Equality omitted reform: an exploration of 'egalitarian' and 'efficiency' principles in Irish health care provision within an institutionalist framework.

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.2017-11-1