Building health system resilience through policy development in response to COVID-19 in Ireland: From shock to reform

Abstract

Health systems worldwide are experiencing profound shocks resulting from the COVID-19 pandemic, with increased attention to health system resilience and researching ways to endure shocks. Pre-COVID-19, Ireland had begun a ten-year programme of reform, Sláintecare, aiming to deliver universal, timely access to integrated care. This study examines whether and how the Irish government's pandemic response contributed to health system reform and increased resilience including delivering universal healthcare. Documentary analysis identified and critiqued relevant government, health system and budgetary documents, published March 2020 - May 2021. Thirteen national policy documents were found, showing increased policy rhetoric and intent to implement reform, demonstrated by increased policy alignment with and budgetary allocation to Sláintecare, alongside implementation of key innovations. Ireland's health system response to COVID-19 offers a unique opportunity to advance understanding of government efforts to reform amidst a global pandemic. It indicated policy intent and funding to manage the Irish COVID-19 crisis, but to also build health system resilience through implementing Sláintecare. This case study has international significance, enabling policy development with potential for long-term health system transformation.

1. Introduction

COVID-19 has placed immense pressure on health system functioning, public health and society [1]. The shock of the pandemic has caused four distinct challenges: additional disease burden and mortality [2], a severe toll on mental health and well-being [3], delayed necessary and urgent non-COVID care [4] and acute economic loss [5], not least through widespread unemployment and other social determinants of health [6]. When caused by a sudden and extreme change, or shock, such pressures profoundly destabilise health system supply and demand; increasing need whilst undermining ability to care [7].

Health system resilience may be understood as a system's ability to endure shocks throughout the 4-phase lifecycle: being prepared; identifying onset and acting rapidly; managing impact to preserve health system access and quality; and dealing with legacy issues thereafter [7]. This requires vigilance in governance and an eye on the upcoming phase. By May 2021, Ireland was firmly in the ‘impact management’ stage of COVID-19 with the vaccination programme offering some hope for progression into the final phase – dealing with legacy [8]. To achieve this, however, improvements in long-term health system performance are required [9], ideally with a dual focus on reform to better manage the crisis while also locking in better health system design for a more resilient future [10].

Notably, the economic burden has for many high-income countries not been as bad as first feared [11]. This, coupled with very low interest rates, has given many European countries room for manoeuvre. Driven by a recognition of mistakes made during the 2008 financial crisis, there appears to be consensus that investing in structural changes to public health and social care systems is a high priority during this pandemic [12].

COVID-19 arrived in the third year of a ten-year plan for health reform that aimed to achieve universal healthcare in Ireland—Sláintecare [13]. Developed by a special all-party parliamentary committee on the future of healthcare in 2017, Sláintecare's main focus was to introduce universal healthcare, address inequitable and poor healthcare access and shift care into primary and community settings. Sláintecare also recommends population-based planning and integrated care within regions, free general practitioner (GP), primary and in-patient care, a radical reduction in waiting times to access diagnosis and care and the removal of private care from public hospitals, as well as much expanded public health initiatives [14]. In September 2018, a special Sláintecare Implementation Office was established in the Department of Health and up to February 2020, Sláintecare was progressing, albeit at a lesser pace than originally envisaged in the 2017 Sláintecare report [15].

In the face of a major shock, such as COVID-19, the temptation to deescalate healthcare reform is more pronounced. It might be thought that precious resources need to be targeted towards the shock and its immediate consequences and not diverted to short and longer-term health system change. However, one way that governments can resolve this tension is to focus investments on elements of the reform agenda that address both by strengthening health systems’ resilience. An obvious example has been the innovation and widespread adoption of telemedicine [10,16], albeit with some implementation shortfalls [17]. Nonetheless, this adaptive measure has allowed the system to cope with reduced resources, to deliver needed care and, critically, to establish a constructive longer-term legacy within a much shorter timeframe than is typically required [18,19].

In the crisis of the moment, such foresight for future potential can be challenging, but those governments that can sustain it, will be better positioned both presently and into the future.

Ireland's health system response to COVID-19 offers a distinctive opportunity to advance understanding of government efforts to reform amidst a global pandemic. The core goal of this article is to outline how key policy and budgetary decisions articulated during different stages of the crisis sought, and were enacted, to bolster health system resilience through enhanced delivery and accelerated reform.

