Health Policy 122 (2018) 147–156

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Health Policy
journal homepage: www.elsevier.com/locate/healthpol

Demographic factors and attitudes that influence the support of the

general public for the introduction of universal healthcare in Ireland:
A national survey
Catherine D. Darker, Erica Donnelly-Swift, Lucy Whiston ∗
Public Health & Primary Care, Institute of Population Health, School of Medicine, Trinity College Dublin, Russell Centre, Tallaght Cross, D24 DH 74, Ireland

a r t i c l e i n f o a b s t r a c t

Article history: Ireland is still struggling to end the inequitable two-tiered health system and introduce universal health-
Received 24 May 2017 care (UHC). Public opinion can influence health policy choice and implementation. However, the public
Received in revised form are rarely asked for their views. This study describes the demographic and attitudinal factors that influ-
16 November 2017
ence the support of the public for the introduction of UHC. It provides data on a nationally representative
Accepted 18 November 2017
survey sample of n = 972. There are high levels of support for the introduction of UHC (n = 846 87.0%).
Logistic regression analyses indicated that demographic factors, such as, the location of respondent,
Keywords:
whether the respondent was in receipt of Government supported healthcare, a purchaser of private
Universal healthcare
Healthcare access
health insurance or neither; plus attitudinal factors, such as, opinions on the Government prioritising
General public healthcare, healthcare being free at the point of access, taxes being increased to provide care free at the
Stakeholder analyses point of access and how well informed participants felt about UHC were associated with agreeing with
Ireland the introduction of UHC in Ireland. This paper is timely for policy leaders both in Ireland and interna-
tionally as countries with UHC, such as the United Kingdom, are facing difficulties maintaining health
services in the public realm.
© 2017 The Authors. Published by Elsevier Ireland Ltd. This is an open access article under the CC
BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction safeguarding people against the financial hardship associated with

Universal healthcare (UHC), sometimes referred to as univer-
sal health coverage, universal coverage or universal care, usually
refers to a healthcare system, which provides healthcare and finan-
cial protection to all citizens of a particular country. It is organised
around providing a specified package of benefits to all members of
a society with the end goal of providing financial risk protection,
improved access to health services, and improved health outcomes
[1]. The World Health Organization (WHO) defines a universal
health system as one where ‘all people can use the promotive,
preventive, curative, rehabilitative and palliative health services
they need, of sufficient quality to be effective, while also ensuring
that the use of these services does not expose the user to finan-
cial hardship’. In Ireland, the definition used in current policy for
the introduction of UHC does not mention the issue of affordability
but instead places the emphasis on access based on clinical need
[2]. This is contrary to a key underlying tenet of UHC which is risk
protection. Health payments are a heavy financial burden for mil-
lions around the world. Financial risk protection is concerned with
∗ Corresponding author.
E-mail addresses: catherine.darker@tcd.ie (C.D. Darker), swiftdoe@tcd.ie
(E. Donnelly-Swift), whistonl@tcd.ie (L. Whiston).
paying for health services. The concept of financial risk protec-
tion, or conversely the absence of a risk of financial hardship, has
been the focus of interest to economists and researchers for many
years, and measuring the ability of a health system to protect peo-
ple against the financial hardship associated with paying for health
services has become an important issue for research and analysis
across countries at all income levels [3]. It is unclear why health
policy in Ireland has chosen to adopt a definition of UHC which is
silent on the issue of affordability.
The WHO has advocated UHC as the best means of improving
global health. However, achieving UHC is not without challenges:
from defining the goal of UHC to identifying the most appropriate
methods to achieve it. The idea of UHC can be seen in the 1948 WHO
Constitution [4] of which Ireland is a signatory. The concept of UHC
was first introduced in Ireland through the 1948 Health Act [5]. UHC
is also embedded in the 1978 Alma-Ata declaration that contains a
number of important principles in relation to health. It specifies that
all people regardless of race, religion, political belief, economic or
social condition be entitled to enjoy the highest attainable standard
of health as a fundamental right. In 2005 [6], 2011 [7] and 2013
[1] UHC has become the focus of various WHO campaigns as the
importance and benefits of universal coverage become ever more
apparent.

