A FEW YEARS ago, I volunteered with a children’s cancer charity in Tanzania. One weekend, a team of us travelled 500 kilometres inland, from the headquarters in Dar Es Salaam to a regional hospital in a town called Ifakara.

As we sped along the smooth motorway, I got chatting to the driver. At one point, the fresh-looking tarmac was replaced by a ludicrously bumpy dirt road. It took us an hour to edge ten kilometres through a small town – before reaching a junction where we abruptly transitioned back onto a new-looking road. When I asked the driver about it, he laughed. “I think they voted for the wrong party.”

While Tanzania has many strengths, multiparty democracy is not one of them. The ruling party, Chama Cha Mapinduzi, has won every election since independence in 1961. This particular village made the costly error of voting for the wrong candidate – the outcome was clear.

In Ireland, we too have a problem with localism in our politics, impeding our ability to think big and to deliver on long-term strategic measures. This affects priority areas like climate action, capital infrastructure and health, to name a few. I do not want to imply that corruption in rural Tanzania is equivalent to what occurs here, but local loyalty plays an important part in Irish politics and culture. Our sense of home forms a central part of who we are. This is a wonderful thing, to be cherished.

That said, this imprint of localism on our political system is often negative. In Reflections on the Irish State, the late Garret Fitzgerald wrote that, while “strong local loyalties are important and have a very positive role to play, a problem can arise … when they take precedence over the good of the people of the whole State”.

Struggling to function

As a doctor, I have had the opportunity to see our health system from several angles (and nine hospitals, at the last count). While our health service has many strengths, an abiding weakness since the foundation of the State has been our struggle to enact health reform, in particular those which are progressive and seek to achieve universal coverage.

Ireland does not have universal healthcare, making us an outlier among our neighbours and the developed world. Universal healthcare means that health is upheld as a right of all citizens. Here, however, healthcare resembles a complex and peculiarly Irish combination of public entitlement, item of charity and economic commodity. Rather than a shared human right, healthcare remains something for which one must be deemed eligible. We create categories: public or private; medical card or fee-paying; and, at the national level, this county or that one. Charity is bestowed; rights are claimed. Political localism and fragmentation in our health system are inextricably linked.

During the twentieth century, particularly after World War II, most Western nations established universal health systems, such as Sweden, France, New Zealand and of course the United Kingdom, which established the National Health Service in 1948, funded through taxation.

For many reasons – including the power of the Catholic Church, a weak labour movement, and the fact we were broke – this did not happen here. We did things differently – for example, through the Irish Hospital Sweepstakes.

The Sweepstakes began in the 1930s as raffles to raise money for building new hospitals and repairing existent ones. People who could afford to do so bought tickets. The returns exceeded all expectations. Remarkably, by 1931, the Sweepstakes were providing £1m per annum, at a time when the State spend on public assistance was around £3m. Irish hospitals undertook what Minister Seán MacEntee described as ‘haphazard expenditure’ – that is, a frantic, uncoordinated spending spree which did not translate to better outcomes at the national level.

Decades later, in 1967, a Dublin surgeon named Patrick Fitzgerald was asked to prepare a report for government on the best way to optimise hospital administration. Professor Fitzgerald interpreted his brief rather briskly and authored a report calling for a complete overhaul of Ireland’s fragmented hospital system. The Fitzgerald Report bluntly declared that health services should be developed strategically, for the benefit of all, through a regionalised system, rather than “a large number of small institutions scattered throughout the country”. It caused major controversy.

Political failures

Ireland is a different place today, but the same themes recur. Instead of Sweepstake raffles, we have corporation tax bonanzas – more money than we know how to spend. And yet we still do not have universal healthcare – despite the fact that we have a strategy, called Sláintecare, which set out a ten-year roadmap to achieve it, seven years ago.

The incoming government has brokered deals with independent TDs in exchange for their support, though such deals do not feature explicitly in the Programme for Government. Nor does universal healthcare, for that matter. Sláintecare earns one or two passing mentions. The further extension of medical cards will be kept “under review”.

Through the National Treatment Purchase Fund, we will continue to outsource waiting list backlogs to the private sector. Assessments of Need, for children with developmental problems, will be conducted by private therapists if capacity is not there in the public system – due in part to our failure to retain the same therapists.

There is, however, no mention of any high-level, strategic effort to tackle root problems, nor a successor to Sláintecare, which will expire during the lifetime of this government along with the universalism at its heart.

In the recent general election, Minister for Health Stephen Donnelly lost his seat. As both a Wicklow voter and healthcare worker, I felt some sympathy. It seemed to me that Donnelly’s national portfolio proved hard to balance with the local constituency concerns so essential to re-election. Donnelly, to be fair, had his achievements – such as the public-only consultant contract, which is key to disentangling the unfair public-private disparities embedded in our hospitals.

Pushing uphill

Recent Ministers for Health seem to fall into one of two groups. On one side, we have Donnelly, and perhaps James Reilly, who notably tried and failed in 2014 to achieve universal health coverage through the alternative route of universal health insurance. In the other group, we have ministers like Michael Martin, Leo Varadkar and Simon Harris, who have a notable trait in common: they emerged sufficiently unscathed from the role to go on to be Taoiseach.

It seems plausible that thinking big and aiming for major, progressive changes may not guarantee continued political success (something Noel Browne discovered 75 years ago).

At its core, Sláintecare aims to achieve a universal, single-tier health and social care system, providing access to timely and excellent care based on clinical need and not ability to pay.

No country in history has achieved this difficult goal without a combination of luck, money and political leadership from the very top. Sláintecare will expire soon, and while progress has been made, the fact is that universal healthcare has not been achieved in Ireland.

In low-income nations, universal healthcare is a question of means. In wealthy nations like ours, it is a question of priorities. The incoming government must now choose theirs.

Dr Domhnall McGlacken-Byrne is a doctor specialising in public health and paediatrics.