2. Methods

2.1. Search strategy and selection criteria

Key government, health-related policy and budgetary documents were identified through searching relevant Irish government websites and a process of purposive sampling. Selection criteria included: 1) those published between March 2020 and May 2021; and 2) any government publications that dealt specifically with the health system, health reform and COVID-19. Broader cross government documents that did not mention the health system were excluded. This resulted in thirteen documents that were analysed for their content in relation to health system resilience and reform, specifically looking for intent to implement Sláintecare. All documents were publicly available (links provided in Table 1).

Table 1.

National Irish government, health system and budgetary policy documents: March 2020 to May 2021

COVID-19 waves	Date	National policy documents	Potential for Sláintecare reform/ transformative resilient health system change
Wave 1	March 2020	Cross-departmental actions announced	These cross-departmental actions included a contingency fund for €435 million for the health system to strengthen the COVID-19 response.
Wave 1	March 2020	National Action Plan in Response to COVID-19 [28]	The first government-wide action plan for COVID-19 has a strong emphasis on public health measures as a ‘lynchpin’, community solidarity and actions, freeing up hospitals for surge capacity and a range of cross-governmental measures put in place including details of COVID-19 governance structures.
Wave 1	1 May 2020	Roadmap to reopen the economy and society [29]	The roadmap details a five phased reopening plan including the resumption of non-COVID health and social care.
Wave 1	16 June 2020	Programme for Government. Our Shared Future [23]	The health section in the Programme for Government is entitled universal health care, the first two sections on health are entitled ‘delivery of care in a COVID-19 environment’ and ‘implementing Sláintecare’.
Wave 1	June 2020	Service Continuity in a COVID environment. A Strategic Framework for Delivery [34]	This HSE document guides ‘the reintroduction of services that were suspended or reduced as a result of COVID-19’, specifying how ‘service reintroduction represents an opportunity to reform and deliver elements of Sláintecare’. It details five key ways of working which are supportive of the HSE 2020 National Service Plan priorities including: enhancing and supporting general practice; digitally enabled healthcare delivery; and measures to reduce hospital admissions. It notes the alignment between these areas and Sláintecare's vision stating ‘there is an urgent need to reconceptualise how we deliver care, to both address the present health needs of our population in a COVID environment and protect the future viability of health services by progressing the implementation of the Sláintecare vision’ [21: 22].
Wave 1	July 2020	A safe return to our health services [35]	This is the first in a series of HSE documents entitled ‘A safe return to health services’ detailing a phased return to non-urgent care.
Wave 2	Sept 2020	Resilience and Recovery 2020-2021: Plan for Living with COVID-19 [36]	The second major government plan during the COVID-19 pandemic includes €600 million of funding for the 2020/21 HSE Winter Initiative. It has two relevant health sections – one entitled ‘health system resilience and responsiveness’, which seeks to ensure public health, health services and the wider public services have well-planned and resourced responses to outbreaks until there is a vaccine. The other is the resumption of public services including non-COVID health and social care.
Wave 2	October 2020	HSE Winter Planning within the COVID-19 pandemic Oct 2020 April 2021 [22]	This plan was devised in the context of COVID-19, stating ‘a Community First approach to the delivery of care will be central to delivering safe, efficient and effective services through winter and beyond. Service delivery will be re-oriented towards general practice, primary care and community-based services. By ‘shifting services left’ and prioritising Primary Care and Community Services, we will advance the goals of Sláintecare and mitigate the impact of COVID-19. The enhancement of community services will allow people to remain at home, prioritising older people and those with chronic conditions’ [4: 15]. The primary investments in the Winter plan are costed and there are a number of references to ‘alignment’ with Sláintecare priorities [15].
Wave 2	October 2020	Budget 2021 [37]	Budget 2021 allocated more than ever before to health, with ‘an increase in core Health expenditure of €1.8 billion, with, a further €1.8 billion specifically earmarked for Covid-19 related expenditure[11: 25].
Wave 3	March 2021	COVID-19 Resilience and Recovery 2021 - The Path Ahead [39]	This third government-wide report introduced five different levels of restrictions, level 5 being the most stringent. It specifies ‘future-proofing of our public health system for future pandemics’ in line with Sláintecare and details plans for the resumption of non-COVID are in the health system (P7).
Wave 3	March 2021	HSE National Service Plan (NSP) [40]	The HSE NSP 2021 is ‘fully aligned to the vision of Sláintecare’. In the foreword, it states ‘now, for the first time ever, we have the financial plans to bring these plans Sláintecare and other HSE plans to life’ (P1). The NSP specifies how it will be delivered within the strategic framework of the HSE Corporate Plan 2021-2024 which was ‘informed by Sláintecare, the Programme for Government and impact of operating within a COVID-19 environment’ (P10). It has a section entitled ‘whole-system reform’ where it states that the ‘unprecedented level of funding within Budget 2021 will enable and support acceleration of our reform priorities resulting in permanent improvements to health and social care services in line with Sláintecare’ (P11). There is a section in the NSP entitled ‘enhanced community care, supporting capacity building in the community is key to realising the vision of Sláintecare’ (P 46). One of the ‘over-arching priority areas outlined is to ‘develop greater integration between community and acute services, including increasing community access to diagnostics and specialist advice, to promote a modernised and streamlined service model in line with Sláintecare’ (P71).
Wave 3	May 2021	HSE Corporate Plan 2021 – 2021 [41]	The HSE Corporate Plan states ‘the transformation described in this Plan will enable us to progress Sláintecare by addressing waiting times, shifting care from hospital to community, and improving financial controls’ (P4, HSE, 2021). It details the additional financial resources needed to implement Sláintecare (P26). Two of the six objectives are to: ‘enhance primary and community services and reduce the need for people to attend hospital; and to improve scheduled care to enable more timely access and reduce the number of people waiting for services…. building on the learnings from COVID-19 to strengthen the Irish health system’ (P8, HSE, 2021).
Wave 3	May 2021	Healthy Ireland Strategic Action Plan 2021–2025 [42]	Healthy Ireland has a cross-government approach involving 14 government departments, with 56 actions across six themes. It focuses on promoting health and well-being, preventing illness, keeping people well in their own homes and communities for as long as possible. It specifically targets 18 of the most deprived communities as part of the Sláintecare Healthy Communities programme, working with local authorities, other government agencies, NGOs & HSE to tackle health inequalities.
Wave 3	May 2021	Sláintecare Implementation Strategy and Action Plan 2021 -2023 [24]	The Sláintecare Implementation Strategy & Action Plan sets out two high-level reform programmes with 11 projects associated with them. It outlines a three-year implementation plan with a specific budget and quarterly targets/milestones to be achieved for each quarter in 2021 and annually for 2022 and 2023. It provides detail on funding of €1.23 billion for Sláintecare in 2021 as well as Sláintecare governance structures.