https://doi.org/10.1016/j.healthpol.2017.11.009
0168-8510/© 2017 The Authors. Published by Elsevier Ireland Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-
nc-nd/4.0/).
148 C.D. Darker et al. / Health Policy 122 (2018) 147–156
Over recent years funding for the health service in Ireland has
declined, amidst the most severe economic crisis since the 1930s,
while the demands for care and patient expectations have increased
[8,9]. The health system managed ‘to do more with less’ from 2008
to 2012, achieved mostly by transferring the cost of care onto peo-
ple and by significant resource cuts [10]. This is evident in reduced
home care hours, increased wait-times, expensive agency staffing
and accentuated inequities of access for patients within the health
system. Alongside this there was a growing discourse in society to
have a health system that is accountable, effective, efficient and
capable of responding to the emerging and on-going needs of the
public. This has been illustrated through debates on UHC interna-
tionally [11] and in Ireland [2].
The structure of the Irish healthcare system has a number of
unusual features [12] and is commonly referred to as a ‘two-tiered’
system. ‘Two-tier’ refers to the fact that people who can pay pri-
vately or have private health insurance (PHI) can get a diagnosis
quicker and can secure faster hospital treatment, even in public
hospitals, because they can afford the monthly premiums [13].
About 46% of the population have PHI [14]. Those who cannot afford
PHI must often face long waiting lists for acute care [10], for exam-
ple longer waiting times for minor operations and diagnostics such
as CT scans [15]. About two fifths of the population have medical
cards under the General Medical Services (GMS) scheme, which are
means tested and mostly allocated on the basis of income. These
cards enable people on low or no income to access general prac-
tice (GP) and hospital care without charge and medicines at a low
cost. Healthcare financing relies predominantly on general taxa-
tion, which accounted for an estimated 69 per cent of total financing
in 2015, with out-of –pocket payments by individuals and PHI con-
tributing an estimated 13 per cent each [16]. Ireland is unusual
amongst its European neighbours in not having universal access
to primary care [17]. A recent analysis conducted by the European
Observatory on Health Systems and Policies found that the high-
est formal payments in any primary care system exist in Ireland,
where patients without a medical card (e.g. when income rises
above a specified threshold) pay between D 45 and D 65 for each
GP visit, with no reimbursement [17]. According to recent OECD
data on 34 countries, Ireland is in the bottom third for both out-of-
pocket expenditure and also unmet medical needs particularly in
relation to medical examinations [18], whereby people indicated
that they need medical treatment in the previous 12 months but
did not receive it [18]. Cross sectional analysis of health seeking
behaviour within primary care in Ireland revealed that those who
had to pay out-of-pocket payments to see a GP were more likely to
put off going to the doctor than those with a GMS card [19]. Simi-
larly analysis on the impact of the introduction of copayments on
prescriptions reported a reduction in medication adherence [20].
An antidote to this inequitable two-tiered system is UHC. Possi-
ble options for the implementation of UHC, including funding and
restructuring as well as dealing with possible positive and negative
outcomes are outlined in the Slaintecare report [2]. Details of the
complicated nature of the Irish health system are explained in a
recent analyses [21].
In more recent years Ireland has recommitted its intention to
introduce UHC by looking to change the underlying funding model
to an insurance based system – universal health insurance (UHI).
The 2011-16 Programme for Government states, “under this sys-
tem there will be no discrimination between patients on the grounds
of income or insurance status” [22]. In the final days of the previ-
ous Government, UHI became seriously delayed and abandoned
in the run up to the 2016 General Election, with the Minister for
Health indicating on foot of the publication of costings for UHI that
the multi-payer model of private competing insurance companies
is not viable stating it was ‘not acceptable, either now or any time
in the future’ [23]. More recently the Government has formed a
cross-party committee, the primary role of which is to ‘establish
a universal single tier service where patients are treated on the basis
of health need rather than on ability to pay’ [24]. This committee,
called the Oireachtas Committee on the Future of Healthcare, pub-
lished its report entitled Slaintecare in May 2017 outlining a ten
year plan for the introduction of UHC in Ireland [2].
The issue around universalisation has therefore been an ongoing
background debate for decades and periodically comes to the fore
when the standing Government seeks to institute reforms. Despite
these commitments by Ireland at international and national level,
the two-tiered system still exists. This begs the question as to why?
The legitimacy and sustainability of any major policy decision
increasingly depends on how well it reflects the underlying values
of the public. Experts and stakeholders provide essential technical
input but their role is distinct from that of the citizen and cannot
replace it. It is increasingly understood that citizens should be a
stakeholder in framing health policy decisions [25] and it is recog-
nised that citizens’ values should define the boundaries of action in
healthcare in any democracy[26–29]. This is particularly the case
