Ireland Country Health Profile 2019 the Country Health Profile Series Contents

State of Health in the EU Ireland Country Health Profile 2019 The Country Health Profile series Contents

The State of Health in the EU’s Country Health Profiles 1. HIGHLIGHTS 3 provide a concise and policy-relevant overview of 2. HEALTH IN IRELAND 4 health and health systems in the EU/European Economic 3. RISK FACTORS 7 Area. They emphasise the particular characteristics and challenges in each country against a backdrop of cross- 4. THE HEALTH SYSTEM 9 country comparisons. The aim is to support policymakers 5. PERFORMANCE OF THE HEALTH SYSTEM 13 and influencers with a means for mutual learning and 5.1 Effectiveness 13 voluntary exchange. 5.2 Accessibility 16 The profiles are the joint work of the OECD and the 5.3 Resilience 18 European Observatory on Health Systems and Policies, 6. KEY FINDINGS 22 in cooperation with the European Commission. The team is grateful for the valuable comments and suggestions provided by the Health Systems and Policy Monitor network, the OECD Health Committee and the EU Expert Group on Health Information.

Data and information sources The calculated EU averages are weighted averages of the 28 Member States unless otherwise noted. These EU The data and information in the Country Health Profiles averages do not include Iceland and Norway. are based mainly on national official statistics provided to Eurostat and the OECD, which were validated to This profile was completed in August 2019, based on ensure the highest standards of data comparability. data available in July 2019. The sources and methods underlying these data are To download the Excel spreadsheet matching all the available in the Eurostat Database and the OECD health tables and graphs in this profile, just type the following database. Some additional data also come from the URL into your Internet browser: http://www.oecd.org/ Institute for Health Metrics and Evaluation (IHME), the health/Country-Health-Profiles-2019-Ireland.xls European Centre for Disease Prevention and Control (ECDC), the Health Behaviour in School-Aged Children (HBSC) surveys and the World Health Organization (WHO), as well as other national sources.

Demographic and socioeconomic context in Ireland, 2017

Demographic factors Ireland EU Population size (mid-year estimates) 4 807 000 511 876 000 Share of population over age 65 (%) 13.5 19.4 Fertility rate¹ 1.8 1.6 Socioeconomic factors GDP per capita (EUR PPP²) 54 300 30 000 Relative poverty rate³ (%) 15.6 16.9 Unemployment rate (%) 6.7 7.6

1. Number of children born per woman aged 15-49. 2. Purchasing power parity (PPP) is defined as the rate of currency conversion that equalises the purchasing power of different currencies by eliminating the differences in price levels between countries. 3. Percentage of persons living with less than 60 % of median equivalised disposable income. Source: Eurostat Database.

Disclaimer: The opinions expressed and arguments employed herein are solely those of the authors and do not necessarily reflect the official views of the OECD or of its member countries, or of the European Observatory on Health Systems and Policies or any of its Partners. The views expressed herein can in no way be taken to reflect the official opinion of the European Union.

This document, as well as any data and map included herein, are without prejudice to the status of or sovereignty over any territory, to the delimitation of international frontiers and boundaries and to the name of any territory, city or area.

Additional disclaimers for WHO are visible at http://www.who.int/bulletin/disclaimer/en/

2 State of Health in the EU · Ireland · Country Health Profile 2019 83 79 75 81 77 Life expectancy at birth,years deaths. successful inavoiding premature European countriesare more effective. Yet many other western interventionsare generally policies andhealthcare signalling that public health is lower thantheEUaverage, and treatable causesinIreland fromMortality preventable Effectiveness % of total health expenditure, 2017 % of adults workforce planning andbetterbudgetmanagement levels atall ofthesystem. system, building upthehealthsystemtoimprove access andadequately meethealthcare needs, more consistent future demands associated with anageing society. Key areas tobetackled include introducing auniversal health the healthsystemisunderperforming andthatafundamentaltransformation isneededtomake itfittomeet gains andmost people reporting being in good health. Despitethis progress, there isconsensusinIreland that The healthstatusofIrish people hasimproved substantially since2000, with lifeexpectancy registering huge 1 Preventble per 100000population, 2016 Age-standardised mortality rate Volunt r he lth Publc spendn IE IE IE Out-of-poc et mortl t mortl t Tretble 766 773 Highlights Obest Bne drn n Smo n 2000 Bne drn n nsur nce EU EU EU Others Smo n Obest 17 0 2 21 80 22 93 % 13 12 % % 138 161 IE 50

18 % 17 % EU 73 2017 100 % 809 822 32 % other EUcountries. health insurance (13%), which plays amuch biggerrole thaninmost is paid directly outof pocket by households (12%)orthrough voluntary in Ireland, alower share thantheEUaverage (79%). The remaining part the EUaverage. Publicfunding healthspending accountsfor73%ofall years. At EUR3406 per person in2017, itisaround one-fifthhigherthan Health spending inIreland hasincreased atamoderate rate inrecent Health system in 2007, andisnow higherthantheEUaverage. the EUaverage. The obesityrate increased to18%in2015, upfrom 15 % adults reported regular heavy alcoholintake in2014, arate well above 27 %in2002, andnow slightly below theEUaverage. Nearly one-third of In 2018, 17%ofadultsinIreland smoked tobaccoevery day, down from Risk factors treatments. reductions insome riskfactorslike smoking butalsotoimprovements in reductions inmortality from cardiovascular diseases, duein part to and isnow above theEUaverage. The increase was driven by sharp years since2000, thestrongest gains among western European countries, The lifeexpectancy oftheIrish population hasincreased by nearly six Health status Ireland remains theonly western Accessibility patient dissatisfaction. remain animportant source of elective surgery inhospitals for specialistappointments and public system, long waiting times care. For thoserelying onthe universal coverage for primary country without European % of peoplew t n 0% < 52 wees for 2015 %01 f rst spec l st consultt ons Countr EU %01 State of Healthin the EU ·Ireland ·Country HealthProfile 2019 2% 72% 90% Countr EU 2017 EU Countr

% of dults w t n 4% n elect ve proce- < 15monthsfor dure ( npt ent) 87% 97% 6% 8% traction. recommendations is gaining some the implementation ofits Office inSeptember 2018, the Sláintecare Implementation could. With theestablishmentof is not performing as well asit the conviction thatthesystem in theIrishhealthsystemand fundamental changes importance ofsome highlighted the Report of2017 The Sláintecare Resilience

IRELAND 2 Health in Ireland IRELAND

Life expectancy in Ireland has increased one year above the EU average (80.9 years) while it by nearly six years since 2000 was still below the average in 2000.

Life expectancy at birth reached 82.2 years in Ireland Although the gender gap in life expectancy in in 2017, up from 76.6 years in 2000 (Figure 1). Since Ireland is narrowing, Irish men could still expect to life expectancy in Ireland has grown more rapidly live almost four years less than women (80.4 years than in most other EU countries, it is now more than compared to 84.0 years) in 2017. This gap is, however, less pronounced than in many EU countries.

Figure 1. Life expectancy in Ireland has increased rapidly and is now above most EU countries

Yers 2017 2000 90 –

Gender gap: Ireland: 3.6 years 85 – 834

831 EU: 5.2 years 827 827 826 825 824 822 822 821 818 817 817 816 816 814 813 812 811 811 809

80 – 791 784 78 7 78 773 76 758 753 749 748 75 –

70 –

65 – EU Sp n Itl Frnce MltCprusIrelnd Greece Polnd Ltv NorwIcelndSweden Austr F nlndBel um Czech Eston Crot Bul r Portu l Sloven GermnDenmr Slov Hun rL thun Romn Luxembour Netherlnds Un ted n dom

Source: Eurostat Database.