2.2. Analysis

These documents were interrogated and searched for key words such as ‘Sláintecare’, ‘universal’, ‘community’, ‘staffing’, ‘budget’, ‘allocation’, ‘public health’, ‘prevention’, ‘early intervention’, ‘eHealth’, ‘telemedicine’, and ‘reform’ to identify relevant actions to Sláintecare implementation. The analysis revealed critical insights into the intersection between the processes of strengthening health system resilience and accelerating reform. Grounded in a concrete empirical case study, the findings shed new light on the ways in which health system shocks are potentially being used as a springboard for long-lasting whole systems change.

3. Ireland, COVID-19 and ongoing reform

The Irish health system began planning for COVID-19 in January 2020, with the first case reported in Ireland on 29 February 2020 [20]. Ireland has since experienced three waves of infection up to June 2021, with the third being the most severe and long-lasting (see Fig. 1) [21]. The waves are measured according to numbers of confirmed COVID-19 cases per 100,000. In the second week of January 2021, Ireland recorded the highest weekly rate of infection per 1000 population in the world.

Fig. 1.

New daily cases per 1000,000 in Ireland from Our World in Data

The lines reflect the development of daily new confirmed cases of COVID-19 across Ireland (dark blue), Brazil (orange), India (grey), United Kingdom (yellow) and the United States (turquoise) from March 2020 to June 2021.