for UHC as patients and the public have been identified as key
enablers for the implementation of any universal programme [30].
According to the OECD the general public bring new ideas and expe-
riences to the decision-making process; encourage policy makers
to think more carefully about the objectives of health services and
to be more open and explicit about the choices being made [31].
The call for public participation also suggests a shift in political
philosophy about who has the democratic right to make healthcare
decisions. The WHO have also used the language of rights when
arguing that: ‘The people have the right and duty to participate indi-
vidually and collectively in the planning and implementation of their
health care’ [32]. Members of the general public want to be involved
in decision-making at the national level [33] and they overwhelm-
ingly want their preferences to inform priority-setting decisions in
healthcare [34].
Public input into healthcare decision-making, at least in theory,
is clearly advocated in Ireland. The importance of patient involve-
ment has been acknowledged in numerous policy documents such
as ‘A Vision for Change: Report of the expert group on mental
health policy’ [35], ‘The National Health Strategy: Quality and fair-
ness – a health system for you’[36], the Madden Report [37] and
most recently in ‘Healthy Ireland – A Framework for Improved
Health and Wellbeing 2013–2025 [38], as well as in numerous
Health Service Executive (HSE) national service plans [39–41]. In
Ireland researcher-administered questionnaires with 738 patients
and family members attending outpatient services reported that
86.2% were supportive of greater patient participation in national
level healthcare design, delivery and policy [42].
The key prevailing issue relating to the Irish health system is
how to end the inequitable two-tiered health system that exists.
There has been one formal assessment of the general public’s views
and opinions on universalisation in Ireland, however, this study
included a convenience sample of patients attending for treatment
in a primary care setting[43]. Beyond the media headlines little
is actually known about the general public’s views on universal
healthcare. We sought to identify what demographic factors and
opinions influence the support of the general public for the intro-
duction of universal healthcare (UHC) in Ireland.
2. Materials and methods
2.1. Design
A cross-sectional survey on the views and opinions of the gen-
eral public on the introduction of UHC in Ireland.
 C.D. Darker et al. / Health Policy 122 (2018) 147–156
2.2. Sampling
A sample of 972 participants were recruited. This provided a 3%
margin of error with a 95% confidence level and total population of
4,757,976 based on the 2016 National Census [44].
Random sampling was employed with random digit dialling
of 85% mobile numbers and 15% landline numbers. This ensured
listed and non-listed numbers have the same probability of being
contacted. To ensure a representative sample soft quotas for age,
gender, location, and social class were monitored. The data was
weighted at analysis stage. Weightings were based on data from the
2011 Census and the Joint National Listenership Research (JNLR).
The JNLR includes a sample of over 16,000 respondents aged over
15 conducted annually over 50 weeks of the year [45]. This was used
alongside Census data to keep weightings as up to date as possible.
2.3. Procedures
Data collection took place over a two-week period in December
2016. A market research company who specialise in healthcare
research were contracted to conduct questionnaires over the phone
as part of an omnibus poll. The research team provided the data
collectors with definitions for all key terms used in the question-
naire and meetings took place to ensure in depth understanding
of the topic and questionnaire. All data collectors were provided
with a full day of training, a briefing on the project and 10–15% of
interviewer calls were monitored for quality control.
The questionnaire was anonymous and researcher-
administered over the phone. Consent was implied in completing
the questionnaire.
Ethical approval was provided by the School of Medicine Level
1 Research Ethics Committee in Trinity College Dublin (reference
20160208).
2.4. Measures
The questionnaire was developed based on a literature review
with standardised questions employed where possible. For exam-
ple, Question 3b, ‘The government should prioritise spending on
healthcare rather than reducing taxes’, was based on work by the
Think-tank for Action on Social Change (TASC) which asked about
investing in public services in general [46]. A definition of UHC
based on the WHO definition was read out to participants after
question one (‘I feel well informed about universal healthcare’) was
answered. The definition provided was ‘“Universal Healthcare” is
that all people have access to the health services they need (pre-
vention, promotion, treatment, rehabilitation and palliative care)
free at the point of access.’ (See Supplementary File A: Question-
naire). Further explanation was provided as required throughout
the questionnaire after question one was answered. The question-
naire was piloted with 384 members of the general public in two
locations in Dublin, Ireland with contrasting levels of deprivation in
a face-to-face researcher-administered format. The pilot data was
not included in the current paper as the data were collected through
different mediums (telephone versus face-to-face) and also a con-
venience sample was utilised in the pilot.
2.4.1. Demographics
Participants were asked about their age, gender, where in the
