Current reform proposals contain ingredients which will further undermine Ireland's fragile citizenship culture, writes Anthony O'Halloran
Much of the recent media debate on health reform proposals has focused on the removal of local authority members from new regional health authorities.
The debate is evolving on a "politicians-versus-the-rest basis" and if this trend continues, broader issues of democratic accountability and citizenship are likely to be suffocated amid internecine party warfare and accompanying public outrage.
We must be careful to avoid such an outcome or there is a real danger that democracy and citizenship will both be casualties. For a variety of reasons, citizenship and its associated rights-based approach is not deeply ingrained in Irish political culture.
Chief among these reasons is the all-pervasive clientelist culture. Citizens rely very heavily on political representations to have their grievances addressed.
In return, politicians expect their "clients" to vote for them. Thus, rather than asserting their rights, citizens depend on an elected intermediary to address their grievances.
This reality has proved near fatal to the evolution of a rights-based culture. The citizen relies on the local "strongman" rather than legally centred remedies. This culture is often passed off as a form of democratic representation. Nothing could be further from reality.
Clientelism erodes the concept of citizenship particularly for the poor. By personalising grievances it encourages clients to ignore systemic and structural reasoning.
Current reform proposals contain ingredients, which will further undermine Ireland's fragile citizenship culture, most notably the notion of consumer representation on the new authorities. What is required is citizen representation not consumer representation.
It seems the reform proposals have been strongly influenced by the so-called new public management ethos, an approach, which seeks to apply market principles to the provision of public goods.
Individuals are treated as market consumers rather than citizens with enforceable rights. The approach would merely consolidate existing inequalities, which favours "clients" who can afford to bypass the public system.
This is the opposite of a citizenship model, which confers members of the polity with universal rights of access to high quality healthcare. Access is guaranteed rather than contingent on ability to pay.
It is equally important that new structures are democratically accountable. Local authority members will argue during the coming months that emerging proposals are an attack on local democracy. It will be suggested that removing local authority members from the new structures will undermine democratic accountability.
However, there is little evidence to support the view that existing structures encourage transparency and accountability. On the contrary, rather than encouraging democratic accountability, political appointments to health boards are seen as rewards for party activists.
Politicians genuinely interested in democratic accountability are on very shaky ground when they are defending the status quo.
New structures imbued with a new public management ethos will totally ignore the requirements of democratic accountability. In other words, one system of weak democratic accountability will simply be replaced with a similar system.
So how can the new structures be made democratically accountable? Firstly the Dáil should be afforded a central role in monitoring the activities of new authorities. Authorities should be accountable to a well-resourced Oireachtas committee.
Similarly, it is essential that the relevant minister is democratically accountable to the Dáil for policy outcomes - overall responsibility for policy matters ought to remain with the minister. New structures must not be used as an excuse for transferring existing ministerial responsibility elsewhere. One of the few advantages of the present system is that at least the public can clearly identify the responsible minister.
Secondly, there should be direct elections to the new authorities. Apart from facilitating true democratic accountability, direct elections would give citizens a sense of ownership of the new structures.
The current debate will test the extent to which politicians and civil society are committed to citizenship and democracy in this crucial area. Let's hope that decision-makers have the courage to resist consumerist rhetoric.
At present there is a genuine opportunity to put in place a health service based on the twin principles of citizenship and democracy. This opportunity should be grasped with enthusiasm.
Anthony O'Halloran is a research fellow with the department of government, University College Cork