The main causes of death remain is partly due to improvements in diagnostics and circulatory diseases and cancer changes in death registration practices, but is also related to population ageing. The increase in life expectancy in Ireland since 2000 has mainly been driven by reductions in mortality Most adults report being in good health, but the rates from circulatory diseases, notably ischaemic proportion is smaller among low-income groups heart disease (Figure 2). Despite this progress, circulatory diseases remain the leading cause of death About 83 % of Irish adults reported being in good in Ireland (30.1 % of all deaths) followed by cancer health in 2017, the highest share among all EU (29.9 %). Among the different types of cancer, lung, countries and substantially above the EU average of colorectal and breast cancer are the most frequent 70 % (Figure 3). As in other countries, there are some causes of death in Ireland. disparities in self-rated health across income groups. Only 73 % of people in the lowest income quintile Deaths from respiratory diseases have decreased assess their health as good, compared to 93 % in the starkly since 2000, reflecting in part recent drops highest. These disparities already exist in children’s in tobacco consumption, although mortality rates health: children from well-off parents are more remain well above the EU average. On the other likely to be in good health than those growing up in hand, mortality rates from Alzheimer’s disease have low-income households. increased greatly since 2000. This strong increase

4 State of Health in the EU · Ireland · Country Health Profile 2019 -100 Source: Eurostat Database, based onEU-SILC (data refer to 2017). incomes are roughly thesame. Note: 1.Theshares for thetotal population andthepopulation onlow EU population that reports beingingood healthinthe Figure 3. Ireland hasthehighest share of the Source: Eurostat Database. in diagnostic anddeath registration practices. Note: Thesize of thebubbles isproportional to themortality rates in2016. Theincrease inmortality rates from Alzheimer’s disease islargely dueto changes Figure 2.Circulatory diseases andcancer are still theleading causes of death Unted n dom 100 % c -50 50 0 hn Luxembour Netherlnds Prostte cncer Dbetes Low ncome Romn Germn Lthun Denmr Hun r Portu l Sloven Slov Bul r Bel um Norw Sweden e 2000-16(orner Czech Eston Greece Fnlnd Crot Icelnd Austr Polnd Cprus Irelnd Frnce Ltv Mlt Spn Itl EU 0 Br % of dults whoreport ben n ood helth est cncer Totl populton 20 est

Color Alzhemer’s dsese

er) Pneumon ectl cncer 40 40

60 Lun cncer H h ncome Str 80

oe State of Healthin the EU ·Ireland ·Country HealthProfile 2019 Chronc obstructvepulmonr dsese 100 80 population. However, duetorising lifeexpectancy currently relatively low, accounting for13%ofthe The proportion of people aged over 65inIreland is remain healthybut notall as they age The Irishareliving longer than before, because ofhealth problems. or severe limitationsincarrying outusualactivities condition, andaround oneinthree reported some aged 65andover reported having atleastonechronic disabilities. Around 50%ofIrishmenand women old age are lived with somechronic diseasesand and men(Figure 4). However, many years oflifein another 20 years, with a2.5-year gap between women In 2017, Irish people aged 65could expecttolive demands onhealthandlong-term care systems. to double26%by 2050, which leadto will growing and declining rates, fertility this share is projected Ae-stndrdsed mortlt rteper100000populton,2016 100 Isc hemc hertdsese 120 140 160 5

IRELAND Figure 4. Many years of life after age 65 are lived with some chronic conditions and disabilities

IRELAND Lfe expectnc t e 65 Women Men

8 65 214 190 ers ers 134 125

Ye rs wthout Ye rs wth ds blt ds blt

% of people ed 65+ reportn chronc dseses % of people ed 65+ reportn lmttons n usul ctvtes due to helth problems Women Men Women Men

13% 12%

20% 50% 50% 49% 51% 21% 66% 68%

No chronc At le st one No lmt ton Some lmt tons dse se chronc dse se Severe lmt tons

% of people ed 65+ reportn depresson s mptoms1 Women Men

14 % 10 %

Note: 1. People are considered to have depression symptoms if they report more than three depression symptoms (out of eight possible variables). Source: Eurostat Database (data refer to 2017).

6 State of Health in the EU · Ireland · Country Health Profile 2019 stable at23%from 2007to2017. 1: Basedonmeasureddataoftheactual weightandheightofpeople, which isamorereliable measure, theobesityrate isevenhigher inIrelandbuthasremained Section 5.1). ongoing tofurtherreduce tobaccoconsumption (see 2015, oneofthelowest rates intheEU. Initiatives are that they hadsmoked cigarettes inthe past monthin about 13%of15-to16-year-olds inIreland reported among adolescents, especially among girls. Only are only 10-12%. Smoking hasbecomeless popular such asSweden andNorway, where smoking rates higherthaninthebest but still performing countries smoked daily in2018, arate close totheEUaverage smoking rates, more thanoneinsixIrishadults(17%) Although progress hasbeenmadeinreducing remain close to the EUaverage decade, smoking rates among adults Despite reductionsover the past Source: IHME(2018), GlobalHealth Data Exchange (estimates refer to 2017). sweetened beverages andsaltconsumption. death can beattributed to more thanoneriskfactor. Dietary risksinclude14components suchaslow fruitandvegetable consumption, andhighsugar- Note: Theoverall numberof deaths related to these riskfactors (12000) islower thanthesumof each onetaken individually(14000) because thesame Figure 5. Abouttwo-fifths of alldeaths canbeattributed to modifiablelifestyle riskfactors deathsin2017(6000deaths)areone-fifth ofall due close totheaverage across theEU(39%). About tobehaviouralbe attributed riskfactors, ashare Around deathsinIreland 40%of all in2017can important impactonmortality Behavioural riskfactorshave 3 EU 17% Irelnd 19% Tobcco Riskfactors

State of Healthin the EU ·Ireland ·Country HealthProfile 2019 EU 18% Irelnd 16% Detr rss (Figure 5). tolowof deathscanbeattributed physical activity associated with roughly deaths, 7%ofall 3% while deathsinIreland.16 %ofall Alcohol consumption is consumption) are estimatedtoaccountforabout fruit and vegetable intake, andhighsugarsalt to tobaccoconsumption. Dietaryrisks(including low Section 5.1). Policy Action Plan(Department ofHealth, 2016)(see key steps identified inthecountry’s Obesityand of physical activity inthe prevention ofobesityare support healthy eating andacknowledging therole active intheEU. Implementing fiscalmeasures to and they are alsoare among themost physically proportion ofIrishadultsconsume vegetables daily consume unhealthy foodsatleastonceaday, ahigh However, even thougharound one-third ofIrishadults higher thaninmostotherEUcountries. result, overweight andobesityrates inIreland are and obesityalsorose toreach 19%in2013-14. As a (Figure 6). Among 15-year-olds, therate ofoverweight obesity increased from 15%in2002to182015 adults andteenagers. Among adults, therate of Overweight andobesityrates have increased among healthissues inIreland public Overweight andobesityrepresent growing EU 3% Irelnd 3% Low phsclctvt EU 6% Irelnd 7% Alcohol 1

IRELAND Figure 6. Overweight and obesity, and alcohol consumption, are major public health concerns in Ireland

IRELAND Smon (chldren)

Veetble consumpton (dults) 6 Smon (dults)

Frut consumpton (dults) Bne drnn (chldren)

Phscl ctvt (dults) Bne drnn (dults)

Phscl ctvt (chldren) Overweht nd obest (chldren)

Obest (dults)

Note: The closer the dot is to the centre, the better the country performs compared to other EU countries. No country is in the white ‘target area’ as there is room for progress in all countries in all areas. Source: OECD calculations based on ESPAD survey 2015 and HBSC survey 2013-14 for children indicators; and EU-SILC 2017 and EHIS 2014 for adults indicators. Select dots + Effect > Trnsform scle 130%