country they live (location) and level of education. Self reported
health, level of healthcare cover, social class and knowledge of UHC
were also recorded.
Self-reported health (SRH)
SRH was assessed by the answer to a single item ‘How is your
health in general?’. There were five response categories: ‘very good,
“good”, ‘fair’, ‘bad’, and ‘very bad’. This question has become a stan-
149
dard measure for SRH and due to its format can be compared with
Irish and international data [47]. For analysis this variable was col-
lapsed into ‘good self-rating of health’ including ‘very good’ and
‘good’ and ‘poor self-rating of health’ consisting of ‘fair’, ‘bad’ and
‘very bad’.
2.4.2. Level of healthcare cover
Whether the participant was eligible for the GMS scheme, had
private health insurance or neither. Due to small numbers for anal-
ysis PHI and neither were collapsed together.
2.4.3. Social class
The social grading classification system from The British
National Readership Survey (NRS) has been well established and
used since the 1960s and was employed in this study [48]. This was
determined based on a series of questions about the chief income
earner of the household in which the participant resides. This
included questions on their employment status, type of employer,
occupation, role and qualifications. Social class was divided into 5
categories; AB upper/middle class, C1 lower middle class, C2 skilled
working class, DE other working class and F farmers.
2.4.4. Knowledge of UHC
Participants were asked to indicate how much they agreed with
the following statement on a 5-point scale from ‘strongly agree’ to
‘strongly disagree’. ‘I feel well informed about universal healthcare’.
Participants were asked to answer this question before being pro-
vided with the definition of UHC. Categories were collapsed down
to ‘agree’ (which included ‘strongly agree’ and ‘agree’) and ‘ dis-
agree/neither’ (which included ‘neither’, ‘disagree’ and ‘strongly
disagree’). The collapse of the answer categories was determined by
those participants who indicated that they did not definitely ‘agree’
or ‘strongly agree’.
2.4.5. Opinions and views on UHC
Participants were asked to indicate how much they agreed with
the following statements on a 5-point scale from ‘strongly agree’
to ‘strongly disagree’. ‘Having the health service as a public system
is important’, ‘The government should prioritise spending on health-
care rather than reducing taxes’, ‘I want healthcare free at the point
of access’, ‘People who can pay for healthcare should pay’, ‘I am pre-
pared to pay higher taxes for healthcare free at the point of access’.
During analysis categories were collapsed down to ‘agree’ (which
included ‘strongly agree’ and ‘agree’) and ‘ disagree/neither’ (which
included ‘neither’, ‘disagree’ and ‘strongly disagree’). The collapse
of the answer categories was determined by those participants who
indicated that they did not definitely ‘agree’ or ‘strongly agree’.
2.5. Analyses
A weighted logistic regression model was employed to assess
the odds of participants who did not support the introduction of
UHC in Ireland versus the odds of participants who did support
the introduction of UHC in Ireland, taking demographic factors and
opinions into account.
Contingency tables were examined to ensure adequate sample
size for each parameter. The final logistic regression model was
selected based on the lowest Akaike’s information criterion (AIC).
Interactions were checked for and none found. Tolerance and gen-
eralised variance inflation factors (GVIF) for independent variables
were assessed to determine the presence of multicollinearity. All
values were within acceptable limits with tolerance values lower
than 1 [49] and GVIF values less than 2 [50].
Results are displayed in terms of odds ratios (OR) and 95% confi-
dence intervals (CI). ORs range from 0 to infinity with 1.0 meaning
no difference in odds and ORs greater than 1.0 meaning that the
150 C.D. Darker et al. / Health Policy 122 (2018) 147–156
ratio of those who support the introduction of UHC versus those
who do not support the introduction of UHC in the selected group
is greater than the reference group. If the 95% CI for OR crosses 1
this indicates that there is no evidence to suggest that there is any
difference between the reference and selected group when com-
paring those who do and do not support the introduction of UHC in
Ireland.
Analysis was conducted using statistical software SPSS Version
22.
3. Results
3.1. Response rate
A total of 1102 people were invited to complete the question-
naire on UHC after random digit dialling and eligibility checks.
From this 972 participants completed the questionnaire provid-
ing a response rate of 88.2% as illustrated in Fig. 1: Flowchart of
participants.
3.2. Descriptive analyses
A demographic description of the sample is provided in Table 1
(non-weighted) and Table 2 (weighted). These are broken down
by support for the introduction of UHC in Ireland. An overview of
opinions relating to UHC in Ireland are also illustrated.
Examination of Table 1 (non-weighted) shows that females
account for 44.5% (n = 433) of the sample, 33.6% (n = 327) were aged
between 25 and 44, 54.3% (n = 522) had a third level qualification
and 57.0% (n = 554) of participants had PHI.
The introduction of UHC in Ireland was supported by 87.0%
(n = 846) of participants. The majority of participants also sup-
ported the Government prioritising spending on healthcare rather
than reducing taxes (82.0%; n = 797), healthcare free at the point
of access (81.2%; n = 789) and that having the health system as a
public service is important (93.3%; n = 907).
3.3. Regression analyses
The final logistic regression model as determined by the AIC is