Data sourced: (https://ourworldindata.org/covid-cases accessed 24/08/2021) [22]

The effect of COVID-19 on the Irish health system has been wide-ranging and includes: a significant public health response with three extensive and severe national lockdowns; the suspension of routine health and social care; and the mobilisation and redeployment of staff in response to increased COVID-care demand during surges. In many instances, the health system responses to meet new and existing demand for care, in the context of COVID-19, have been rapid and agile [23], [24], [25], [26]. However, there have also been mistakes made in terms of high numbers of deaths in private nursing homes, failures to protect and support staff, delayed decisions such as mandatory wearing of face masks and lapses in political leadership [27]. Interestingly, many of Ireland's health system responses to COVID-19 reflect priorities in the Sláintecare reform plan, which are also key pillars of a resilient health system [14, 25, 26]. These include the universal nature of the COVID-19 public health and health system response, new ways of working and long over-due investment in eHealth and system capacity.

4. Policy analysis

In the Republic of Ireland, the Department of Health is responsible for health policy development and the Health Service Executive (HSE), established under the Health Act 2004, has statutory responsibility for the management and delivery of health and personal social services [28].

The extent of the crisis and the turbulent impact of COVID-19 on public life in Ireland is arguably reflected in the high number of government policy and health system reports published since the onset of the pandemic (from March 2020 to May 2021). Thirteen public policy documents were identified as central to tracking the government's health system and policy response (see Table 1). Of particular interest is whether these documents demonstrate that the government's pandemic response is contributing to Sláintecare implementation and therefore universal healthcare reform, while also seeking to enhance the resilience of the Irish health system.

Chronologically, the policy documents reflect different stages of the shock cycle, including the pandemic's onset and acting rapidly, to managing its impact, preserving health system access and quality and reviewing, learning and dealing with legacy issues across Ireland's three different waves of the pandemic (wave 1: March to July 2020; wave 2: August to November 2020; and wave 3: Late November to June 2021) [21].

Table 1 presents these documents, categorised by their classification as government-wide policy documents and health system/policy documents, and provides a summary of the extracts that demonstrate alignment with key reform priorities.

4.1. Responding to wave 1: March to July 2020

Early government documents focused on providing a holistic response to the pandemic, developing cross-departmental actions into a National Action Plan in response to COVID-19 [29]. This brought additional resources to the health system to cope with the pandemic response including testing, personal protective equipment (PPE) and surge hospital capacity. However, even in these early documents, central elements of Sláintecare are evident, with public health measures named as ‘a lynchpin’ of the government action plan and the emphasis being on community actions and keeping people out of hospitals. The ‘Roadmap to Reopen the Economy and Society’, published in May 2020, dealt with the resumption of non-COVID care as a majority of non-essential health services were postponed following the advice of the National Public Health Emergency Team on 27 March 2020 [30].

In the early weeks of COVID-19 during March 2020, government announced a contingency fund of €435 million to invest in the health service to strengthen the COVID-19 response, including: building up public health capacity for contract tracing; freeing up hospitals for surges; developing community responses; increased staffing, acute capacity and ambulance services; centralising procurement for PPE; and ventilation [23].

Despite financial barriers to accessing care in Ireland, the government implemented universal, free care at the point of delivery for all COVID-related diagnosis and care early in the pandemic. COVID-19 also allowed the long-awaited introduction of Independent Health Identifiers (IHI) in Ireland with anyone who received a COVID-19 test, was contact traced or signed up for a vaccine being allocated an IHI. The introduction of IHIs had been recommended for over 15 years in Ireland but progress on actual implementation was extremely slow prior to COVID-19 [31]. This not only indicates important synergies between the COVID-19 response and building a better system for the future, but also that new policy had an immediate impact on the health system.

4.2. Wave 1 legacy and preparing for wave 2: June to September 2020

It took four months for a new government to be formed in June 2020. This government, made up of the two main centre-right political parties (Fianna Fail and Fine Gael) and the Green party, entitled its health section in the long-negotiated Programme for Government ‘universal healthcare’. It restates some of the 2017 commitments, e.g., “many of the healthcare responses to COVID-19 are important elements of Sláintecare and we will identify how to keep the gains. Underpinning our approach will be the provision of more health services in the community, increases in capacity, including bed, ICU and critical care capacity, and the promotion of good public health policy” ([24] p44). However, the document is light on universalism as a core value; there is only one mention of universalism in the health section alongside an emphasis on ‘affordable’ healthcare and ‘extend(ing) free GP care to more children’ rather than universal coverage [24].

Prior to COVID-19, under-capacity across the Irish public health and social care system was identified as a key area in need of investment, but progress was very slow [14, 32]. In 2020, Ireland had 2.8 acute hospital beds per 1,000 population, well below the OECD average of 3.7 and five intensive care beds per 100,000, one the lowest rates in the OECD where the average is 12 [33, 34].