Heavy alcohol consumption is an Social inequalities in risk factors important risk factor in Ireland contribute to inequalities in health

About one-third of adults in Ireland reported regular As in most other EU countries, many behavioural risk heavy alcohol consumption (binge drinking2) in 2015, factors in Ireland are more common among people a higher proportion than in most other EU countries. with lower education or income. Smoking rates among Regular binge drinking is twice as frequent among adults who have not completed secondary education men than women. are more than twice as high as among those with a university degree. This disparity is more pronounced Binge drinking among adolescents is, however, less in Ireland than in many other EU countries. Social widespread in Ireland than across the EU. The share differences also exist for obesity, as those with lower of 15- to 16-year-olds who reported binge drinking educational attainment display higher rates – but at least once over the past month stood at 28 % here the difference in Ireland is smaller than on compared to 38 % across the EU in 2015. While average across the EU. The higher prevalence of risk recording a comparably low rate is good news for factors among socially disadvantaged groups is an Ireland, it should still be a reason for concern, since important driver of inequalities in health and life early drinking initiation can lead to harmful alcohol expectancy. Reducing health inequalities is one of consumption habits later in life. the four key objectives of the Healthy Ireland agenda (Department of Health, 2013).

2: Binge drinking is defined as consuming six or more alcoholic drinks on a single occasion for adults, and five or more alcoholic drinks for adolescents.

8 State of Health in the EU · Ireland · Country Health Profile 2019 4 000 EUR PPPpercpt 4: OOPpayments includedirectpayments, cost-sharingforservicesoutsidethebenefitpackage andinformalpayments. measureofthecapacitytopaymore meaningful forhealthcareinIreland, butevenGNIisnotatruemeasureoftheproductive capacityof thedomesticeconomy. 3: Giventhatasignificantproportion oftheGDPinIrelandconsistsprofits from foreign-ownedcompaniesthatarerepatriated, gross nationalincome(GNI)isa a predominantly tax-based healthsystemandbelow stood at73%. This share, however, isrelatively low for of government financing intotal healthexpenditure employees andtheself-employed. In2017, theshare taxation andaUniversal SocialCharge levied on Most healthexpenditure isfinancedthrough general Source: OECD Health Statistics 2019 (data refer to 2017). Note: Health spending asashare of GNI(9.0 %)inIreland issubstantially higherthanasashare of GDP(7.2 %). Figure 7. Healthexpenditure isabove theEU average onaper capitabasis currently being initiatedfollowing political consensus Fundamental reforms totheIrishhealthsectorare practitioners (GPs) ornot-for-profit publichospitals. sector purchasespublic carefrom private general purchaser–provider splitexistsincases where the both purchaser and provider ofservices, althougha social care services. Inmany instances, theHSEis for themanagement and delivery ofhealthand oftheDepartmentthe aegis ofHealth, isresponsible Service Executive (HSE), a government agency under provided by theDepartment ofHealth. The Health and performance oversight forthehealthsectoris to care. Leadership, policy direction, governance voluntary healthinsurance, mainly forquicker access In addition, more thantwo infive people purchase funded predominantlythrough generaltaxation. Ireland’s healthsystemisanationalservice health systemareunderway Comprehensive reforms to Ireland’s 4 2 000 5 000 3 000 1 000 Government &compulsor nsurnce 0 Norw Thehealthsystem

Germn

Austr

Sweden Netherlnds

Denmr

LuxembourFrnce

Belum

Irelnd Voluntr schemes &household out-of-pocet pments

Icelnd Unted ndom Fnlnd State of Healthin the EU ·Ireland ·Country HealthProfile 2019

EU Mlt

Itl Europe. are above thoseofmany othercountriesin western for specialistsandseniordoctorsnurses, (Figure 8). Salariesinthehealthsector, in particular discharges) islower inIreland thantheEUaverage (measured intermsof number ofadmissionsand doctor consultations per person) andhospitalcare care services(measured intermsofnumber of to highhealth prices. The useofboth primary comparably young demographic –ismainly due (Figure 7). This surprisingly highlevel – given the power), around one-fifthabove theEU average at EUR3406(adjustedfordifferences in purchasing In 2017, healthspending per capita inIreland stood Ireland isabove the EUaverage Health spending in per capita future ofhealth care in2017(Box 1). from across-party Parliamentary Committeeonthe in theEUafterSlovenia (Section 5.2). insurance 13%, contributed thesecondhighestshare in 2017 was modest(12%), while voluntary health health spending from out-of-pocket (OOP) payments the EUaverage of79%. The proportion ofoverall Spn

Czech

Sloven

Portul

Cprus

Greece

Slov

Lthun 3

Eston

Polnd

Hunr

Bulr

Crot

Ltv Shre of GDP Romn % of GDP 00 25 50 5 7 100 125 4

IRELAND Figure 8. The use of both primary care and inpatient care is lower in Ireland than the EU average

Number of doctor consulttons per ndvdul

IRELAND 14 Low nptent use Hh nptent use Hh outptent use Hh outptent use

12 S CZ HU 10 DE MT LT NL EL 8 ES EU PL EU vere 75

IT BE LU SI AT EE BG 6 IS LV IE HR NO FR RO D 4 PT FI SE 2 CY

Low nptent use Hh nptent use Low outptent use EU vere 172 Low outptent use 0 50 100 150 200 250 300 350 Dschres per 1 000 populton

Note: Data for doctor consultations are estimated for Greece and Malta. Source: Eurostat Database; OECD Health Statistics (data refer to 2016 or the nearest year).

Spending on inpatient care in Ireland is 50 % above the EU average. On the other hand, per higher than in most other EU countries capita spending on pharmaceuticals and medical devices was below the EU average in 2017. That For many health spending components, Ireland being said, new initiatives are on the way to enhance spends more than the EU average per capita (Figure 9). the availability of newer and cheaper medicines Spending on inpatient care is the fifth highest in (see Section 5.3). the EU, around one-third above the EU average. For long-term care, per capita spending is more than

Box 1. The Sláintecare Report provided a roadmap to deliver comprehensive system reforms but the Department of Health has been selective so far in implementing its recommendations

The final report of the cross-party Parliamentary care through alignment of community services and Committee on the future of health care, commonly hospital services on a population basis within clear known as the ‘Sláintecare Report’ (Houses of the geographical areas, to allocate resources through Oireachtas, 2017), provides a vision for a new health regional health areas, and to develop a sustainable system in Ireland that would provide a universal, workforce and modern eHealth infrastructure. These single-tier health service where patients are treated actions are developed further in the Sláintecare based solely on need, reorienting services towards Action Plan, published in March 2019. However, while primary care settings. the Strategy and Action Plan commit to expanding eligibility for health care on a phased basis, they do The Sláintecare Implementation Strategy, published not wholly commit to legislating for entitlement by the government in 2018, outlines specific actions to care and the expansion of services required to for the next three years and a ten-year strategic deliver universal health coverage, as laid out in the direction. Among other things, it details actions Sláintecare Report (see Section 5.3). to strengthen primary care and deliver integrated