presented in Table 3 with crude and adjusted ORs for participants
who support the introduction of UHC in Ireland compared with
those who do not support the introduction of UHC in Ireland (‘dis-
agree’ or ‘neither’). The model was statistically significant and fit
the data well [x2 [20] = 159.712, p < 0.001; Hosmer and Lemeshow,
p > 0.05]. This was the most parsimonious model with the lowest
AIC.
Statistically significant factors associated with support for UHC
included location, GMS status and attitudinal related factors (e.g.,
‘The government should prioritise spending on healthcare rather than
reduce taxes’, ‘I want healthcare free at the point of access’, ‘I am pre-
pared to pay higher taxes for healthcare free at the point of access’ and
‘I feel well informed about UHC’).
Adjusting for the effects of other factors, the odds of participants
living in Dublin agreeing with the introduction of UHC were greater
than those living in Connacht or Ulster (OR 2.16, 95% CI (1.13, 4.11)).
The odds for those who do not have a GMS card agreeing with the
introduction of UHC were lower than the odds of those who have
a GMS card (OR 0.53, 95% CI (0.29, 0.99)). The odds for those who
agreed that the Government should prioritise spending on health-
care rather than reducing taxes were greater than the odds of those
who indicated ‘disagree’ or ‘neither’ (OR 3.43, 95% CI (2.12, 5.57)).
The odds of participants who agreed that they wanted healthcare
free at the point of access were greater than the odds of those who
did not want healthcare free at the point of access (OR 4.72, 95%
CI (2.95, 7.54)). The odds of those prepared to pay higher taxes for
healthcare free at the point of access were greater than the odds
of those who were not prepared to pay higher taxes for healthcare
free at the point of access (OR 1.91, 95% CI (1.21, 3.03)). The odds of
those who felt well informed about UHC agreeing with the intro-
duction of UHC were greater than the odds of those who did not
feel well informed about UHC (OR 2.13, 95% CI (1.32, 3.44)).
4. Discussion
General public support for the introduction of UHC is influ-
enced by demographic factors and related attitudinal factors. The
introduction of UHC in Ireland was supported by 87.0% (n = 846) of
participants. Of those that supported the introduction of UHC, this
was influenced by factors including location, GMS status, opinions
on the government prioritising spending on healthcare, healthcare
being free at the point of access, taxes being increased to provide
care free at the point of access and feeling informed about UHC.
Differences in context and reform proposals generate differ-
ences in the interests of stakeholders and their positioning on
reform making it difficult to make cross-national comparisons [30].
However, in the absence of general population information on this
topic it would appear that the high level of support for UHC reported
in this study is reflective of support for UHC demonstrated interna-
tionally. Web-based surveys with 2241 medical students revealed
that 86.8% were supportive of UHC in Ontario and 51.1% in Cali-
fornia [51]. A similar sentiment was reported from postal surveys
with 1675 physicians in the United States with 89% agreeing that all
Americans should receive needed medical care regardless of ability
to pay [52].
When asked if Government should prioritise spending on
healthcare rather than reducing income taxes 82.0% (n = 797) of
participants agreed with this statement. The 2015 Behaviour and
Attitudes Survey asked a similar question but focused on public
services in general rather than just health services. A total of 69% of
participants agreed with focusing on spending on public services
[46]. This is lower than the support for prioritising spending on
healthcare perhaps illustrating the importance placed on health-
care and the support for improving services in this area. This is
of importance for health policy leaders and makers, particularly in
Ireland, as recent examples of protest and demonstrations from the
public have been proven to be effective. For example, public outcry
against the removal of the GMS card for those over the age of 70, and
the attempted removal of GMS cards to very sick children resulted
in a rolling back of these policies during the economic recession.
Higher socioeconomic status was the principal determining fac-
tor for the willingness of members of the general public to support
participating in national health insurance in a cross sectional study
in St Vincent and the Grenadines [53]. An examination of individual
level dynamics in healthcare attitudes toward UHC between 2008
and 2010 in the United States revealed that respondents did not
take a position towards UHC reflective of their income [54]. Sim-
ilarly in the current study social class was not a significant factor
influencing support for the introduction of UHC.
The current two-tier system has been shown to be ineffective for
all groups, GMS and private, with GMS patients facing long wait-
ing times and private patients high insurance premiums and out
of pocket payments for both groups [55]. Despite the system not
working for any group GMS status influenced participants’ opinions
on the introduction of UHC with those with GMS cards slightly more
likely to support the introduction of UHC. This is to be expected as
those who have PHI nor neither PHI nor a GMS card could be the
ones who experience the most change from the introduction of
UHC, and may anticipate that not all change will be positive. For
example, the creation of a single tier service may mean that those
currently with PHI could experience longer waiting times for hos-
 C.D. Darker et al. / Health Policy 122 (2018) 147–156 151