Two HSE documents, both published in June 2020, explicitly note their alignment with Sláintecare. The first specifies how “service reintroduction represents an opportunity to reform and deliver elements of Sláintecare”, and that it is guided by the “principles and priorities of Sláintecare” ([35] p4). The second states that “part of the HSE's response to these challenges is an urgent acceleration of change in our care model, to address our current health needs and protect the future viability of health services. This means rapidly progressing the implementation of the Sláintecare vision” ([36] p4).

The second major cross-departmental government COVID-19 plan published in September 2020 includes €600 million in funding for the 2020 HSE Winter Plan, specifying the importance of health system resilience and responsiveness and the resumption of non-COVID care [37]. The HSE Winter Plan 2020-2021 names ‘community first’ as its approach to care delivery in order to “advance the goals of Sláintecare and mitigate the impact of COVID-19” ([23] p4). Costed with the biggest ever allocation for a winter plan, the document also states that it is “guided by the vision, principles, approach and priorities of Sláintecare”, with immediate implementation ([23] p7).

4.3. During wave 2: October to December 2020

The 2021 Budget, announced in October 2020, included a sizeable increase in the health budget - equivalent to a 20% increase year on year - around half of which aimed to directly address structural weaknesses in the Irish health system:

Health is the key priority for Budget 2021 as funding for the Health service is critical to meeting the health needs of our citizens during the pandemic ... The Health allocation for 2021 is over €22 billion. This reflects an increase in core Health expenditure of €1.8 billion, with a further €1.8 billion specifically earmarked for Covid-19 related expenditure ... There is an overall commitment of over €3.5 billion this year to support the Health service in tackling Covid-19 directly, while at the same time investing to build up the capacity and resilience of the Health Service … The additional allocation of core funding has a focus on Sláintecare priorities such as greater access to primary care and medicines but also on increasing capacity in key areas such as acute [hospitals] ([38] p13).

In addition to expanding funding for COVID-19 related services and staff protection, the budget funds additional beds and community services, new models of providing care, the Sláintecare public-only Consultant Contract and a scheme to reduce long waiting times and lists - the “access to care” fund (Fig. 2) [39]. It also specifies under ‘delivering enhanced community and social care services’ that €425 million is allocated to “reducing our dependence on the hospital centric model of care and supporting capacity in the community” noting that “whilst pivotal to the Sláintecare vision, [this] is also crucial in the context of the ongoing management of the COVID-19 pandemic” ([38] p113). By August 2021, in line with Budget 2021 commitments, an additional 42 critical care beds were open and permanently staffed bringing critical care beds up from 255 at the start of the pandemic to 297, 17 months later [40]. All this lays the foundations for health reform and starts to meet the targeted funding levels originally proposed in the 2017 Sláintecare report to achieve universal healthcare.

Fig. 2.

Health budget, Ireland 2021 – Major items (€million)

‘Protection from COVID’ relates to extra funds given to enhance all aspects of healthcare devoted to protecting vulnerable groups, staff and patients from the disease; ‘Additional beds’ relates to 2,600 extra beds in hospital and community settings; ‘Extra community services’ relates to enhanced non-COVID care in primary and community settings; ‘Access to care fund’ relates to a new scheme to reduce waiting lists; and ‘Models of care’ relates to new care delivery pathways. The blue bars represent the budgeted amounts allocated to each category in the 2021 Irish Health Budget.

4.4. During wave 3: January to May 2021

Even during this very difficult wave and extensive lockdown, the third major government COVID-19 plan, published in March 2021, reinforced commitments to Sláintecare stating that government policy was “continuing to build health system resilience in line with Sláintecare” ([41] p7). Alongside this, the HSE published two key strategic documents in March 2021, months later than expected [42, 43]. Both the 2021 HSE National Service Plan (NSP) and the HSE Corporate Plan clearly align themselves with Sláintecare. In the ‘investment and opportunity’ section of the HSE NSP, it says “a key focus of the health budget 2021 will be to deliver the strategic and permanent reform set out in Sláintecare and build on the positive and innovative changes made during the COVID-19 pandemic in 2020” ([42] p83).

