Increases in health spending do not necessarily mean expanded services or better health. In 1998, when health spending went up by 11 per cent, little over a third of that increase was available for services initiatives. The Department of Health pointed out to the Dail's Public Accounts Committee last year that of the 55 per cent increase in spending from 1994 to 1999, pay costs accounted for 58 per cent.
The health services had been obliged to pay the national agreements and had also employed an extra 11,000 staff. The health services currently employ 80,000.
The new staff were required to develop new services, replace trainee nurses now in full-time education, avoid sole rostering in situations where staff might be vulnerable to accusations of abuse and replace the dwindling religious orders which frequently worked unpaid overtime or took no salary.
The Department of Health told the committee that in addition to the extra pressures on health spending caused by the rise in, and gradual ageing of, the population and by increased life expectancy, there was the problem of so-called health inflation. Costs of medicines are rising at a faster rate than prices generally, reflecting the effects of new expensive drug and surgical treatments and new technologies.
Followers of the haemophilia tribunal hearings will understand why the Department of Health instanced the "`enormously expensive" replacement of plasma-derived blood products with synthetic products as a necessary improvement.
These pressures on health spending exist in other countries, too, which is why Ireland's health spending must rise just to maintain our present relative position. Cost control in health is a hot topic in many countries. New research on health inequalities - the differing health experience of diverse socio-economic groups - is giving rise to debate about the direction as well as the level of much health spending.
Should heart operations take precedence over hip replacements or better support for the parents of children with mental handicap?
The Commission on Health Funding pointed out in 1989 that such choices tended to be made in an arbitrary way and mainly in the interests of the most powerful groups in society.
In 1994 the Department of Health under the then minister, Mr Brendan Howlin, announced plans to research the public's preferences. This kind of thoughtful debate on health choices is eclipsed, however, in the continuing recriminations between health professionals, politicians and the public about the more readily apparent aspects of the healthcare crisis.
The Department of Health's chief medical officer, Dr Jim Kiely, argued in his annual report in December for widening the debate about the health services to a debate about health itself, and health inequalities in particular. We should see health, he wrote, as "a fundamental human resource, something to be invested in, inextricably linked to social and economic progress". We should place "the promotion of health and, in particular, the narrowing of inequalities of health experience between differing segments of our population at the centre of all our efforts at social and economic development".
As Irish income per head exceeds the average of fellow EU member-states, but health spending per head struggles to stay above the 80 per cent of the average in those countries in 1960, it is clear we do not see health as central to our social and economic development.
It is also clear that, although we need to continue to increase health spending quite substantially, this will not suffice to address the complexities of the current crises in the health services. Health service reform is also essential.