Table 1
Non-weighted demographic description broken down by agreement with UHC.

Covariate Agree Disagree Neither Total

846 87.0% 65 6.7% 61 6.3% 972 100.0%

Age
18–24 91 10.8 2 3.1 7 11.5 100 10.3
25–44 280 33.1 20 30.8 27 44.3 327 33.6
45–64 306 36.2 24 36.9 21 34.4 351 36.1
65+ 169 20.0 19 29.2 6 9.8 194 20.0
Missing – – – – – – – –

Gender
Male 459 54.3 44 67.7 36 59.0 539 55.5
Female 387 45.7 21 32.3 25 41.0 433 44.5
Missing – – – – – – – –

Province
Dublin 243 28.7 16 24.6 12 19.7 271 27.9
Rest of Leinster 229 27.1 19 29.2 19 31.1 267 27.5
Munster 233 27.5 17 26.2 18 29.5 268 27.6
Connaght/Ulster 141 16.7 13 20.0 12 19.7 166 17.1
Missing – – – – – – – –

Education
Secondary level or lower a 392 46.8 32 50.0 16 26.2 440 44.7
Third level b 445 53.2 32 50.0 45 73.8 522 54.3
Missing – – – – – – 10 1.0

GMS Status c
GMS d 212 25.1 11 16.9 7 11.5 230 23.7
Private health insurance 466 55.1 44 67.7 44 72.1 554 57.0
Neither 168 19.9 10 15.4 10 16.4 188 19.3
Missing – – – – – – – –

Social Class
Upper middle class 138 16.3 10 15.4 20 32.8 168 17.3
Lower middle class 232 27.4 21 32.3 18 29.5 271 27.9
Skilled working class 138 16.3 7 10.8 8 13.1 153 15.7
Other working class 296 35.0 24 36.9 10 16.4 330 34.0
Farmers 42 5.0 3 4.6 5 8.2 50 5.1
Missing – – – – – – – –

Having the health service as a public system is important

Agree 805 95.2 49 75.4 53 86.9 907 93.3
Disagree/Neither 41 4.8 16 24.6 8 13.1 65 6.7
Missing – – – – – – – –

The government should prioritise spending on healthcare rather than reduce taxes
Agree 731 86.4 29 44.6 37 60.7 797 82.0
Disagree/Neither 115 13.6 36 55.4 24 39.3 175 18.0
Missing – – – – – – – –

I want healthcare free at the point of access

Agree 730 86.3 31 46.2 29 47.5 789 81.2
Disagree/Neither 116 13.7 35 53.8 32 52.5 183 18.8
Missing – – – – – – – –

People who can pay for healthcare should pay

Agree 567 67.0 15 23.1 42 68.9 659 67.8
Disagree/Neither 279 33.0 50 76.9 19 31.1 313 32.2
Missing – – – – – – – –

I am prepared to pay higher taxes for healthcare free at the point of access
Agree 566 66.9 19 29.2 26 42.6 611 62.9
Disagree/Neither 280 33.1 46 70.8 35 57.4 361 37.1
Missing – – – – – – – –

I feel well informed about UHC

Agree 421 49.8 23 35.4 11 18.0 455 46.8
Disagree/neither 425 50.2 42 64.6 50 82.0 517 53.2
Missing – – – – – – – –

Self-reported health
Poor 169 20.0 16 24.6 6 9.8 191 19.7
Good 677 80.0 49 75.4 55 90.2 781 80.3
Missing – – – – – – – –

– = Not applicable.
a
Secondary level education includes primary school education (up to the age of 12) and secondary school education (up to the age of 18) and is equivalent to A Levels.
b
Third level education is any qualification above school e.g. undergraduate degree, postgraduate diploma.
c
Participants could select more than one method of health cover. A total of 74 (7.6%) participants indicated having private health insurance as well as some form of a GMS
card. These participants were included within the GMS category.
d
The state provides a general medical services (GMS) card primarily based on income but also for other criteria such as age and other government schemes. This provides
free at the point of contact access to healthcare services.
152 C.D. Darker et al. / Health Policy 122 (2018) 147–156

Table 2
Weighted demographic description broken down by agreement with UHC.

Covariate Agree Disagree Neither Total

848 87.5% 61 6.3% 60 6.2% 969 100.0%

Age 969 100.0

18–24 97 11.4 2 3.3 7 11.7 106 10.9
25–44 329 38.8 22 36.1 30 50.0 381 39.3
45–64 272 32.1 20 32.8 18 30.0 310 32.0
65+ 150 17.7 17 27.8 5 8.3 172 17.8
Missing – – – – – – – –

Gender 969 100.0

Male 406 47.9 38 61.3 33 55.0 477 49.2
Female 441 52.1 24 38.7 27 45.0 492 50.8
Missing – – – – – – – –

Province 969 100.0

Dublin 251 29.6 17 27.4 13 22.0 281 29.0
Rest of Leinster 227 26.8 16 25.8 17 28.8 260 26.9
Munster 229 27.1 16 25.8 16 27.2 261 27.0
Connaght/Ulster 140 16.5 13 21.0 13 22.0 166 17.0
Missing 1 0.1

