Implementing universal healthcare in Ireland: An Advocacy Coalition Analysis

Background

“Sláintecare” is the wide-ranging 10-year Irish universal healthcare reform programme launched in 2017 and designed to move beyond the current two-tier system. A highly distinctive feature is the all-party political consensus in 2016 which led to adoption of the reforms. Yet despite this seemingly solid starting-point, implementation of Sláintecare has proven challenging, and analysis thus far has indicated both alignment with, and divergence from, the 2017 vision of universalist healthcare in Ireland.

Methods

We draw on the Advocacy Coalition Framework (ACF) and policy entrepreneurship to conceptualise Sláintecare implementation as a nascent policy subsystem and explain challenges arising out of changing leadership and governance structures since 2017. Our conceptual approach synthesises insights from interviews with 17 key figures across government, healthcare regulators, thinktanks and academia.

Results

We find that policy beliefs regarding Sláintecare implementation are fragmented by alignment with, and divergence from, the original 2017 Sláintecare vision. However, this does not adequately explain the stability and longevity of coalitions involved in Sláintecare implementation. We suggest that interdependencies – in terms of organizational interactions and use of political resources – can also play a key role. This provides learning both for Sláintecare implementation going forward, as well as for other countries where implementing universal healthcare can be contested.

Conclusions

The Sláintecare reforms show that consensus at the design stage of universal healthcare reform may not translate to shared beliefs with regard to implementation. Wider frameworks supporting policy actor interdependency, leadership, and policy entrepreneurship can prove important beyond shared beliefs in driving implementation.

Key messages

• The unique all-party political consensus and in support for of Irish healthcare reform enabled design of universal healthcare reforms, but may also constrain implementation.

• The stability of coalitions implementing Sláintecare are shaped by interdependencies between policy actors and policy entrepreneurship as well as shared beliefs.