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Optimum Territorial Reforms in Local Government: An Empirical Analysis of Scale Economies in Ireland
Get PDFEconomies of scale are often the underlying rationale for local government amalgamations. Yet the international evidence on the relationship between municipal output or size (in population terms) and costs as measured by expenditure per capita is unconvincing, with doubts over whether size matters at all for the efficient provision of local public services. Given the 2014 structural reforms aimed at local government territorial consolidation in Ireland, we use pre- and post-merger data to investigate whether there is any evidence of scale economies in the Irish local government system. The econometric study finds empirical evidence of “U-shaped” cost curves for Irish local councils in 2011 and 2016. In both years the range of turning points are near the median council size, suggesting that many local authorities were operating in the diseconomies region before and after the 2014 territorial reforms and amalgamations. With more territorial changes currently planned, policymakers should look at further amalgamations only on a case-by-case basis but also at other mechanisms to deliver efficiencies, either through strategic alliances and more shared services arrangements or other ways of inter-municipal cooperation as is common in many continental European countries
Editor’s Foreword: Getting Bit by the Research Bug: Why Medical Students Should Get Published
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News: Kassala Is Dying: Challenges of Healthcare in Sudan
No full textSudanese doctors working in Ireland detailed their knowledge and experience of medicine in Sudan and highlighted the current chikungunya epidemic in Kassala in a novel event organized by the Trinity Chapter of the Association of Medical Students Ireland (AMSI TCD) earlier this month.
The panel based discussion mediated by AMSI Local Officer Eyad Ibrahim included four expert doctors, Dr. Amin Amin, Dr. Nemer Osman , Dr. Hatim Ibrahim, and Dr.Ismail Mohammed. The doctors, representing the group Sudanese Doctors in Ireland (SDI), spoke about global health, medical inequality and the tumultuous political climate in Sudan to an audience of largely medical students.
Dr. Amin, an orthopaedic surgeon at Connolly Hospital Blanchardstown, introduced both the talk and the harrowing ongoing situation in Kassala. Specifically, he raised concern about the rapid outbreak of the mosquito borne virus chikungunya. “Everybody has it and you won’t find another man, woman or child who doesn’t,” he said emphatically.
In a melancholic tone, he described that the treatment for this infection was supportive management such as intravenous fluids and paracetamol — resources readily available in any Irish hospital, but lacking in Kassala and Sudan in general. With proper treatment, only those vulnerable with pre-existing conditions such as diabetes, frailty, or co-infection with other viruses such as Zika, would suffer debilitating morbidity or death. Most would fully recover with symptoms mainly comprising fever and joint pain. However, the lack of governmental aid and recognition of this crisis have resulted in more severe widespread consequences.
“The town stops, farmers don’t work, teachers won’t show up at school, it’s more morbidity than mortality,” Dr. Amin said.
The latest report by the Central Sudanese Doctors’ Committee reported over 16,000 infections and 45 deaths due to chikungunya. In response, the 600 Sudanese doctors currently in Ireland have spread the tragic tweet #KassalaisDying in solidarity with the social media campaign aiming to raise awareness. The campaign reflects that in addition to people literally dying from this infection, the magnitude of debilitation is grinding the city to a halt.
In addition, panelists discussed interesting differences of healthcare management in Sudan. These included more realistic aspects of tropical diseases such as malaria and dengue fever. Dr. Ibrahim, consultant endocrinologist working in Ulster Hospital in Belfast, recalled a few insightful examples.
While working in the White Nile Estate near Khartoum in Sudan as an SHO in 1991, a lady presented to hospital with fits due to eclampsia. Dr. Ibrahim was required to deliver the baby with the help of only a few nurses.
“We had to use an oven to sterilize the equipment, we had to be our own surgeon and anesthesiologist,” he said.
Dr. Ibrahim recalled that the completely healthy woman returned to the hospital a few days later for a check up, thanking him for the help, however he reminded the audience that happy endings like this were not always the case.
He went on to describe the challenges of the practical aspects of managing mosquito-borne pathologies other than chikungunya. One recommendation to prevent illness is to use bulky full-body suits for outdoor occupations.