Education 969 100.0

Secondary level or lower a 386 46.0 31 51.7 16 26.7 433 44.6
Third level b 453 54.0 29 48.3 44 73.3 526 54.2
Missing 10 1.2

GMS Status c 969 100.0

GMS d 224 26.4 12 19.7 8 11.9 244 25.1
Private health insurance 444 52.3 39 63.9 40 67.8 523 54.0
Neither 180 21.3 10 16.4 12 20.3 202 20.9
Missing

Social Class 969 100.0

Upper middle class 102 12.0 7 11.5 15 25.9 124 12.8
Lower middle class 232 27.4 20 32.8 19 31.7 271 28.0
Skilled working class 177 20.9 9 14.8 10 16.7 196 20.3
Other working class 286 33.8 22 36.1 10 16.7 318 32.8
Farmers 50 5.9 3 4.9 6 10.0 59 6.0
Missing 1 0.1

Having the health service as a public system is important 970 100.0

Agree 807 95.3 47 75.8 54 88.5 908 93.6
Disagree/Neither 40 4.7 15 24.2 7 11.5 62 6.4
Missing – – – – – – – –

The government should prioritise spending on healthcare rather than reduce taxes 969 100.0
Agree 730 86.2 29 47.5 36 60.0 795 82.0
Disagree/Neither 117 13.8 32 52.5 24 40.0 173 17.9
Missing 1 0.1

I want healthcare free at the point of access 969 100.0

Agree 738 87.1 31 50.8 29 48.3 798 82.4
Disagree/Neither 109 12.9 30 49.2 31 51.7 170 17.5
Missing 1 0.1

People who can pay for healthcare should pay 970 100.0
Agree 559 65.9 46 74.2 40 66.7 645 66.5
Disagree/Neither 289 34.1 16 25.8 20 33.3 325 33.5
Missing – – – – – – – –

I am prepared to pay higher taxes for healthcare free at the point of access 970 100.0
Agree 560 66.1 20 32.3 27 44.3 607 62.6
Disagree/Neither 287 33.9 42 67.7 34 55.7 363 37.4
Missing – – – – – – – –

I fell well informed about UHC 969 100

Agree 407 48.1 21 34.4 11 18.0 439 45.3
Disagree/Neither 440 51.9 40 65.6 50 82.0 530 54.7
Missing – – – – – – – –

Self-reported health 970 100.0

Poor 169 19.9 15 24.2 6 10.0 190 19.6
Good 679 80.1 47 75.8 54 90.0 780 80.4
Missing – – – – – – – –

– = Not applicable.
a
Secondary level education includes primary school education (up to the age of 12) and secondary school education (up to the age of 18) and is equivalent to A Levels.
b
Third level education is any qualification above school e.g. undergraduate degree, postgraduate diploma.
c
Participants could select more than one method of health cover. A total of 65 (6.7%) participants indicated having private health insurance as well as some form of a GMS
card. These participants were included within the GMS category.
d
The state provides a general medical services (GMS) card primarily based on income but also for other criteria such as age and other government schemes. This provides
free at the point of contact access to healthcare services.
 C.D. Darker et al. / Health Policy 122 (2018) 147–156 153

N= 4,713,993
Population of Ireland

N= 33,223
Randomly digit dialled
numbers

Excluded N= 29,295
- Not available e.g. Engaged,
no reply, voicemail, not
available to speak

N= 3,928
Phone answered

Excluded N= 2,826
- Not eligible n=1,371
- Omnibus refusal n=1,455

N= 1,102
Invited to take part in
UHC questions

Excluded N=130
- Refusals n=129
- Duplicates n=1

N=972
Completed
questionnaires

Excluded N=10
- At least one missing
observation

N=962
Included in regression
analysis

Fig. 1. Flowchart of Participants.

pital treatment under UHC than they currently do, but lower out of
pocket payments for primary care services.
The current research had a number of strengths and limitations.
This is a nationally representative sample with 972 participants
(response rate of 88%) providing the views and opinions of the
general public on UHC at a time when one of the question marks
over the implementation of a plan for healthcare in Ireland centres
around public opinion. The questionnaire included questions that
have been previously used and extensive piloting was conducted.
Data collectors were trained and the data collection process was
monitored for quality. However, the sample was not weighted in
terms of GMS status with the proportion of GMS holders accounting
for 23.7% (n = 230) of the sample versus 36% of the general popu-
lation. Focusing on level of education 54.3% (n = 522) of the sample
154 C.D. Darker et al. / Health Policy 122 (2018) 147–156

Table 3
Factors Associated With Agreeing With the Introduction of UHC in Ireland (n = 962; 99.0%).