In mid-May 2021, as wave 3 of COVID-19 was easing and the government's vaccination plan was gaining traction with increasing components of the at-risk adult population vaccinated, the Department of Health published two new strategy documents, both of which required cabinet approval [25]. These publications specify addressing health inequalities and delivering universal healthcare as key government priorities. The new Healthy Ireland Strategy Action Plan is embedded in Sláintecare for the first time and has a particular emphasis on reducing health inequalities, which dovetails with a key priority of the Sláintecare Implementation Strategy and Action Plan, published the same week [44]. The 2021-2023 Sláintecare Implementation Strategy specifically names two high-level reform programmes: 1. ‘Improving Safe, Timely Access to Care and Promoting Health & Wellbeing’ and 2. ‘Addressing Health Inequalities, [which] will bring us on a journey towards universal healthcare’ [25]. The Sláintecare Implementation Strategy and Action Plan 2021-2023 reignites the policy intent of the 2017 Sláintecare reform commitments, restates the 2017 Sláintecare waiting list targets and details a plan to achieve timely access to care including moving towards universal healthcare. It outlines quarterly and annual milestones for the three years of the plan and the significant budget allocation for 2021 [25]. It specifies that the “aim is to deliver universal health services that offers the right care, in the right place, at the right time, at no or low cost” ([25] p5).

In May 2021, the long-awaited introduction of public health consultants was agreed with medical unions committing to create 84 public health consultant posts for the first time [45]. Prior to this, public health specialists were not graded as consultants despite decades of campaigning for parity with their medical peers. While this was not a specific Sláintecare commitment, it is in line with the emphasis on public health and population health planning required to introduce universal healthcare and tackle health inequalities. On 31 May 2021, the new Sláintecare contract, which requires consultants employed by the State to carry out solely public-only work, was released. This was a key Sláintecare measure originally proposed in the 2017 Sláintecare report to ensure equitable access to public hospital care. It was committed to by government in 2019 with a view to introduction in 2020 [39].

4.5. Policy summary

The singular focus on COVID-19 and the longer-term COVID-19 health system response meant that planned health policy implementation was initially put on hold in 2020. For example, the 2020 Sláintecare Action Plan was never published and key areas identified for progress in 2020 such as the roll-out of Regional Health Areas and improved access to care were paused. However, this analysis of relevant government and health system policies demonstrates that Sláintecare's vision and implementation was prioritised in government policy documents from mid-2020 onwards and far more than at any previous time since the publication of the original Oireachtas report in May 2017. Furthermore, many of the COVID-19 responses in Ireland reflect priorities in Ireland's Sláintecare reform plan [25, 26].

5. Discussion

The Irish health system is an illuminating example of a government attempting to utilise a crisis to build resilience and advance its reform agenda. The Irish government amended policies, expanded its budget and implemented key innovations quickly (such as free COVID-19 care, IHIs, new contracts and opening new hospital beds) taking advantage of this window of opportunity for change. The existence of a dedicated implementation office for reform meant that despite the pandemic and many staff reallocated to the COVID-19 response, a focus on reform implementation remained. A key lesson for other countries is the importance of recognising the potential for change that a shock brings. However, actually implementing that change through a refocus and harmonisation of policy, funding and innovation is bringing it a step further. Sustaining such reform requires courageous leadership, excellent coordination and persistent implementation.

Bringing about major health system change is clearly no easy task in a rapidly evolving situation, highlighted by the high number of policy documents. Over time, the documents double down on Sláintecare; the 2021-2023 Sláintecare Strategic Implementation Strategy and Action Plan even emphasises universalism in its top two priorities, a feature of Sláintecare which has been previously downplayed [25]. Furthermore, there has been more Sláintecare funding during the pandemic than in the previous three years. All of this led Paul Reid, HSE Chief Executive, to say in April 2021 that the HSE “did more of Sláintecare in the last year than we would have in the next 3-5 years and we see the benefits for that” [46]. Even in the third wave and most extensive of lockdowns the commitment to reform persisted. Furthermore, the state's engagement with the private sector (private hospitals, nursing homes and GPs) during COVID-19 goes beyond what was recommended in the 2017 Sláintecare report and provides a potential route for whole system reform – utilising all existing health resources in Ireland. Ireland's health system response to COVID-19 provides rich learning, leading Laura Magahy, the Executive Director of Sláintecare, to note how the Sláintecare Implementation Strategy and Action Plan 2021-2023 builds on the progress of Sláintecare reform to date and on the lessons learned from COVID-19 [25].

