… no prizes for guessing… end 'human rights-violating' austerity.

Problem is, once you come back from all of the highs of this Keynesian Lollapalooza, Irish Government continues to run an insolvent state with spending not matched to revenues and with the expenditure programmes outcomes not matched to the needs of the society at large. Delivering neither fiscal sustainability, nor growth, nor value for money, our fiscal house is grossly out of shape five years into various reforms. Worse, the fiscal mess we are in has nothing to do with the lack of economic growth and everything to do with the policy institutions that the current Government inherited from the decades of political clientelism presided over by its predecessors.


Let us look at some numbers.

In the first six months of 2013, Irish State has managed to spend EUR27.12 billion on current expenditure, just EUR352 million shy of the level of spending in the same period of 2012 and EUR3.2 billion more than we spent in the six months through June 2011. Meanwhile, tax revenues rose from EUR15.3 billion in January-June 2011 to EUR17.6 billion this year. Crunchy austerity based on savage cuts, five years in still looks more like a tax squeeze and spending re-allocation from one programme to another.

Meanwhile, Department of Health spending is now running at EUR6,539 million for H1 2013, down on EUR6,754 million in H1 2011 - a whooping reduction of EUR215 million. Do keep in mind that 2011-2012 increases in the cost of beds charged to the private insurers (aka to ordinary insurance purchasers) have more than offset the above reductions in spending. Net current (ex-capital) spending on health has shrunk by just EUR128 million over the last two years.

The Department of Health is a great example to consider when dealing with the failure of our reforms. It is a frontline service by definition - the one we all are willing to pay for. Yet, it is also a symbolic dividing line between the poor (allegedly having no access to the services) and the rich (allegedly all those who hold health insurance and as 'private' patients overpopulate public wards preventing the poor from getting necessary hospital beds). Healthcare was also an epicenter of rounds of reforms over decades, including the decades of rapid economic growth and prosperity. And it is one of the two largest departments by voted spending, with budget only slightly behind the EUR6.545 billion spend in H1 2013 at the Department of Social Protection.

For this spending we - the middle classes and other payers - get little value for money in services. Over 35% of Irish households have to purchase private insurance to access any meaningful level of health services. In case you still rest in the camp of those who believes that such purchases of insurance are purely voluntary and constitute luxury, Irish Government is considering making health insurance purchasing purely obligatory.

Even with this expenditure, access to basic, quality of life-improving procedures and healthcare maintenance is shambolic. While run of the mill emergencies are getting reasonably decent attention, complex and time-sensitive treatments are wanting. Thus, Ireland ranks at or below the European averages in treatment of majority of chronic and long-term diseases, before we control for differences in population demographics. Our primary care and access to specialist consultants is pathetic outside the emergency rooms and hospitals' ICUs. Despite seeing the fastest rise in the healthcare expenditure per capita over 1997-2007 period in the entire EU27, per EU assessment, Irish healthcare expenditure increases have made only "a modest contribution to [improved mortality], substantially less than one third of the total, and possibly only a few percentage points".

In reality, of course, Irish healthcare is run for the benefit of Irish healthcare staff. In 2005-2007 pay and salary bill for HSE stood at an average 50.7% of the entire HSE non-capital budget. In 2009 it was 50.1%. In 2010, Irish salaries (excluding other income) for medical specialists were the highest in the EU, with the second highest paid cohort of physicians (in the Netherlands) coming at an average salary discount of roughly 25% relative to their Irish counterparts. These salaries were not inclusive of the Irish doctors earnings from private patients.

Per EU 2012 assessment, 33% of Irish people find access to hospitals unaffordable (8th highest in EU27) and the same find access to GP out of their financial reach (4th highest in EU27), while 53% claim that they cannot afford medical or surgical specialists (8th highest).

This is hardly surprising. Between December 2005 and mid-2012, Irish consumer price inflation (CPI) on cumulative basis has hit 9.5%. Health CPI over the same period totalled 21.4% - more than double the rate of overall inflation. Of EU15 states, Ireland and Holland were the only states where health costs were rising faster than general inflation in the last 7 years. 2005-2011 inflation run at 47.3% in Hospital services (state-controlled charges), followed by dental services 28.6%, Out-patient services 23.5% and Doctors' fees at 21.3%. This inflation took place from the already high cost base present in Ireland at the end of 2005.