Independent variables Crude OR 95% CI Adjusted OR a 95% CI

Age
18–24 Base Base
25–44 0.69 (0.31,1.54) 0.64 (0.24, 1.67)
45–64 1.10 (0.64, 1.89) 0.88 (0.41, 1.87)
65+ 0.98 (0.55, 1.72) 0.84 (0.31, 1.74)

Gender
Male Base Base
Female 1.52 (1.03, 2.24)e 1.10 (0.70, 1.74)

Province
Dublin 1.32 (0.76, 2.31) 2.16 (1.13, 4.11)e
Rest of Leinster 0.84 (0.49, 1.43) 0.78 (0.42, 1.46)
Munster 1.05 (0.62, 1.76) 1.14 (0.62, 2.10)
Connaght/Ulster Base Base

Education
Secondary level or lower b Base Base
Third level c 0.73 (0.49, 1.08) 0.90 (0.54, 1.48)

GMS Status
GMS d Base Base
Private health insurance/Neither 0.54 (0.32, 0.89) 0.53 (0.28, 0.99)*

Social Class
Upper middle class Base Base
Lower middle class 1.16 (0.50, 2.72) 1.57 (0.59, 4.20)
Skilled working class 0.91 (0.41, 2.01) 1.52 (0.62, 3.74)
Other working class 0.61 (0.26, 1.43) 1.09 (0.41, 2.84)
Farmers 0.61 (0.27, 1.35) 1.18 (0.46, 3.01)

Having the health service as a public system is important

Agree 4.31 (2.45, 7.57)e 1.65 (0.81, 3.34)
Disagree/Neither Base Base

The government should prioritise spending on healthcare rather than reduce taxes
Agree 5.35 (3.56, 8.04)e 3.43 (2.12, 5.57)e
Disagree/Neither Base Base

I want healthcare free at the point of access

Agree 6.80 (4.52,10.23)e 4.72 (2.95, 7.54)e
Disagree/Neither Base Base

People who can pay for healthcare should pay

Agree 0.82 (0.54, 1.24) 0.72 (0.44, 1.19)
Disagree/Neither Base Base

I am prepared to pay higher taxes for healthcare free at the point of access
Agree 3.15 (2.13, 4.67)e 1.91 (1.21, 3.03)e
Disagree/Neither Base Base

I feel well informed about UHC

Agree 2.62 (1.71, 4.02)e 2.13 (1.32, 3.44)e
Disagree/Neither Base Base

Self-reported health
Poor Base Base
Good 0.85 (0.51, 1.40) 1.21 (0.68, 2.17)
a
Logistic regression- adjusting for other factors included in the model.
b
Secondary level education includes primary school education (up to the age of 12) and secondary school education (up to the age of 18) and is equivalent to A Levels.
c
Third level education is any qualification above school e.g. undergraduate degree, postgraduate diploma.
d
The state provides a general medical services (GMS) card to households on low income. This provides free at the point of contact access to healthcare services.
e
Statistically significant.

had a third level education or higher. This is comparison to 34% of
the general population aged between 15 and 64 [56]. Additionally,
caution must be taken when interpreting results as the number of
respondents who selected the ‘disagree’ or ‘neither’ category for
the introduction of UHC was substantially lower that the number
of respondents whom agreed with the introduction of UHC.
5. Conclusion
This paper is relevant and timely for policy leaders both in
Ireland and internationally. In Ireland the Slaintecare Report [2]
has been published outlining a ten year plan for the introduction
of UHC in Ireland and implementation remaining the key question
now. Internationally, these findings are of interest as countries with
UHC, such as the United Kingdom, are facing difficulties maintain-
ing health services in the public realm with ongoing debate on the
privatisation of the NHS [57] and other countries, such as the United
States, are debating universal elements for their healthcare system.
The current study provides a template that can be used to explore
public opinions of UHC in other countries. There is a high level of
support for the introduction of UHC in Ireland, which is influenced
by demographic, and related attitudinal factors. Patients and the
general public have been acknowledged as having a key role to play
in all areas of healthcare. This research provides timely information
from a representative sample for the ongoing debate on the future
of healthcare in Ireland. Future research should explore what peo-
 C.D. Darker et al. / Health Policy 122 (2018) 147–156
ple want to obtain from the introduction of UHC and what they are
willing to contribute to ensure that the voice of patients and the
public is heard at all stages of developments. It would be interest-
ing for this to be explored from a number of different stakeholder
groups such as clinicians.
Funding
This research was funded by the Adelaide Health Founda-
tion, which is a not-for-profit health charity. More: http://www.
adelaide.ie/
Conflict of interest statement
The authors report no conflict of interest.
Acknowledgement
The authors would like to thank the participants who responded
to the survey. This research was funded by the Adelaide Health
Foundation, which is a not-for-profit health charity. More: http://
www.adelaide.ie/
Appendix A. Supplementary data
Supplementary data associated with this article can be found, in
the online version, at https://doi.org/10.1016/j.healthpol.2017.11.
009.
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