Dr. Josep Figueras:

I really want to tackle the members' questions but an overview could be helpful. I shall return to the indicators in a minute, if members wish.

Consider the question of whether value for money is being obtained. The relevant slide is very simple and I do not like its approach but it is still fairly solid. On the vertical axis is health expenditure and on the horizontal axis is amenable mortality for males and females. I refer to mortality that is amenable to health care. Is value for money being obtained? The vertical line shows countries such as Luxembourg, France, Belgium and Ireland, which is clearly pointed out, and also Finland, Italy, Spain and Cyprus. They are all on the line that shows relatively low levels of amenable mortality for males. For the same amount of money, there is a huge variation. One could argue, therefore, that Ireland could be lower down and get the same levels as Spain, Italy or Cyprus, for instance. That is an indictment of the data, however, because the system in Cyprus still does require a fair number of reforms, yet it has low levels of amenable mortality. I should be cautious in saying this. Perhaps this measure of the impact of the health system may also be affected by diet and lifestyle factors. Cyprus, which is in the Mediterranean, has a very good diet, as with the Greeks. If one makes a comparison with the countries on the right of the graph, such as Portugal, the Czech Republic, Estonia and some others, one can see they do not spend very much money per person and have higher levels of mortality.

That is an overall picture of Irish life expectancy, health outcomes and risk factors. I will discuss this area for ten minutes and then I will be happy to answer questions on the details. My job is to reflect with the members on how international comparisons can help them to think about how to proceed. The questions in the data are very much the ones faced by Ireland and elsewhere.

The EOHSP's approach is the one it has been using for other countries. Consider the question of whether Ireland should reform its statutory funding system. I refer to the debate on taxation and social health insurance. Clearly, the experiences with competing insurers have not been very positive. I will be very happy to discuss in detail the Czech and Dutch experiences. I know these very well because I participated in the reform evaluations. Perhaps this debate should be on whether Ireland should reform its general tax system or its social health insurance system.

What we say, in a slightly superficial tone which I hope the members do not mind, is that it is not a matter of a Bismarck or Beveridge system. Both Otto von Bismarck and Beveridge are dead. The current debate is not about social health insurance versus taxation but about whether the system is sustainable, efficient to administer and flexible in a crisis. I have a fair amount of experience of how various systems in Europe have reacted in times of crisis in terms of compensating for the shortfalls. We can discuss and debate that but I believe the question is how we adjust either the social health insurance system or taxation system in such a way that the health system can remain stable, deal with crises, provide the appropriate amount of resources, and account for progress and differences between taxation and insurance in some instances. I have data on this so I invite members to push me on whatever area they wish, as long as I have the answers, of course.

Most countries have a mixed system. The other kind is very rare and the trend is in the opposite direction. Owing to the impact of social health insurance on labour costs, most countries tend to increase the amount of taxation to compensate or subsidise the insurance system. All in all, if I were to dare to make a suggestion for the committee's consideration based on international experience, it would be on the fact that a move to social health insurance would not bring additional resources. There has been a fallacy in other countries that social health insurance will flood the system with resources. They are not available, basically, and if they are very large, they will end up having an impact on the labour costs. Second, the administrative cost of transactions may be high so one may need to proceed cautiously if one wants to move to a social health insurance model. I will be very happy to debate this.

On statutory resources, are there any other sources of statutory funds that we can use? I have a list of what other counties have been doing, particularly in times of crises. There are some interesting insights from our studies. All of the studies are available. We produced one on the impact of the crisis in Ireland, which I hope the committee has seen. Has the Chairman seen it?