By international comparisons, from 2005 through mid-2012 Ireland had the lowest rate of inflation in the EU15, while our health services inflation was the second highest after the Netherlands.

Austerity, it seems, has been a boom-time for healthcare costs. Or put differently, while the rest of the world defines efficiency-improving reforms as changes in delivery of services that reduces the cost of services given fixed or improving quality of delivery, in Ireland we define efficiency gains as providing fewer services at a higher cost.

Despite this, in Irish media and policy circles, assessment of healthcare systems performance starts and ends with the comparatives on public spending levels. Good example of such assessment was the 2010 report to the Oireachtast, titled "Benchmarking Ireland’s Health System". A foreigner reading this report can easily conclude that (a) Irish healthcare is run on a shoestring, (b) achieves great outcomes in terms of reduced rates of prevalence of and mortality from key diseases, and (c.) is delivered to the middle class and the rich, bypassing the poor.

In reality, of course, the inequality of access to Irish healthcare system means that the middle and upper-middle classes are required to buy expensive insurance to gain access to health services. Our achievements in combatting key diseases are primarily driven by our younger (and thus healthier) demographics.

And when it comes to access, only 17.2% of all non-maternity related hospitals admissions in 2011 (the latest for which we have data) were for private patients, with the balance going to public patients. On average, people on private insurance had 2.4-2.6 visits to GP in 2007-2010, while those on medical cards had 5.3-5.2. In 2012, the rich-favouring distribution of access to Irish healthcare so often decried by the media and politicians meant that 39% of population or just under 1.8 million people had access to medical cards, more than the number of private health insurance holders.

Health spending represents the case where we have at least some indications and metrics concerning the inefficiency of services provision. In contrast, in other major areas of state expenditure, there is no basis for efficiency assessments and none are being developed.

Irish welfare system is absurdly complicated, and unbalanced - providing potentially excessive services for able-bodied adults on long-term dependency and insufficient services for adults in temporary need of supports and to people with severe disabilities. Related services - in particular in the areas of skills development and training, placement supports for the unemployed - are glaringly out of touch with reality of the labour market demands. Over the last five years, Irish economy produced ever-increasing shortages of skills in several areas, most notably internationally-traded ICT services, financial services, and back- and front- office support services. Yet Irish system of unemployment supports, planned by Forfas and managed by Fas/Solace, failed to reflect these long-term trends. By the time state training behemoths turn around to face the music, the demands for skills will change again.


Irish state spending - with or without austerity - is a rich sprinkling of waste over a thin layer of substance. And it remains such in the face of five years of boisterous pro-reform rhetoric.
Irish austerity has failed, so much we can all agree on. But the real failure is not in cutting spending too much, but in failing to deliver any real gains in efficiency of public services provision or quality of these services. And it failed in containing the costs of the State, especially if we are to use long term sustainability as the benchmark for assessing the reforms.

The likes of Jack O'Connor and Fiana Fail ‘Nua’ might have discovered a magic trick for conjuring economic growth out of public spending, but reality is that the actual working population is by now sick and tired of being taxed to fund the perpetuation of the public sector mess, best exemplified by our healthcare.

13/7/2013: The Moral failure of Irish policy exposed

This post by @happybeingme70
http://alexslye.wordpress.com/2013/07/12/my-response-to-minister-reilly/
is simply superb.
It is poignant, powerful, full of dignity and on-target. Read it, spread the word about it.

Economics 10/04/2010: HSE fails children and families

Updated below

On several occasions last year I wrote about HSE failures to carry out its job and provide requisite follow up support for adoption process in Ireland. This week, the chickens came home to roost for our healthcare bureaucrats. Except, as is usual in such cases, it is not the bureaucrats who are bearing the cost of such gross failure to do their job, but ordinary families and children.

A disclaimer is due - this is not an academic analysis post. It is an angry post.

Since at least May 2009, HSE was on the notice that it is failing to comply with the documentation support required by Russian authorities in the cases of cross-border adoptions of Russian children. The Ministers for Children and Health were fully aware of the situation.