10 State of Health in the EU · Ireland · Country Health Profile 2019 EUR PPPpercp t 1 000 1 200 those working inthehealth system asmanagers, educators andresearchers. 5: Dataonthenumberofnurses anddoctors inIreland isslightly overestimated(by 5-10%) as itincludesnotonly thoseproviding directcaretopatientsbutalso 100 foranemergency department visit forthose of EUR800–islevied forinpatient services, andEUR Card, acharge ofEUR80 per day –uptoamaximum care funding inIreland. For people without aMedical Co-payments are animportant component ofhealth for those without aMedical Card Co-payments areappliedextensively themselves (seeSection5.2). Card, must cover thecosts ofaccessing GPservices (58 %), who hold neitheraMedicalCard noraGP Visit medicines orhospitalfees. The remaining population that covers GPcharges butdoesnotcover thecostsof (10 %ofthe population) have accesstoaGP Visit Card limited co-payments. Someother population groups hospital servicesfree ofcharge andmedicines with Card, which provides accessto primary care and population inMarch 2019)are foraMedical eligible or with certainmedicalconditions(32%ofthe Residents with anincomebelow adefinedthreshold diagnostics. system and gain fasteraccesstohospitalcare and insurance tobypass long waiting listsinthe public system exists, asmany individuals buy private of charge oratareduced cost. However, a ‘two-tier’ are entitledtoreceive care in public hospitalsfree residency, age andsocioeconomicstatus. residentsAll care inIreland, with eligibility varying according to There isnouniversal entitlementto public health dependenteligibility onsocioeconomicstatus Ireland hasa two-tier healthsystem, with Source: OECD Health Statistics 2019, Eurostat Database (data refer to 2017). health component; 4. Includes onlytheoutpatient market. Note: Administration costs are not included. 1.Includes curative-rehabilitative care inhospital andother settings; 2.Includes homecare; 3. Includes onlythe Figure 9. For most healthservices percapitaspendinginIreland isabove theaverage EU 800 600 400 200 0

spend n

of totl Inpt ent cre

1 110

835 Outpt ent cre spend n

of totl

871

858 State of Healthin the EU ·Ireland ·Country HealthProfile 2019

spend n Lon -term cre

of totl

21%

720

0 nursing workforce. retention thathave ledtosevere shortages within the There are growing issuesover recruitment and per itemdispensed, uptoamaximum ofEUR20 per Medical Card must pay prescription charges ofEUR2 about EUR40-65. For pharmaceuticals, people with a without areferral from aGP. Costs per GP visit are since 2010andmany nurses only work part time the EUaverage of8.5, but thenumber hasdecreased high, at12.2 per 1000 population in2017compared to Conversely, thenumber ofnurses iscomparatively respond toitsneeds(seeSection5.3). increasingly dependent onforeign-trained doctorsto them tocomplete theirtraining, andthecountryis for new graduates create abottleneck formany of capita inEurope, thelimitedinternshipopportunities having thehighestnumber ofmedical graduates per in thetraining capacity ofnew doctors. Despite of 3.6(Figure 10) 1 000 population in2017compared totheEUaverage recent years butremains relatively low, at3.1 per The number ofdoctorsinIreland hasincreased in recruiting andretaining healthprofessionals The Irishhealthsectorisfacing challenges in month foranindividual orafamily (seeSection5.2). Scheme, which caps co-payments atEUR124 per Card can, however, enrol intheDrugsPayment month per person orfamily. Those without Medical

471 nd med cldev ces Phrmceut cls

spend n

of totl

14 5 .

This isrelated partly torestrictions %

483

522 Irelnd

spend n

of totl

3% Prevent on

89 5 . EU 11

IRELAND Figure 10. Ireland has a low number of doctors but a relatively high number of nurses

Prctcn nurses per 1 000 populton IRELAND 20 Doctors Low Doctors H h Nurses H h Nurses H h 18 NO

FI IS 14 IE DE

12 LU BE NL SE SI D 10 FR EU EU vere 85 MT 8 U HR LT HU RO EE CZ ES PT AT 6 IT PL S LV CY BG 4 EL

2 Doctors Low Doctors H h Nurses Low EU vere 36 Nurses Low 0 2 25 3 35 4 45 5 55 6 65 Prctcn doctors per 1 000 populton

Note: In Portugal and Greece, data refer to all doctors licensed to practice, resulting in a large overestimation of the number of practising doctors (e.g. of around 30 % in Portugal). In Austria and Greece, the number of nurses is underestimated as it only includes those working in hospital. Source: Eurostat Database (data refer to 2017 or the nearest year).

Reforms are underway to strengthen primary Capacity constraints persist in both primary and care and address capacity issues in hospitals secondary care. There are long waiting lists in both settings for some services, and occupancy rates The majority of GPs in Ireland are private in hospitals are the highest in the EU and above practitioners who provide private care for paying recommended levels (see Section 5.2). Despite patients but are also contracted by the government increasing since 2012, the number of hospital beds to provide free care for public patients with Medical remains low, at 2.9 per 1 000 population (compared Cards or GP Visit Cards. Secondary and tertiary care is to an EU average of 5.1). Sláintecare reform proposals predominantly provided in public hospitals. Although aim to improve service provision and meet future GPs act as gatekeepers to secondary care, Ireland’s demand by reorienting services from hospital to health system is hospital-centric and primary care primary care settings (see Box 1). The new GP contract infrastructure remains underdeveloped. signed between the government and GPs in April 2019 paves the way for further primary care reforms.

12 State of Health in the EU · Ireland · Country Health Profile 2019 Source: Eurostat Database (data refer to 2016). refer to premature mortality (under age75). Thedata isbased ontherevised OECD/Eurostat lists. amenable) mortality isdefined asdeath that can bemainlyavoided through health care interventions, includingscreening andtreatment. Both indicators Note: Preventable mortality isdefined asdeath that can bemainlyavoided through publichealth andprimaryprevention interventions. Treatable (or Figure 11.Preventable andtreatable causes of inIreland mortality are below theEU average countries. from treatable outside causesfalls thetopthird ofEU it comesto preventable mortality, mortality while is doing betterthanmany otherEUcountries when preventable andtreatable causes(Figure 11). Ireland in termsofeffectiveness istolookatmortalityfrom A firstindicationofhow theIrishhealthsystemfares Ireland arecomparatively effective healthandcarein Public 5.1 5 Unted ndom Chronc lresprtor dseses Ischemc dseses hert Lun cncer Performance of thehealthsystem Effectiveness Luxembour Netherlnds Lthun Germn Denmr Romn Hunr Ae-stndrdsed rtes mortlt per100000populton Portul Sloven Slov Bulr Belum Norw Sweden Czech Eston Fnlnd Crot Icelnd Austr Polnd Cprus Irelnd Greece Frnce Ltv Mlt Spn Itl Preventble cusesofmortlt EU 0 50 100 100 110 115 118 121 129 150 133 134 138 139 140 140 141 Others Sucde Accdents (trnsport ndothers) 154 155 158 161 161 161 166 200 184 195 218 250 232 232 244 262 300 310 State of Healthin the EU ·Ireland ·Country HealthProfile 2019 325 350 332 336 colorectal cancer, breast cancerandstroke. causes, themaincausesare ischaemic heartdisease, accidents andothers). For mortalityfrom treatable heart disease, lung cancerandaccidents (transport prevention measures inIreland include ischaemic be avoided through arange of public healthand The maincausesof premature deaththatcould Unted ndom Brest cncer Colorectl cncer Ischemc dseses hert Luxembour Netherlnds Lthun Germn Denmr Romn Hunr Ae-stndrdsed rtes mortlt per100000populton Portul Sloven Slov Bulr Belum Norw Sweden Czech Eston Fnlnd Crot Icelnd Austr Polnd Cprus Irelnd Greece Frnce Ltv

Mlt Spn Itl EU Tretble cusesofmortlt 0 50 62 62 63 67 67 68 69 71 71 71 76 77 78 80 80 100 87 87 89 90 93 Others Pneumon Stroe 95 128 130 150 140 143 168 176 200 194 203 206 208 250 13

IRELAND Full implementation of the Healthy Ireland A concerted effort by the HSE, the Irish Cancer Society agenda could further reduce preventable deaths and many non-governmental organisations and women’s advocacy groups with strong government IRELAND A number of public health initiatives in recent years support appears to have reversed this trend. Data have aimed to reduce preventable deaths. Adopted in from March 2019 suggest that 70 % of girls in the 2013, the Healthy Ireland initiative currently provides target group have received the first vaccine dose in the national framework to improve health and the last school year. Moreover, HPV vaccination will be wellbeing of the population. The importance of public rolled out to boys from September 2019. health interventions is reiterated in the Sláintecare Implementation Strategy and Action Plan. Figure 12. Vaccination rates in Ireland are around the EU average but vaccination hesitancy is growing To further reduce smoking rates, plain packaging for all tobacco products became mandatory for all Irelnd EU products sold as of October 2018, as foreseen in the Dphther, tetnus, pertusss Public Health Act of 2015. The law requires all forms Amon chldren ed 2

of branding to be removed from tobacco products. 94 % 94 %

Addressing high obesity rates – in particular among children – is the main objective of the sugar- sweetened drinks tax, which was part of the law Mesles passed in 2017 that became effective in May 2018. Amon chldren ed 2 This tax applies to water and juice-based drinks with 92 % 94 % an added sugar content of over 5 g per 100 ml.