“Realistically, no one is going to wear a huge suit, if they’re too poor and they can’t afford it, they are just going to go out into the fields to work in order to feed their children,” he said. He added that infection from mosquitoes is an around the clock threat, with lower socioeconomic groups in Sudan at the highest risk.
Dr. Nemer, consultant oncologist in Limerick Regional Hospital, went further to discuss low cost methods of diagnostics that are necessary with scarce resources. He said that it was common to use vinegar to locate lesions of cervical cancer caused by HPV, a problem routinely screened for by Pap smears in Ireland, but a more widespread and devastating situation for women in Sudan.
“In the East, you can’t do these fancy tests and biomarkers, you have to use what we had, and what we had is vinegar,” said Dr. Nemer.
Another aspect raised was the turbulent political climate of Sudan. The doctors suggested that funding was directed towards benefiting government officials resulting in resources taken away from healthcare.
“People like to spend money on things that matter most to them. Here in the West, the government likes to spend money on health and education,” said Dr. Amin. “However, in Sudan, the government likes to spend money on military and security.”
Activists have criticized the delay in the government’s response to the situation in Kassala, which had a significant impact on the situation in the region. The delay was significant enough for the infection to spread from a small number of 30-40 people to the whole region of Kassala and other areas like Port Sudan. Currently, the number of infected people is around 16,000.
The spread to other areas was facilitated by fear in the region that resulted in dispersion, as well as heavy rains allowing for the mosquito vector to travel. Factors such as patient education, treatment and quarantine availability as well as lack of transport and infrastructure added to the severity.
Speaking about the healthcare challenges in developing countries such as Sudan, Dr. Ibrahim stated that the lack of medical diagnostic resources necessitates developing better clinical skills. In his practice in Ireland, he pointed out that he finds some tests that are ordered here can be unnecessarily excessive.
“Some of the investigations we do here are very wasteful, and our clinical skills are not being developed to their potential. I encourage my juniors to use their clinical skills rather than rely on unneeded diagnostic tests…in Sudan the better clinical skills are a necessity,” he said.
Furthermore, Dr. Amin said that often times these investigations are done in order to avoid consequence of legal action. “Even though you know for certain a patient has a fracture from presentation, you will still X-Ray them. Even if it was subtle fracture you would put them in CT scanner head to toe,” he said.
Dr. Ismail, consultant rheumatologist in Craigavon Hospital in Northern Ireland, simplified the striking difference in medicine practiced in Sudan and Ireland.
“It’s non-comparable,” he said.
The doctors offered electives in Sudan to medical students interested in experiencing medicine in a developing country and even offered to pay for some of the expenses such as accommodation and visas.
“Both the students and the country benefits from people going over,” Dr. Nemer said as the event concluded. “Hopefully one day in the future Sudan will cease from being the hotbed of disease and illness that it is.”
The audience was left with a quote by the great Sudanese writer Tayeb Salih.
“Everyone starts at the beginning of the road, and the world is in an endless state of childhood.”
With content from Dane Wanniarachige
Students React to #KassalaisDying Event
“When I first heard about the event I remember feeling a great deal of pride, being of Sudanese origins myself. Seeing Sudanese doctors in Ireland —which are not few— represented and given such a platform filled me with joy. But it was clear that this event was more than just Sudanese doctors talking about medicine.
The event offered a unique and eye opening —as well as saddening— insight into the practice of medicine in under developed nations, the doctors experience in that regard formed a unique insight into what otherwise is a distant reality. In addition, I greatly enjoyed the rich information volunteered by the great practitioners who could at least be described as admirable.
As a student I have benefited greatly from the event, both medically and in a humanitarian aspect, I look forward to continued contact with the organization throughout my medical career.”
—Mawaheb Elnour, 1st Year Medical Student, Trinity College Dublin
“As a student who isn’t born or raised in Sudan, I felt overwhelmed by discovering about the health-related predicaments that entail the daily lives of individuals in that country. I realized that while here in Ireland, we’re trying to find cures to big conditions such as cancer or cystic fibrosis, back in Sudan, something like malaria, something that people in Ireland are completely unaware of, is affecting myriads of helpless, innocent people daily.
It made me question my duty as a future doctor and as a citizen to this world. It prompted me to ask myself, what am I doing to make even the slightest change for people who don’t deserve to lose their lives over conditions that do have a cure. This event opened my eyes to the reality and status of health-care in third world countries and it motivated me to take part in missions or projects that can help ease the health-related obstacles that nations such as in Sudan face.”
