Provided by the author(s) and NUI Galway in accordance with publisher policies. Please cite the published version when available. Equality omitted reform: an exploration of 'egalitarian' and Title 'efficiency' principles in Irish health care provision within an institutionalist framework. Author(s) Malone, Patrick Publication Date 2016-05-11 Item record http://hdl.handle.net/10379/5780 Downloaded 2021-09-23T09:37:21Z Some rights reserved. For more information, please see the item record link above. EQUALITY OMITTED REFORM: An exploration of ‘egalitarian’ and ‘efficiency’ principles in Irish health care provision within an institutionalist framework. by Patrick Malone A thesis submitted to the School of Political Science and Sociology In conformity with the requirements for The degree of Doctor of Philosophy National University of Ireland Galway, Ireland December, 2015 Supervisor: Dr Michelle Millar Internal Examiner: Dr Tony Varley External Examiner: Dr Vivienne Byers Abstract This thesis is an exploratory study of the theory and practice of equality in shaping modern policy conceptions of access and entitlement to health care provision. In most modern democratic societies, the principles of access and entitlement to sufficient health care services is characteristic of both a social right, which every citizen in society should possess, and an assurance, that in times of illness and vulnerability, social security is guaranteed. A central facet to the realisation of this principled obligation bestowed onto government is the degree to which a philosophical vision of equality permeates in the policymaking environment. Thus, a central question addressed in this thesis is the extent to which ‘equality’ featured as a core policy goal in successive health care reforms. Furthermore, this study also examines the degree to which achieving ‘efficiency’, in terms of both the infrastructural development of the Irish health services and the governance framework overseeing health service delivery, has paralleled with the instilment of an ‘outright’ egalitarian ethos in the policymaking trajectory. Through the theoretical frameworks of: Egalitarianism; Efficiency; and Institutionalism, this study provides a comprehensive examination on the evolution of the Irish health care system in terms of applied policy and practices related to ‘equality’ and ‘efficiency’ in service provision. In particular, the institutionalist theoretical frameworks applied in this study provides some significant insights in respect to chronicling the origins and entrenchment of the core policy constructs which both shape and constrain modern conceptions on; equality of access and entitlement to health care provision in egalitarian terms. Central policy constructs reviewed in this context are: eligibility of entitlement to public health care services; incentivising of the private sector market in health care; and the public-private mix of two-tier access to health care services. In contextualising the research themes of this study in empirical practice; the qualitative data compiled from interviews conducted with key stakeholders in the Irish health care domain provides some rich insights into how these concepts are being perceived and addressed in the contemporary policymaking environment. In this study, it is argued that equality has not been a core facet in successive health care reforms. As such, it is posited that the achievement of an outright vision of equality has been constrained due to the structures of ‘access’ and ‘entitlement’ being governed by a ‘mixed-motives’ system containing both libertarian and egalitarian precepts in health service delivery. In this context, it is evident that the primary egalitarian emphasis of policy actors has been to instil a spirit of fairness in health care delivery under an ethos of ‘equality of opportunity’ and ‘equity’. Under this framework, the policy focus has not been on universal entitlement, but rather to direct publicly funded health care provision towards those in most need; the lower-income groups and most vulnerable in our society. Furthermore, it is posited that the primary essence of health care reforms in contemporary times has been centred on the achievement of ‘efficiency’ in the governance structure whereby equality is perceived to exist in an ‘implicit’ rather than ‘explicit’ sense through policy goals such as; ‘positive’ patient outcomes and ‘quality’ in service delivery. ii Acknowledgements As I reflect on this challenging and deeply inspirational journey through my PhD studies, I appreciate that this research could not have taken place without the encouragement and enormous support of many people. Firstly, I would like to express a deeply felt gratitude to my thesis supervisor Dr Michelle Millar. Michelle has been a great mentor and has always been more than generous in providing me with expertise, extensive knowledge, support and advice. I am especially grateful for the patience, kindness and inspiration she has afforded to me throughout the course of my PhD studies. Thank you for everything Michelle. I wish to also thank Dr Liam Coen for his support and guidance at various stages of this research. Liam has always been very generous in providing me with fresh insights and thorough advice when needed. For that I am very grateful. Also, I would like to thank Dr Lisa Moran for her support and advice. Additionally, I would like to thank Professor Chris Curtin, Dr Anne Byrne, Dr Tony Varley, Dr Vesna Malesevic, Kay Donohue, Michael Donnelly and all members of staff at the School of Political Science and Sociology, NUIG for their encouragement, advice and support. To my interview participants, thank you sincerely for taking the time to participate in this study and for offering a valuable contribution to this research. I would also like to thank Eamonn Furey for his friendship, advice and our many discussions and welcomed tea breaks. I wish to also express my heartfelt gratitude to my many friends and colleagues that I have met through my PhD studies for their friendship, kindness and support. It will be always deeply appreciated. To my cousin Martina Jordan, thank you for your advice, always being there and giving me your full backing during all my educational endeavours. I would also like to thank Lisa Hynes for all her support and kindness. To my parents, Peggy and Pat, I will be forever thankful for your love, support and constant supply of encouragement. You both have always been persistent in helping me in every way possible to fulfil my educational paths and life ambitions. My brother and sisters, Hazel, James, and Lorraine, in your own unique ways you are always a great source of encouragement and support to me. I will always be grateful and fondly remember the help, kindness and patience which you have all shown me during this challenging and exciting experience. Without all of your support and reassurance, this undertaking would not have been possible. iii Statement of Originality I, Patrick Malone, hereby certify that all of the work described within this thesis is the original work of the author. Any published (or unpublished) ideas and/or techniques from the work of others are fully acknowledged in accordance with the standard referencing practices. Signed: Patrick Malone Date: 17 December 2015. iv Table of Contents Abstract……. ................................................................................................................... ii Acknowledgements ........................................................................................................ iii Statement of Originality ................................................................................................ iv Table of Contents ............................................................................................................ v List of Figures ................................................................................................................. ix List of Tables ................................................................................................................... x Chapter One: Introduction .......................................................................................... 1 1.1 Background context and rationale for this study .................................................... 1 1.2 Aims and Objectives ............................................................................................... 5 1.3 Theoretical Underpinnings...................................................................................... 6 1.4 Discussion on Methodology and Research Design ............................................... 12 1.5 The Investigative and analytical process. ............................................................. 13 1.6 Outline of Thesis ................................................................................................... 19 1.7 Conclusion ............................................................................................................ 20 Chapter Two: Conceptualising the principles of ‘equality’ and ‘efficiency’ as determinants in social policy outcomes ....................................................................... 22 2.1 Introduction .......................................................................................................... 22 2.2 Conceptualising the principle of ‘Equality’ in health care provision ................... 23 2.3 Defining equality through the theoretical strands of: Libertarianism; Utilitarianism; Liberal