After many years of discussion, the Public Health Alcohol Act came into law in October 2018 with Heptts B the objective of reducing alcohol consumption. Amon chldren ed 2 The law includes minimum unit pricing on alcohol, 94 % 93 % restrictions on advertising and warning labels on alcohol products, and the separation and reduced visibility of alcohol products in mixed trading outlets.

Vaccination rates in Ireland are around the Influenz EU average, but hesitancy has been growing Amon people ed 65 nd over 58 % 44 % While childhood vaccination rates against many major infectious diseases are around the EU average and close to the WHO recommended target of 95 % (Figure 12), there has been a slow but notable decline in recent years. In 2017, vaccination rates against Note: Data refer to the third dose for diphtheria, tetanus, pertussis and hepatitis B, and the first dose for measles. diphtheria, pertussis and tetanus, as well as measles, Source: WHO/UNICEF Global Health Observatory Data Repository for mumps and rubella, were all one percentage point children (data refer to 2018); OECD Health Statistics 2019 and Eurostat Database for people aged 65 and over (data refer to 2017 or nearest year). below the rates seen in 2014 (Department of Health, 2018a). The decrease was even higher for influenza vaccination among older people (down by three percentage points compared with 2014).

Even more worrying was a sudden drop in the vaccination rate against the human papillomavirus (HPV)6 among girls in secondary schools. Within two years, the uptake dropped from 87 % to 51 % in school year 2016/2017 – far below the national target rate of 85 % – following the spread of disinformation about the safety of this vaccination, mainly through social media.

6: HPV vaccination reduces greatly the risk for women to develop cervical cancer. The current vaccination schedule in Ireland recommends two vaccine doses within six months for girls younger than 15 years.

14 State of Health in the EU · Ireland · Country Health Profile 2019 Ae-stndrdsed rte of vodble dmssons per100000populton ed 15+ Source: OECD Health Statistics 2019 (data refer to 2017 ornearest year). Figure 13. Hospitalisation rates for ambulatory care-sensitive conditions are around theEU average limited (Box 2). practice ofnurses are underway butare still very doctors iscrucial. Initiatives toexpandthescopeof task-sharing between nurses and primary care and Action Plan. To achieve thisobjective, more reform proposal, theImplementation Strategy in thecommunity isacornerstoneoftheSláintecare towards one where care is predominantly provided Moving away from ahospital-centred care model benefit MedicalCard andGPCard holders. contract commencing in2020, which will potentially in 2019includes astructured diseasemanagement in primary care. The reformed GPcontract signed to improve themanagement ofthesechronic diseases above theEUaverage. This signalsuntapped potential across EUcountries afterHungary –around 50% highest hospitalisationrate forasthmaandCOPD chronic heartfailure, Ireland records thesecond therewhile are fewer admissionsfordiabetesand average fortheseconditions(Figure 13). However, hospitalisation rates in Ireland are around theEU be effectively treated inthecommunity. Overall, avoidable as patients with theseconditionscan obstructive pulmonary disease(COPD)are largely congestive heartfailure orasthmaandchronic Hospital admissionsfordiseasessuch asdiabetes, suggests room for improvement inprimarycare Many admissionsareavoidable, hospital which 1 000 800 600 400 200

Portul 0

Itl

Spn

Icelnd Netherlnds

Unted ndomSloven

Eston

Sweden

Norw State of Healthin the EU ·Ireland ·Country HealthProfile 2019 Irelnd

Denmr

Frnce advanced nursing practice launched in2017. supported by anew educational programme for new ANPposts by 2021. Thisdevelopment isalso reforms. Funding hasbeenallocated to deliver 700 number of registered ANPs isthefocus of ongoing nursing andmidwifery workforce. Expanding the in February 2019. Thisonlyrepresents 0.6 %of the low, withonly328 ANPs andmidwives registered However, thenumberof registered ANPs remains care. outcomes andsatisfaction, aswell ascontinuity of shows that ANPs contribute to improved patient better career opportunitiesfor nurses. Evidence the aimof improving patient care andoffering first accredited ANPs were introduced in2002 with and theprovision of autonomous patient care. The the prescription of certain medicines anddiagnostics exclusively performed by doctors. Suchtasks include who cantake over many tasks that were previously introduction of Advanced Nurse Practitioners (ANPs), been expanded over thepast decade withthe The scope of practice of nurses inIreland has outcomes, buttheirdeployment isstill limited enhanced access to care andimproved patient Box 2.Advanced Nurse Practitioners have Asthm ndCOPD Fnlnd

Belum

EU21

Austr

Czech Conestve flure hert

Mlt

Germn

Slov

Polnd

Hunr

Lthun Dbetes 15

IRELAND relatively low in Ireland, as in most cases people will 5.2 Accessibility use their PHI coverage for these services. Ireland remains the only western European IRELAND After a reduction during the financial crisis, the country without universal coverage for number of people with PHI coverage has grown again primary care in recent years to about 45 % in 2017. The government subsidises the uptake of private insurance with a Despite being one of the central recommendations of tax credit, which may further explain why private the Sláintecare Report of 2017, the rollout of universal insurance is generally concentrated in higher access to primary care has not yet made much socioeconomic groups. Since patients with private progress. In fact, the Sláintecare Implementation coverage have quicker access to care, the way PHI Strategy published by the government in July 2018 coverage is subsidised exacerbates inequalities in proposes a phased approach and only commits to access to care. the development of a roadmap of how and when

universal coverage can be achieved by the end of 2021. Figure 14. The share of out-of-pocket spending Hence, in the immediate future, coverage for primary in Ireland is below the EU average, but voluntary care will most likely not increase much, although the health insurance plays a bigger role recent GP contract agreed between the Irish Medical Organisation and the Department of Health was Irelnd EU conditional on agreement to the expansion of free 2 % 1 % care7. 12 % 16 % In 2017, only 42 % of the population had free access to 4 % GP and practice nurse care, down from 44 % in 2012. 13 % The largest group covered in 2017 were Medical Card 73 % holders, who account for 32 % of the population. An 79 % additional 10 % have access to free GP care with their GP Visit Card. While access to the Medical Card has been drastically reduced since 2012 as a result of the Publc/Compulsor helth nsurnce economic recovery and associated rise in income, an Voluntr helth nsurnce

increasing number of people have access to a GP Visit Out-of-pocet Card. In recent years, it has been universally rolled Others out to all children under 6 and people aged 70 and over.

