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

Abstract

BackgroundThe 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.MethodsThe 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.ResultsIn 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.ConclusionsThe 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.

Child Health Care in Ireland

“…It's not clear how much the Irish health system can, or intends to, reduce health inequalities. The system has had a very severe reduction in its budget over the last five years (13), and while Ireland has coped with this better than might have been expected (58,59), there has been an impact on many parts of the service. It is likely that poorer and more vulnerable children have suffered more from this than their wealthier peers (for example, some of the first cuts in education services were to specific extra services for Traveller children).…”

L’impact de la crise économique sur les systèmes de santé des pays de l’OCDE

“…pour les deux-tiers de la population non titulaires de cette carte pour les soins hospitaliers, y compris les urgences, et pour les médicaments [4,8]. Les Pays-Bas ont augmenté de 224 à 350 euros la franchise qui s'applique avant tout remboursement par l'assurance maladie et laissent à présent les 20 premières séances de kinésithérapie à la charge des patients.…”

“…En Irlande, les salaires des fonctionnaires ont été réduits de 5 à 15 % -selon leur niveau de départ -à partir de 2009, tandis que les forfaits versés aux pharmaciens pour la délivrance de médicaments ont été diminués de 24 à 34 %, selon le prix du produit [4]. En Estonie, les prix des services ont été réduits de 6 % en 2009 et à nouveau de 5 % en 2011 [15].…”

“…Les dépenses des assurances privées ont également ralenti sur les deux dernières années, reflé-tant parfois une diminution des effectifs assurés. En Irlande, par exemple, le nombre de personnes souscrivant une assurance privée supplémentaire a diminué de 52 % en 2006 à 46 % en 2012 [4]. Les dépenses directes des ménages, qui comprennent aussi bien les dépenses de soins non remboursées que les co-paiements, ont également augmenté moins rapidement, et ceci dès 2009.…”

“…Ces prêts sont assortis de conditions, imposant la mise en place de réformes dans un grand nombre de domaines économiques et, notamment, dans le secteur de la santé. Le Fonds monétaire international (FMI), la Banque centrale européenne et la Commission européenne, ensemble de bailleurs communément désignés sous le nom de « Troïka », définissent ces réformes avec les gouvernements et surveillent régulièrement leur mise en oeuvre [4][5][6][7].…”