—Iffah Khalid, 1st year Medical Student, Trinity College Dublin
“I found the event really inspiring as it prompted us to consider the challenges faced by doctors in Sudan; not only during epidemics, but also in daily life with limited resources. Before the talk I had very limited knowledge on Sudan, but listening to the consultants and their passion for their the country made me want to find out more about Sudan and possibly visit in future! It was one of my favourite AMSI events so far, I’m looking forward to future events like it!”
—Blaithin Thomasius, 3rd Year Medicine Student, Trinity College Dublin
“I think it is a very innovative event by connecting with experienced practitioners. The speakers addressed some recent and concerning diseases, from which the students could gain valuable knowledge and critical thinking that are outside of the books. The speakers described the healthcare conditions in a developing setting and brought up political, financial and geographical aspects of the diseases.It was very interesting, even when I’m not from medical discipline.”
—Yue Peng, Final Year Biochemistry Student, Trinity College Dubli
State/Industry Medicine Pricing Agreements, Cost Savings and Counterfactuals: the Case of Ireland
Get PDFIreland’s Minister for Health claimed cumulative savings of €600 million for the 2016-2020 framework agreement with the Irish Pharmaceutical Healthcare Association. These savings are estimated using an implausible counterfactual of no agreement, since multiannual State/industry agreements are longstanding, while, since 2013, the State has powers to set medicine prices. A better counterfactual is the status quo: replicating the 2012-2015 agreement and extending its term for one year. This alternative counterfactual results in estimated cumulative savings of only €290 million. Greater transparency and more prudent choice of comparator for savings estimates would provide confidence in the estimates and more accurately demonstrate the likely savings that will be achieved
Decomposing the Drivers of Changes in Inequality During the Great Recession in Ireland using the Fields Approach
Get PDFIn this paper we take as a case study a developed country that both experienced one of the highest sustained growth periods in recent decades, but also had one of the largest economic declines during the recent crisis period; Ireland. In particular, given the availability of data and the period from the peak before the economic crisis and the lowest point in the crisis, we focus on the period around the boom 2007-2012. We find that inequality in terms of disposable income decreased over the period, with an increase in the redistributive effect of the tax-benefit system offsetting a rise in market income inequality. We utilise the Fields regression decomposition to understand the impact of demographic, labour market and other drivers. We find that the explanatory power of the Fields regressions fell over time, reflecting the asymmetric shock induced by the economic crisis. Labour market drivers had the largest impact on the level of income inequality over the period, accounting for 64 per cent of variability in 2007, but rising to 75 per cent in 2012. Educational attainment is positively associated with inequality. However, the effect greatly diminished between 2007 and 2012. Changes in the demographic structure and changes in the level and distribution of market incomes increased inequality. We also decomposed the change in inequality into price and quantity effects that result from a change in the return and composition respectively
An Analysis of Taxation Supports for Private Pension Provision in Ireland
Get PDFThe size and distribution of the taxation supports for private pension provision has been a contentious issue. Research produced or commissioned by representative groups of the pensions industry in Ireland maintains that the tax supports are merely tax deferment, and the effective tax relief is lower than the ‘headline’ relief on pension contributions. Research by the OECD, on the other hand, suggests that pension savings are essentially tax free to the majority of pension savers. This paper estimates the value of the favourable tax treatment to private pensions provision, expressed as a percentage of the original amount invested, and analyses how it varies with income level, gender, saving period, and other factors. The net effective tax relief on pension savings on each Euro invested in a private pension is estimated by comparing the increase in the present value of pension savings over the lifetime of the individual when compared to other savings. We report that the net effective relief is considerably higher than estimated by the widely cited industry research, and depends on the value of the pension fund at retirement. We identify three distinct groups of individuals in the current regime of incentivising pension savings: those on low incomes who are offered no incentive, the standard rate tax-payers where the net effective tax relief is about 25-30 per cent, and the higher rate tax-payers where the net effective relief is about 31-51 per cent. We argue that current regressive taxation supports for pension savings should be reformed, and reformed before the proposed imminent introduction of an auto-enrolment retirement saving scheme