The problem is a simple one. After a Russian child is adopted into Ireland (or any country for that matter), the agency supporting the adoption (in the case of Ireland - HSE monopoly behemoth, plus a small organization relating to the Church of Ireland - PACT) must supply a report on how the kids are adapting to their new family and environs. It is a brief standardized assessment document and HSE is required to collect and transmit it to the Russian authorities. HSE has staff on its usual lavish pay who are responsible for doing the work. It has managers, on an even more lavish pay, who are responsible for making sure the process is adhered to. There is no nuclear science involved. Just a routine follow up.

Unlike PACT (which appears to be fully compliant), HSE has simply decided not to do its job. Yes, this is exactly what they did. Since May 2009 the HSE has failed to provide the Russian authorities and the Irish adoptive parents with any information as to when and how the HSE will comply with the international obligation. Adopting couples - years into the process and even those already approved by the Russian authorities - were stonewalled by the HSE. In other words - the usual practices of 'do nothing, say nothing' that marks HSE work in virtually all areas of its responsibilities has been applied.

Between 50 and 70 reports were not submitted to the Russian authorities over a couple of years, prompting last May a blacklisting of Ireland by Russian adoption agencies. The blacklisting was not enforced by Moscow in order to give HSE enough time to comply. 9 months later, with no progress from HSE, and actually nearly total stonewalling by HSE not only of the Irish families, but also of the Russian authorities, Moscow's patience has run out. Thus, last week, HSE regional bodies responsible for providing adoption support were blacklisted by Russia again, preventing hundreds of families from proceeding with adopting children.

At the same time, tiny PACT seems to have been able to do their job and avoid blacklisting. Despite not having all the vast resources of HSE nor the Department of Health.

I have no personal interest in the adoption process. But, like any normal person in the country, I have a general human interest in seeing families being able to adopt kids who are in the need of having a proper family. I do have a number of friends who either have adopted kids from different parts of the world or who are currently in the process of adopting kids (so I can see the great potential these fantastic people bring to the lives of formerly orphaned children). And as a fellow human being, I cannot stomach an unaccountable bureaucracy, like HSE, standing between these families, these kids and their dreams.

More than anything else in these times of the crises, the callousness, the laziness and the arrogance of some of our official bodies responsible for adoption highlight the need for a deep reform in this country's public sector. Those in HSE, who failed to do their jobs must be fired, barred for life from ever taking another public sector job and left pension-less, for their victims are the most vulnerable people in this world - innocent children and fantastic families that go though years of hard work to adopt them.


Update: per readers tip-offs (hat tip to B & A), The Minister for Children, Barry Andews TD has presided over the de facto closing of the intercountry adoption in this country. On his watch, China, Vietnam, and Russia all have either seen their adoption treaties with Ireland expire or not complied with. Mr Andrews was fully aware of the problems in the cases of Russia and Vietnam treaties since Spring 2009 and despite having assured the adoptive parents that the issues will be resolved has, so far, failed to do much about it.

The Adoption Board itself has apparent difficulties communicating with the adoptive parents and the broader public. The latest Annual Report the organization has bothered to issue dates back to 2008. This document represents the latest public communication from the Board available on its site. Done truly in HSE's best traditions of public communications, then.

Children and Parents Caught in HSE-created nightmare

I would encourage everyone reading this post to check the comments below. As one of the commentators puts it, the reason these comments are unsigned is because HSE has created such an atmosphere of intimidation, that people forced to deal with it are concerned about the reprisals against their cases. This is truly despicable.


This post is not about economics, though my old prof Gary Becker might disagree... It is about a monumental screw up that is our system of family support and the horror of the HSE monopoly in adoption process administration. And it makes me absolutely sick to think that there are thousands of couples in this country - either in the process of adoption or thinking about starting on that long road - who are being failed by the HSE, the Irish state and our politicians.

Here is the story.

Over the last 5 years almost 75% of all inter-country adoptions into Ireland came from three countries: Russia, Vietnam and China. Several of my friends have happily adopted kids from all three of these countries, giving both the adoptive parents and the children a real future as families. At present some 1,000 Irish families are seeking to adopt from Russia and Vietnam.