Due to the criteria of entitlement, access to a Medical Source: OECD Health Statistics 2019 (data refer to 2017). Card is very unevenly distributed throughout the population. Only around 20 % of the population in Long waiting times remain a the age group 25-34 had access to it in 2017, while substantial problem in Ireland coverage for people over 70 stood at 75 %. Waiting times for diagnostics and medical treatments Private health insurance in Ireland have historically been high in Ireland, and a number is widespread and contributes to of different initiatives have tried to reduce them inequalities in access to care in the past (Siciliani, Borowitz and Moran, 2013). While in some cases improvements were achieved Despite the lack of comprehensive coverage for a initially, a long-term solution to this issue has not substantial part of the population, the share of OOP yet been found. Long waiting times for services spending in total health spending (12.3 %) was 3.5 exist throughout the system (HSE, 2018). Within the percentage points below the EU average of 15.8 % community, for example, 23 % of people in need of in 2017 (Figure 14). This is because private health occupational therapy had to wait for more than a insurance (PHI) plays a more important role than in year for assessment in 2017. For ophthalmological all other EU countries except Slovenia. treatment, waiting times were longer than one year At 13 % of total spending, PHI in Ireland is around for nearly 40 % of patients. three times the share observed across the EU (4 %). In hospitals, nearly 14 % of adults waited longer The design of PHI coverage also has an impact on the than 15 months for an elective inpatient surgery; structure of OOP spending in Ireland. For example, the for children the share was 12 %. Some 28 % of all share of inpatient spending in all OOP expenditure is patients had to wait longer than a year for first access

7: This includes a government commitment to extend free GP care to all children between 7 and 12 years of age by 2022.

16 State of Health in the EU · Ireland · Country Health Profile 2019 100% quicker access. insurance may use private insurance coverage for care provision, those who can afford private health thoseonlowWhile incomes primarily rely on public inequality inunmetneedsisdueto waiting times. middle-income groups. The largest income-related costs isslightly lower forlow-income groups thanfor the population thatreport unmetneedsbecauseof of the way public coverage isorganised, theshare of those onhighincome(1%). Interestingly, because health services(4.9%report unmetneeds)than income inIreland encounter greater barrierstoaccess times ordistance. As inothercountries, people onlow had foregone medicalcare duetocosts, long waiting (Figure 16). In2017, 2.8%oftheIrishadult population medical care inIreland are above theEUaverage long waiting timesfortreatment, unmetneedsfor As aconsequenceofnon-universal coverage and Ireland areabove the EU average Unmet needsformedicalcarein Source: OECD Health Statistics 2019. Figure 15. Many Irishpeoplewait alongtimefor cataract surgery andhipreplacement private patients canbetreated using public hospital Capacity constraints inhospitalsandthefactthat for cataract surgery orhipreplacement (Figure 15). comparable western andnorthernEuropean countries in Ireland in2018 was still worse thaninsome that, despitetherecent improvements, thesituation times indifferent ways, theexisting datasuggest challenging, given thatcountriesmeasure waiting internationalcomparisonWhile of waiting timesis in 2018, such astheInpatient/Day Case Action Plan. improve following theintroduction ofnew measures are someindications thatthesituationhasstartedto to outpatientservicesinhospitals. However, there % of ptents wtn >3months 50% 25% 75% 0% 2010 2011 2012 Ctrct surer 2013 2014 2015 Irelnd 2016 2017 State of Healthin the EU ·Ireland ·Country HealthProfile 2019 Portu l 2018 50% 25% 75% % of ptents wtn >3months actions ofitsImplementation Strategy. Sláintecare Report andincluded inthehigh-impact times hasalsobeenidentified asa key priorityinthe (Department ofHealth, 2018b). Tackling long waiting the projected increases dueto population ageing for current demand andisunabletocope with the current infrastructure issimply notadequate a recent health service capacity report foundthat hospitalisations could beavoided (seeSection5.1), are occupiedat any given time. someofthese While EUcountries.all Nearly hospitalbeds 95%ofall Ireland records thehighestbedoccupancy rate among determinant of waiting timesfor public patients. infrastructure and workforce appear tobeakey insurance market (European Commission, 2019). to confront the powerful stakes involved inthe to thisdilemma. Sofar, Ireland hasnotbeenable duplicate insurance market inEurope contributes private patients. The factthatIreland hasthebiggest the availability ofdoctorsandinfrastructure with for public patients, sincethey have tocompete for to provide theactivity, the practice reduces access and public hospitalsrely ontheincomeinorder additional incomeontopoftheir public salary, many doctors profit from this practice asthey earn same premises.the on for publicpatients While insurance) alongside their work commitments (whose costsare typically covered by private health public hospitalsare allowed tosee ‘private’ patients Ireland andrefers tothefactthatseniordoctorsin public hospitals. This practice is widespread in is considering how toremove private practice from ways toaddress inequalitiesinaccesstocare and The Irish government iscurrently investigating 0% Spn 2010 2011 Sweden 2012 Hp replcement 2013 2014 2015 2016 2017 2018 17 Portu l Spn Sweden Irelnd IRELAND Figure 16. Unmet needs for medical care in Ireland are slightly above the EU average

% reportn unmet medcl needs Hh ncome Totl populton Low ncome

IRELAND 20

EU Itl Spn Greece Ltv Polnd Irelnd Cprus Frnce Mlt Eston Fnlnd Icelnd BelumBulr Crot SwedenNorw Czech Austr Romn Sloven SlovPortul Lthun DenmrHunr Germn Luxembour Netherlnds Unted ndom

Note: Data refer to unmet needs for a medical examination or treatment due to costs, distance to travel or waiting times. Caution is required in comparing the data across countries as there are some variations in the survey instrument used. Source: Eurostat Database, based on EU-SILC (data refer to 2017).

5.3 Resilience8

Far-reaching changes are required to make on long-term care (European Commission-EPC, the Irish health system sustainable 2018). This projected increase for Ireland is more pronounced than in many other EU countries and The Irish health system had to prove its resilience raises some fiscal sustainability risks in the long term. when public health spending was cut and staff reduced in the wake of the economic downturn at the The scope of the Sláintecare Implementation end of the last decade. Initially, efficiency gains could Strategy is limited so far be achieved fairly easily to maintain service levels with fewer resources, but after 2013 reduced inputs Unlike many other countries, Ireland has managed finally resulted in fewer outputs. Since then, Ireland to achieve a broad political consensus of what a has moved on: public health budgets have again seen new and transformed health system should look some strong growth in recent years and the number like. The current government appears committed of health workers has increased. to supporting the general vision of the Sláintecare Report and has started to implement some aspects Yet the cross-party political support for the of the ambitious reform proposals (see Section 4). It Sláintecare Report of 2017 among members of the published its Sláintecare Implementation Strategy for Oireachtas (Irish parliament) highlighted the desire the next three years in August 2018 around four key for some fundamental changes and the conviction strategic goals and ten high-level strategic actions. that the Irish health system is not performing as well In March 2019, the newly established Sláintecare as it could. Its findings also indicated that without Implementation Office presented an ambitious transformative changes the current system would not Sláintecare Action Plan, which details further 239 be able to cope with further increases in demand for deliverables to be actioned in 2019 in the context of health care associated with population ageing9. this Implementation Strategy.

According to the latest projections, public spending The actions taken so far include the establishment on health as a share of GDP is expected to increase of a HSE board to improve accountability, the by one percentage point between 2016 and 2070, commissioning of an independent review on and by two percentage points for public spending removing private practice from public hospitals

8: Resilience refers to health systems’ capacity to adapt effectively to changing environments, sudden shocks or crises. 9: Addressing the expected increase of age-related expenditure by making the health care system more cost-effective was one of the country-specific recommendations issued by the Council of the European Union to Ireland in the context of the 2019 European Semester (Council of the European Union, 2019).