Kielland’s Forceps: A Necessary Revolution? Ethical Dilemmas in Obstetrics and Gynaecology: Obstetrics and Gynaecology Essay Prize
No full textThe Kielland’s forceps has been controversial since its inception. The unparalleled range of movement offered by its unique design made it for a time the instrument of choice for occipito-transverse arrest in the second stage of labour. In recent decades use of the Kielland’s forceps declined significantly following a series of damning case reports linking its use to significantly poorer neonatal outcomes, and now many obstetric trainees are not trained in Kielland’s deliveries. However, these case reports have never been replicated, and modern evidence now suggests that the not only is the Kielland’s forceps equivalent in neonatal and maternal outcomes to other forms of vaginal delivery for transverse arrest, but also that is significantly less likely to fail preventing the substantially poorer outcomes associated with sequential instrumentation, or emergency Caesarean section. The potential reintroduction of structured training in Kielland’s delivery raises ethical concerns regarding training related risk, and whether the profession has accurately quantified the potential risks involved. However, modern evidence broadly supports a positive balance of risk and favours the widescale reintroduction of the Kielland’s forceps
Atypical Work and Ireland’s Labour Market Collapse and Recovery
Get PDFAcross many countries, the rise of atypical work has been noted whereby employees are increasingly in less secure contractual situations. While this might lead to more flexible labour markets, there are potential downsides for individuals. We explore the prevalence of atypical work in Ireland which provides a fascinating case study. Ireland experienced a dramatic deterioration in its labour market around the Great Recession with unemployment rising from 4.8 per cent in 2007 to 15 per cent in 2012. This situation was also reversed somewhat quickly with unemployment falling to 8 per cent by 2016. Such dramatic swings provide the context in which we explore whether atypical work increased for new job holders with the onset of recession and whether or not this weakened as the economy recovered. We find that atypical work did increase with the recession and, although moderating, the likelihood of new jobs being atypical persisted into the recovery. This raises important questions about whether economic recovery alone will improve job quality, in addition to job numbers
Targeting the Inflammasome: A cure for Alzheimer’s disease?
Get PDFAlzheimer’s disease is the most common neurodegenerative disease in the world. Despite years of intense research, its pathogenesis remains quite controversial. Many different explanations have been proposed to describe its onset, the most established of which is the β-amyloid hypothesis. This hypothesis proposes that the disease is primarily caused by the formation of β-amyloid plaques in the brain. The presence of these plaques, it is suggested, ultimately leads to neuroinflammation, tau aggregation and, eventually, neuronal death and the often-cited neurocognitive sequelae observed in Alzheimer’s patients. However, recent evidence suggests neuroinflammation may in fact be a root cause of the disease as opposed to acting as an eventual or coincidental manifestation. More specifically, it has been found that the activation of inflammasomes in microglia (the brains immune cells) contributes to the production of proinflammatory cytokines which then potentiates the neuroinflammatory response, with other downstream affects including increased β-amyloid plaque build-up, tau aggregation and a loss in cognitive function. There- fore, more and more studies are suggesting that neuroinflammation - and particularly the inflammasome - could be targeted therapeutically to prevent and treat Alzheimer’s disease in patients
Education in abortion care in Ireland: Medical Students For Choice (MSFC) taking a lead
Get PDFAbortion is a common topic of discussion in Ireland. Provision of abortion care by healthcare workers is restricted in a number of ways by legislation. Among Medical Students and Non-Consultant Hospital Doctors, there is consensus that abortion care should be covered in core curricula. However, current evidence indicates these groups lack knowledge surrounding issues such as legislation and abortion care in an Irish context.
Guidelines dealing with termination of pregnancy provide information on how best to support women considering abortion, however information provided by Government Organisations contains inaccuracies. Both fail to deal with issues surrounding abortion through online Telemedicine services, and legislative ambiguity may prevent healthcare workers from providing information which could make at-home abortions safer.
This paper advises medical students and trainee doctors how best to deal with practical situations, such as women seeking advice on abortions overseas or through online providers. It provides a toolkit for clinicians to draw upon, which is in line with current legislation, guidelines and best practice. Further educational opportunities are available to students through Medical Students For Choice, through clinical attachments and student-led events. The educational benefits of such activities are discussed