By my personal experience of seeing homeless kids in Russia, I know that there are tens of thousands of small children without parents in Russia who are facing years of hardship and very few opportunities to have a successful, fulfilling life. They need love, they need a family, and they need a chance to have a future.

Thus, in harsh econospeak - there is supply and demand. In human terms, the future of kids and adoptive parents is at stake here. You can - and should - get the feel for the issue of human hurt and suffering this HSE-screw up is causing here.

The interim bilateral agreement between Ireland and Vietnam expired on May 1 this year - another present of this Government, on top of higher tax levies, stolen mortgage relief and extorted child benefits, that came our way that day. No new agreement has been signed or, as far as we know, even prepared. The Irish authorities, also to the best of our knowledge, are the sticking point here, despite the fact that they knew of the expiry date well in advance. Irish authorities have managed to send a lowly case worker to Vietnam to sort out the issue of a new agreement - a bizarre twist of protocol and managerial logic. Instead of a decision maker, we sent a clerk.

Now, Russia - as the adoption country - has been also shut down because HSE cannot be bothered to adhere to the legal conditions imposed by the Russian authorities on adopting countries. The procedure is a simple one and a logical one. As a part of the adoption process, Russians would like to know that the kids are doing well in their families and in the new country. Thus, the adopting country is required to submit updates on the kids conditions, health, etc. In the case of Ireland-Russia adoption process, this procedure has been in place for 4 years. However, this year, the HSE - the organization with a state-run monopoly power in the adoption process - simply failed to deliver such reports.

In my conversations with the office of Barry Andrews, Minister for Children, I was unable to obtain a clear (let alone convincing) explanation as to what exactly has happened, but to the best of my understanding, HSE simply failed to collect post-adoption reports and send them to Moscow. My conversation with a contact in HSE revealed that they simply "couldn't be arsed to follow up on the process". Just like that - 'we didn't feel like doing it'... And when I suggested to Barry Andrews' office that there should be someone responsible for the mess, the story got even more confusing. I was told that HSE is not even sure it can compel the parents (at the first mention) or its own social case workers (at the second mention) to collect such reports. Not even sure? Four years after the condition was imposed and after three years of complying with the condition?

Here is what we should know and yet we do not know (courtesy of the HSE, Dept of Health, Adoption Board and so on):

• We have no idea how many post-placement reports are outstanding in the case of Russia;
• We have no idea if HSE is even doing anything to rectify the situation (Russian authorities have told me - and I have no reason to question their sincerity - that Russia is ready to restore full adoption process with Ireland as soon as the post placement reports are delivered. HSE cannot tell me anything!);
• Is there an actual copy of a legal agreement with Russia in existence and if yes, why is it not posted on the HSE and Adoption Board websites? Why are the prospective and adoptive parents not given a copy of such an agreement as it stipulates their fundamental rights and duties?
• Is Ireland ever going to conclude bilateral agreement on adoption with Russia? Will Ireland be in a position to renew the expired bilateral agreement with Vietnam?
• Why there has been no high level delegation to Vietnam to renew the bilateral agreement?
• Why doesn't the Adoption Board extend the validity of adoption applications while this mess continues, so that prospective parents whose declarations expire during the time it takes HSE to get its head out of its posterior are not required to go through a renewal process again?

The bigger problem, however, is that under the current system the HSE - that impenetrable fortress with a formidable 125-strong disinformation department (PR & Media Relations that is) - is a monopoly gatekeeper to the process of parent assessment. Thus, intimidation, veiled threats, delays, and now outright failure to comply with international standards and, potentially, law - all are the norm for the ways in which HSE runs its fiefdom.

Clearly, there is an argument to be made here, that what Ireland needs is a well-regulated, competitive system for assessment and processing of adoption cases. In other countries, such a system exists. Hence, for example, the same Russian document that blacklists HSE also blacklists some privately run organizations operating the adoption system in the US. Of course, American adoptive parents have a choice to continue with the adoption process via another agency. Irish adoptive parents have only one choice of waiting for the demi-Gods of HSE to, as I put it earlier, pull their head out of their postrerior.

At the rollercoster site: here, you can find an open letter on the issue (search for the post by blmf ID:- 27687 Date:- 02/05/2009 15:14). I would suggest we all send a copy to that list of our TDs.