18 State of Health in the EU · Ireland · Country Health Profile 2019 10: The developmentofanintegrated workforce planis, however, akey actionincludedintheSláintecare Action Planof2019. or Australia.Kingdom markets such astheUnitedStates, theUnited position tofindadequatejobsinmedicallabour andnetworks,skills they are ina very advantageous progression opportunities. Moreover, duetolanguage health system, with insufficienttraining andcareer working hoursinanunderstaffedandoverworked to working conditions thatare characterised by long emigrate (oratleastconsider it), partly inresponse A highnumber of young Irish-trained doctors Source: OECD Health Statistics 2019; Department of Health, Key Facts 2018. Figure 17. Thecreation of intern posts lags behindthegrowth inmedicalgraduates reform health workforce planning. Given itsstrategic ensure asustainable provision ofhealthservicesisto A key recommendation oftheSláintecare Report to strengthened and morecoherent Health workforce planning needs to be Report.original commit tofinancial resourcing asspecifiedinthe necessary tostrengthen primary care, anddoesnot adequately address thestaffing mix andskill reforms commitments toreduce waiting lists, doesnot to care. There are alsoconcernsthatitdialsdown health coverage through legislating forentitlement it doesnot wholly committo providing universal expanding forhealthcare eligibility ona phased basis, Report. For example, theStrategywhile commitsto shortofsomekeyfalls aspectsoftheSláintecare some areas, theImplementation Strategy currently so farhasbeentooslow andtoolimitedinscope. In have beenexpressed thattheimplementation process Despite theseimportant reform steps, someconcerns Sláintecare Integration Fund. Healthcare Organisations andaEUR20million alignment ofHospitalGroups andCommunity (see Section 5.2), a government decisionon geographic 1 000 1 400 1 200 800 600 400 200 0 Medc l r du tes 2009 2010 Intern posts 2011 2012 State of Healthin the EU ·Ireland ·Country HealthProfile 2019 2013 medical laboursupply after graduation (OECD, 2019). medical studentsare unlikely toentertheIrish training (Figure 17). As aresult, many non-Irish allow thesestudentstocomplete their postgraduate increase inthenumber ofinternshipopportunitiesto international medicalstudents with acorresponding they donotmatch theexpansioninnumber of they are notsubjecttonumerus clausus policies), yet destination formany internationalstudents(since that Irishmedicalschools have becomea popular country. Among the explanationsisthefact possible on immigration ofmedical staffthanany otherEU States, atthesametimerelyingwhile more heavily of medical graduates per capita among EUMember all it is paradoxical thatIreland hasthehighestnumber proposed rollout ofuniversal GPcare. Inthiscontext, services increasewill with ageing societiesandthe retention are alsoimportant, sincedemandfor Addressing issuesoftraining, recruitment and mix, hasthusfarbeenmissing workforce planning, such asonstaffing costsandskill across professions. Yet vital informationforeffective a high priority in thereform agenda andconceived care models, improved workforce planning should be objectives andthedesire tomove towards integrated importance inbringing aboutmany oftheSláintecare of Health, theHSEand professional medicalbodies. require greater cooperation between theDepartment a sufficient number ofdoctorsinIreland. This would employment policies would helptotrain andretain Hence, more coherent education, training and 2014 2015 10 . 2016 2017 19

IRELAND eHealth solutions will be an important More efficient use of hospital element in the future service delivery model resources can be achieved

IRELAND While Ireland is lagging behind other European As noted in Section 4, about one-third of health countries in the adoption of information technology spending in Ireland is allocated to inpatient care in in the health sector, the potential of eHealth to hospitals. Some initiatives are underway to improve support the delivery of an efficient, modern and the efficient use of hospital resources; indeed, responsive health system is well recognised. The the average length of stay (ALOS) of patients has eHealth priorities in the Sláintecare Implementation decreased over the past decade and is now about 25 % Strategy include the implementation of a national lower than across the EU (Figure 18). electronic health record (EHR) in the acute hospital sector, design and rollout of a community-based Still, there is further potential to get more value EHR and design and rollout of a range of primary for money. A recent report prepared by the Irish and community-based ICT services, including Government Economic and Evaluation Service ePrescriptions and telehealth solutions. observed that the latest increase in hospital funding did not lead to any increase in hospital activity, even These investments will be partly financed by a 20-year though staffing numbers went up (Lawless, 2018). loan from the European Investment Bank (EIB). In While activity-based funding (ABF) was introduced in 2018, the EIB agreed to provide EUR 225 million to 2016 to replace block grants, it is currently limited to support the rollout of Ireland’s transformational inpatient and day cases in around three-quarters of eHealth programme, making it the first eHealth acute care hospitals. Some 30 % of hospital budgets project ever supported by the EIB. are still financed by block grants. The Sláintecare Implementation Strategy sets out an increase in the number of acute care hospitals using ABF and an expansion of the proportion of hospital budgets financed by ABF.

Figure 18. The average length of stay in hospital has decreased and is lower than the EU average

Irelnd Beds ALOS EU Beds ALOS Beds per 1 000 populton ALOS (ds) 6 9

8 5 7

4 6

5 3 4

2 3

2 1 1

0 0 2009 2010 2011 2012 2013 2014 2015 2016 2017

Source: Eurostat Database.

The Irish health system is also characterised by As noted in Section 5.1, strengthening access to shortcomings in care coordination between hospital primary care and community care could also and follow-up care. As shown in Table 1, the number help avoid many hospitalisations for ambulatory of bed days related to delayed discharges for patients care-sensitive conditions. However, for this to happen, who no longer need to stay in acute care hospitals is the lack of capacity and resources at the community much higher in Ireland than in Denmark and Norway. level will need to be addressed. Hospital bed occupancy rates could be reduced if post-discharge planning and care arrangements for the elderly were improved (OECD/EU, 2018).

20 State of Health in the EU · Ireland · Country Health Profile 2019 the effectivenessofthistool. 11: tothesituationin2012,This issimilar despitetheintroduction ofthePerformance and FrameworkAccountability by theHSEin2015, raising questionsabout improve the payer’s position inthemarket (Box 3). of cooperation includes joint price negotiationsto to informationand policy exchanges, oneoftheareas to high-qualityandaffordable treatment. Inaddition ‘BeNeLuxA’ collaboration toenhance patients’ access and Luxembourg inJune 2018intheso-called Ireland joined Austria, Belgium, theNetherlands guarantee accesstonew medicinesfor patients, agreed tocollaborate inexploring possible ways to a number ofmainly southern European countries Valletta Declaration inMay 2017, where Ireland and reference pricing more frequently. After signing the prices andexpandthebasket ofcountriesusedfor Health andmanufacturers in2012and2016torealign including agreements between theDepartment of pharmaceutical spending during the past decade, Ireland hastaken anumber ofmeasures tocontrol may helpreigninpharmaceuticalspending Recent initiative incross-border collaboration Source: Suzuki(forthcoming), “Reducing delays inhospital discharge”, OECD Health Working Papers (data refer to 2016). Table 1.Hospital beddays related to delayed discharges are higherthaninother countries United Kingdom (England) Sweden Norway Ireland Denmark systems andpotential costs to publicfinances. impact onpatient health,theorganisation of health assess upcoming products based ontheirpredicted International Horizon ScanningInitiative. Thiswould In 2018, the BeNeLuxA countries launched the in themarket. reimbursement processes to improve payer’s position increase theefficiency of assessment, pricingand and Austria, withIreland joiningin2018. Itaimsto formed of Belgium,theNetherlands, Luxembourg The BeNeLuxA initiative was started in2015, initially Box 3. Ireland seeks to develop itshorizon-scanning capacity through theBeNeLuxA initiative Number of beddays State of Healthin the EU ·Ireland ·Country HealthProfile 2019 2 254 821 393 124 201 977 30 844 30 82 411 overspending atthehospitallevel, which isalsoa problems are partly triggered by consistent the Department ofHealth(Connors, 2018). These increases from budgetallocations initsoriginal to remain within itsbudget, despitesubstantial In recent years theHSEhasrepeatedly struggled levelsto beanissueatall oftheIrishhealthsystem. Staying health budgetscontinueswithin allocated issue at healthcarelevels all Budget management remainsan becoming increasingly important. systems, more detailed predictive information is long-term access andfiscal sustainability of health potential impact of new high-cost medicines on members) have now joinedthisproject. Given the More thanten countries (inaddition to theBeNeLuxA limitations (European Commission, 2019). due toalack ofcomprehensive planning anddata suggests thatbudgetmanagement is weak, partly budget overrun of7% per hospital. stayed within theirbudgetsin2017, with anaverage (Lawless, 2018)foundthatonly two outof49hospitals Irish Government EconomicandEvaluation Service care atthecommunity level. A recent report by the consequence ofalack ofcapacity fornon-acute Bed days/1 000population 40 34 43 16 5 11

