It is evident that the State has a health system in crisis. The symptoms are everywhere: staff shortages, waiting lists, patient care which too often fails to reach the standards expected in one of Europe's wealthier States.
What is less readily apparent is that the State has a health system which almost defies rational analysis. The OECD has diplomatically described it as "unique". Others might term it "bizarre".
And it is a health system which is changing rapidly. Private medicine is booming, as a result of inadequacies in the public system, which is suffering from lack of resources, poor management, and the vested interests of some medical professionals taking precedence over patients' needs.
Never having offered equitable access to healthcare for everybody in the manner of Britain's National Health Service, the State is now moving rapidly towards an American-style system where people's ability to pay delivers access to care. Some doctors employed in the public service are also earning very large incomes from private practice - far more than they receive from the State.
The strangest element of the Irish health system is the manner in which it combines private and public patient care. There is in Ireland "an extraordinary symbiosis of public and private medicine", the consequence of decades of conflict between State, church and the medical profession, the chief executive officer of the Health Research Board, Dr Ruth Barrington, concluded in her doctoral thesis.
Built on such political foundations rather than on any rational analysis of the health needs of the population, the health system then suffered the large cutbacks of the 1980s. Although spending rose again during the 1990s, the health system will remain in crisis unless there is reform of the deep-seated inequities and irrationalities of the present system - and this will have to include confronting vested interests. Today, it is an open secret that to be a public patient is a status best avoided.
"I know people who would scrub floors, just to get the money for VHI cover, out of fear of having to depend on the public health service," says the chairman of the Irish Patients' Association, Mr Stephen McMahon.
It is in public healthcare that the long waiting lists for treatment occur - nearly 32,000 people this summer. Public patients wait years for treatments which are available within weeks for private patients.
It is small wonder that membership of the VHI, seen as the way to jump queues, has soared from 22 per cent of the population in 1979 - before the 1980s health cutbacks - to 41 per cent today. When other private insurance schemes are included, some 45 per cent of the population is thought to be in the private sector. If private insurance cover continues to grow, the fate of public patients - who will then account for a minority of the population - may cease to be an issue which exercises most politicians. As in America, Ireland's system will be essentially dominated by private insurance companies.
The VHI disputes the view that membership growth is driven by fear of waiting lists.
"It is wrong to say that there is a direct relationship between the growth in membership and the health cutbacks of the late 1980s," according to the VHI's medical director, Dr Bernadette Carr. "It is a cultural thing. Here, if people can afford something, they will pay for it. We are culturally different from the UK. People seem to want to be self-sufficient in education, housing and health."
However, an ESRI study by Prof Brian Nolan, published in 1991 just after the decade of cutbacks, found "constrained public provision playing a major role in the demand for private care and therefore health insurance".
A consumer survey conducted by the ESRI for the EU in 1990 discovered that among respondents who had VHI cover, 62 per cent cited "being sure of getting into hospital quickly when you need treatment" as the most important reason for having it. Having a private room, choosing your consultant, and getting into a private hospital were not regarded as nearly so important.
Dr Carr confirms that waiting times "do not seem to be an issue" for VHI members. "In excess of 80 per cent are admitted for treatment within four weeks of seeing a specialist," she says.
When the VHI was founded in 1957 the motivation was to provide private income for doctors who had successfully, and with the help of the Catholic Church, fought off decades of politicians' efforts at establishing a comprehensive public health system. The VHI and private medicine were heavily subsidised by the State.
Today, VHI members still receive tax relief on their subscriptions and, like other insurance companies, the VHI does not pay the economic cost of the use of public hospital beds.
Private insurance contributes a mere 9 per cent of health spending; most of the remainder is funded by the State from general taxation.
Irish private patients, as a result, get cut-price, preferential access to healthcare. Health insurance premiums are low compared to the US. The Minister for Health, Mr Martin, has recently refused the VHI permission to put up its fees.
"There is huge dishonesty about how we organise the health services," comments one health service administrator. "We are giving one set of taxpayers more rapid access to better treatment for the payment of very little extra money."
At least when the VHI was founded as a semi-state organisation it was not expected to be motivated by the need to make profits. Now, however, with the opening up of the health insurance market to foreign companies such as BUPA and the probable privatisation of the VHI, a new element has entered the Irish health system. It is to be milked for profit by private sector companies. This is a major change.
People without private health insurance - still the majority of the population - are covered by the General Medical Scheme (GMS) or have no cover. The GMS gives free hospital and general practitioner care to holders of medical cards - 31 per cent of the population today. The proportion of the population covered by the GMS has been falling as the threshold for eligibility has failed to keep pace with changing incomes. Membership of the scheme has been as high as 39 per cent of the population. The Irish Medical Organisation has called for 250,000 more medical cards to be provided.
THERE remains approximately 25 per cent of the population who have neither medical cards nor private insurance. They may be on very low incomes. A couple with two children on just £9,000 a year after payment of PRSI will not qualify for medical cards, according to the eligibility guidelines issued to health boards. The system is designed for the elderly and social welfare recipients - not for the working poor. People without medical cards must pay for every GP visit. They will receive free medical care in hospital, apart from a charge of £26 a night for a hospital bed up to a maximum of £260 a year. Since 1991, the entire population has been entitled to free medical care in hospital apart from the nightly charge, but fear of public patient treatment has continued to drive the growth of private health insurance.
It is particularly unusual, by comparison with other countries, that apart from medical card holders, all other patients - including children - must pay for GP visits here. The OECD commented: "There appears to be a general social consensus in Ireland that, apart from the most economically disfavoured parts of society, first-level medical care, such as general practitioners, should not be a publicly provided service."
Is this a general social consensus? The history of the evolution of our healthcare system in the 1940s and 1950s, when this was a hotly-contested political issue, would suggest otherwise.
Prof Nolan comments: "It is very surprising that the notion of free GP care for children has not emerged as an issue."
Consequently, parents on very low incomes must weigh up the cost every time they suspect their child needs to see a doctor.
This has not been seen as a health issue. A Government-appointed expert working group recently considered whether free child GP care might be introduced to provide an incentive for social welfare recipients to take up work without fear of the consequences of losing their medical card. It says something for the current Irish view of health that children's access to healthcare should emerge as an issue only when labour shortages are being considered.
Irish governments 50 years ago tenaciously pursued the goal of a publicly funded system where everybody would be treated equally according to their need. The present Government's position was stated last year in the White Paper on private health insurance. It rejected changing the current two-tier system, commenting that concerns about equity for public patients could be dealt with by "targeted initiatives and general improvements in the public health system".