These investments, activities and strategies refocus the notion of transformative resilience (a key part of managing the impact of any shock) [7]. It is usually understood as transforming a system when it can't cope with a shock by radical rethinking and restructuring [7]. But this analysis adds a more future-facing perspective. Transformative resilience here deals with the ability to use a shock to transform the health system to improve its functioning, invest and build a legacy for when the shock recedes and the new normal emerges. Ireland's investment in its health care system has produced the potential to restore and rejuvenate the Sláintecare reform programme, all in the middle of a global pandemic. Realising, harnessing and maintaining any positive change achieved to date is a further challenge for the Irish health system.

Changes made to reform the Irish health system have the potential to increase resilience of the system for future shocks. Well-functioning health systems tend to be more resilient. Universal health systems, that ensure better access for all, are more resilient to shocks [7]. Building capacity in acute and non-acute care settings also allows more flexibility of care provision (another key resilience strategy), alongside better surge capacity and provision of non-shock care in the case of future pandemics [7].

6. Conclusions

While shocks destabilise a health system they also open up an opportunity for transformation. Rather than putting a break on major reform, the Irish government has utilised the shock of COVID-19 to progress significantly its flagship health reform programme, Sláintecare, to advance universal healthcare. This has been achieved through the development of new policies aligned to Sláintecare goals backed up with massive funding and key innovations. In particular, the government introduced all COVID-19 related care and diagnostics without charges, implemented Independent Health Identifiers, adopted widespread telemedicine practice and developed new Sláintecare aligned contracts for hospitals consultants, GPs and public health consultants alongside beginning new recruitment into primary and community settings and opening new critical care beds.

Radical change can create a constructive legacy for the future but it must be sustained. It will be important to monitor the extent to which the new policies and enhanced budgets in Ireland will continue to translate into change on the ground.

COVID-19 provides governments with a unique opportunity to build health system resilience. Low interest rates in Europe and the priority status of the health sector create a window of opportunity. Advancing reform in a shock is a sign of transformative health system resilience. Furthermore, enhancing the functioning of a health system and delivering universal access itself builds health system resilience. Further research is needed to understand the optimal strategies to take forward reform and resilience building in shocks in different countries.

Contributors

Sara Burke: conceptualistion, data curation, formal analysis, funding acquisition, investigation, methodology, project administration, resources, supervision, validation, visualisation, writing: original draft, review & editing.

Steve Thomas: conceptualistion, data curation, formal analysis, funding acquisition, investigation, methodology, project administration, resources, supervision, validation, visualisation, writing: original draft, review & editing.

Sarah Parker: project administration, writing: original draft, review & editing

Padraic Fleming: project administration, visualisation, writing: original draft, review & editing

Sarah Barry: writing: review & editing.

Declaration of interests

Sara Burke: Sara Burke's research positon is funded by an Irish Health Research Board grant APA-2019-012 which requires co-funding from knowledge user organisations. This research is cofunded by the HSE and Dept of Health for €40,000 from each organisation. The research article critiques Irish government, Dept of Health and HSE policy and strategic documents. The funding agencies have in no way influenced the content of this article which is independent academic research.

Steve Thomas: Steve Thomas's research is funded by an Irish Health Research Board, Research Leader Award to explore health system resilience, reform and staff engagement. Prof Thomas developed a policy brief with the European Observatory on Health Systems and Policies examining health system resilience and is in an unpaid advisory role around the development of a Health Systems Performance Assessment framework for the Irish Dept of Health.

Sarah Parker: Sarah Parker's research position is funded by an Irish Health Research Board grant (APA-2019-012) which requires co-funding from knowledge user organisations, including the HSE and Department of Health. The research article critiques Irish government, Dept of Health and HSE policy and strategic documents. The funding agencies have in no way influenced the content of this article which is independent academic research.

Padraic Fleming: Padraic Fleming's research position is funded by the Health Research Board grant RLA-2020-001. The Health Research Board (HRB) is a State Agency under the Department of Health. The research article critiques Irish government, Dept of Health and HSE policy and strategic documents. The funding agency has in no way influenced the content of this article which is independent academic research.

Sarah Barry: Sarah Barry is a member of the Performance and Delivery Committee of the HSE Board. The role is one of technical assistance and insight