Overall, this 21

IRELAND 6 Key findings IRELAND

• Life expectancy in Ireland has increased more • Waiting times for treatment are widespread rapidly than in nearly all EU countries since in the Irish health system, be it in the 2000 and is now more than one year above community or for specialist visits or elective the EU average, but not all additional years surgery in hospitals. A two-tier health are lived in good health. Around one-third of system, where those with the ability to pay years after age 65 are lived with some chronic for treatment privately get faster access to diseases and disabilities, increasing demands care, combined with low levels of hospital on health and long-term care systems. capacity and the inappropriate use of some hospital resources, contribute to this problem. Initiatives taken in 2018 appear to have been • The health system is generally effective in somewhat effective in reducing waiting times avoiding deaths from preventable causes. in some areas, but it remains to be seen As part of further efforts to reduce smoking, whether this trend will continue. plain packaging for all tobacco products became mandatory in October 2018. Overweight and obesity among adults and • The high reliance on foreign-trained doctors children are growing public health issues in and the fact that a high number of medical Ireland. To tackle this problem, a tax on sugar- graduates in Ireland will never work in Ireland sweetened drinks was adopted in 2017. raise serious questions about coherence between the education, training and employment policies of doctors. Increasing • Ireland spends around one-fifth more on internship and postgraduate training places health per capita than the EU average, but for new medical graduates would go a long the share of public spending is below the way in addressing the current bottleneck and EU average. This can be explained by the increasing the number of fully trained doctors. important role of private health insurance: Ireland has the largest market for duplicate insurance in Europe. Consequently, the • Managing to stay within allocated health financing share of private health insurance is budgets continues to be an issue at all levels three times higher than the EU average. of the Irish health system. This refers to the Health Service Executive at large, but consistent overspending at the hospital level • Ireland remains the only western European is a particular challenge. country without universal access to primary care. More than 50 % of the population have to pay out of pocket for a general practitioner • The Sláintecare Report of 2017 laid out the visit. For those without coverage this can lead ten-year vision for a modern patient-centred to delayed and more expensive treatment single-tier health care system with universal in hospitals. While addressing this problem access for everyone. The publication of stands at the heart of the recent Sláintecare the very detailed Action Plan in 2019 is an reform proposal, the measures taken thus far important step and shows the commitment do not wholly commit to providing universal of the current government to implementing health coverage through legislating for this vision. However, there are questions over entitlement to care. whether sufficient financial resources will be made available to implement all central elements of the reform as envisaged in the original Sláintecare Report.

22 State of Health in the EU · Ireland · Country Health Profile 2019 Key sources

OECD/EU (2018), Health at a Glance: Europe 2018: State European Observatory on Health Systems and Policies, of Health in the EU Cycle, OECD Publishing, Paris, https:// Ireland, Health Systems and Policy Monitor, https://www. doi.org/10.1787/health_glance_eur-2018-en. hspm.org/countries/ireland18092013/countrypage.aspx.

References

Connors J (2018), Budget 2019 Health Budget Oversight & European Commission (2019), Country Report Ireland Management: Alignment of Health Budget and National 2019, February 2019, Brussels Service Plan, Dublin. Government of Ireland (2018), Sláintecare Council of the European Union (2019), Council Implementation Strategy, Dublin. Recommendation on the 2019 National Reform Programme of Ireland. Brussels, http://data.consilium. HSE (2018), Annual Report and Financial Statements 2017. europa.eu/doc/document/ST-10160-2019-INIT/en/pdf Health Service Executive, Dublin.

Department of Health (2013), Healthy Ireland – A Houses of the Oireachtas (2017), Committee on the Framework for Improve Health and Wellbeing 2013-2025, Future of Healthcare Sláintecare Report, Dublin. Dublin. Lawless J (2018), Spending Review 2018: Hospital Inputs Department of Health (2016), A Healthy Weight for and Outputs: 2014 to 2017, Dublin Ireland – Obesity Policy and Action Plan 2016-2025, OECD (2019), Recent trends in international migration Dublin. of doctors, nurses, and medical students, chapter 4 The Department of Health (2018a), Health in Ireland - Key Irish Paradox: Doctor shortages despite high numbers Trends 2018, Dublin. of domestic and foreign medical graduates, OECD Publishing, Paris. Department of Health (2018b), Health Service Capacity Review 2018 Executive Report: Review of Health Demand Siciliani L, Borowitz M and Moran V (eds.) (2013), and Capacity Requirements in Ireland to 2031- Findings Waiting Time Policies in the Health Sector: What Works?, and Recommendations, Dublin. chapter 8 on Ireland, OECD Health Policy Studies, Paris.

Department of Health (2019), Sláintecare Action Plan 2019, Dublin.

European Commission – EPC (2018), The 2018 Ageing Report – Economic and Budgetary Projections for the 28 EU Member States (2016-2070). Institutional Paper 079. May 2018, Brussels

Country abbreviations

Austria AT Denmark DK Hungary HU Luxembourg LU Romania RO Belgium BE Estonia EE Iceland IS Malta MT Slovakia SK Bulgaria BG Finland FI Ireland IE Netherlands NL Slovenia SI Croatia HR France FR Italy IT Norway NO Spain ES Cyprus CY Germany DE Latvia LV Poland PL Sweden SE Czechia CZ Greece EL Lithuania LT Portugal PT United Kingdom UK

State of Health in the EU · Ireland · Country Health Profile 2019 23 State of Health in the EU Country Health Profile 2019

The Country Health Profiles are an important step in Each country profile provides a short synthesis of: the European Commission’s ongoing State of Health in the EU cycle of knowledge brokering, produced with the ·· health status in the country financial assistance of the European Union. The profiles ·· the determinants of health, focussing on behavioural are the result of joint work between the Organisation risk factors for Economic Co-operation and Development (OECD) and the European Observatory on Health Systems and ·· the organisation of the health system Policies, in cooperation with the European Commission. ·· the effectiveness, accessibility and resilience of the The concise, policy-relevant profiles are based on health system a transparent, consistent methodology, using both quantitative and qualitative data, yet flexibly adapted The Commission is complementing the key findings of to the context of each EU/EEA country. The aim is these country profiles with a Companion Report. to create a means for mutual learning and voluntary For more information see: ec.europa.eu/health/state exchange that can be used by policymakers and policy influencers alike.

Please cite this publication as: OECD/European Observatory on Health Systems and Policies (2019), Ireland: Country Health Profile 2019, State of Health in the EU, OECD Publishing, Paris/European Observatory on Health Systems and Policies, Brussels.

ISBN 9789264684461 (PDF) Series: State of Health in the EU SSN 25227041 (online)