Governing healthcare: the case of Universal Health Insurance – by competition

In 2011, the Government committed to the introduction of Universal Health Insurance (UHI) ‘with equal access to care for all’ by 2016 (Government of Ireland 2011: 2). This chapter explores how proposals to implement a system in which every member of the population would be expected to take out health insurance – and mooted by politicians as a way to end Ireland’s two-tier health system – exhibited particular characteristics of advanced liberal modes of governing.Specifically, drawing on Rose and Miller’s (1992) conceptualisation of the ‘aspirations’ of advanced liberal government – governing at a distance, the management of risk, engendering individuals to take responsibility through choice, and the fragmentation of the social state into multiple communities – this chapter demonstrates how while a political rhetoric may have stressed the significance of UHI as a basis for promoting solidarity and fairness, it is hard to avoid the conclusion that the policy would have represented a further shift towards the marketization of Irish healthcare.

The contemporary self in tobacco control: exploring the introduction of the smoking ban in Ireland

This chapter is set in the context of the introduction of an outright ban on smoking in the workplace in 2004, an initiative that is widely regarded by Irish politicians, public health and anti-smoking advocates as a story of success, despite ‘common sense’ commentaries at the time suggested that the ban would be too radical a proposal.Drawing on commentaries from broadsheet newspapers and political speeches from the time, this chapter analyses the introduction of the smoking ban in Ireland as a successful exercise in ‘the conduct of conduct’ (Foucault, 1982) by exploring the types of conduct that were embraced and promoted in the context of the debates over the ban. Informed by the centrality of notions of rational, responsible and civilized selfhood in contemporary public health and health promotion discourses, the chapter reveals how notions of what came to be promoted as rational, responsible and civilized behaviours, and their flipside, irrational, irresponsible and uncivilized ones, were central to the exercise of power. It also reflects on how the regulation of smoking became interlinked with social and moral processes, and how some of these played a symbolic role in promoting boundaries between different social groups.

32 and 37 inches – the healthy body and the politics of waist circumference: a governmental analysis of the Stop the Spread campaign

This chapter focuses on a the 2011 health promotion campaign Stop the Spread, part of which involved the distribution of measuring tapes to the population via pharmacies to encourage people to measure their waists. Drawing on an analysis of campaign materials, the chapter explores the significance of Stop the Spread as a governmental technology and form of biopower in which medical discourse was utilised in an effort to not only re-programme ideas of what a normal healthy body should measure and look like, but also to more directly attempt to change behaviour by gifting people the technology to measure themselves, and to ultimately inscribe those numbers on their bodies. This chapter provides insights into how neoliberal governmentality is evolving in relation to public health policy, not least in the context of soft paternalism which is more directive in its use of techniques and strategies to steer norms and behaviour, whilst remaining highly individualised in terms of its understanding of health and its determinants.

Conclusion: governmentality, health policy and the place of critical politics

This chapter synthesises the main themes of the volume, and provide a broader discussion of the contribution that governmentality-inspired studies can make to our understanding of health and health policy.In particular, the chapter discusses where governmentality-based studies might take us in both methodological and theoretical terms. Cognisant of critiques of governmental analyses, it places a specific emphasis on exploring what, or how, governmentalty can contribute to those themes which have so often occupied critical social policy analysts, not least issues of inequality, the role of politics as social relations, and the place of contestation and resistance in policy processes. Thus, the chapter seeks to explore how we might write critical politics, and critical policy analysis, back into governmentality studies.

Long-term care policy for older people in Ireland: a governmental analysis

This chapter focuses on the long-term care policy for older people in Ireland. Taking a historical perspective, it demonstrates how the long-term care policy for older people bears all the hallmarks of neoliberal government, in which the state has ceded provision of services to the private home and residential care sector, whilst retaining a regulatory role through bodies such as the Health Information and Quality Authority. As the chapter argues, older people’s care increasingly hinges on the ability of older people to make the ‘right’ ageing choices, that is, to remain active and independent, and to act as citizen-consumers, which in turn, allows the state to relieve some of its own burden by shifting responsibility for care management onto older people themselves.

Neoliberal governmentality and public health policy in Ireland

This chapter provides an analysis of some of Ireland’s key public health policy documents since 1994 in the context of advanced liberal government. The analysis reveals how Irish public health strategies increasingly target the individual in terms of responsibilising behaviours, inculcating them to make healthy lifestyle choices and mitigate against health risks. Scrutinising the claims and arguments set out in three health documents-Shaping a healthier future (Department of Health, 1994), Quality and fairness – A health service for you(Department of Health and Children, 2001), and Healthy Ireland (Department of Health, 2013)-they note the increasing shift to a market-based model of healthcare, and of the role of the state as one amongst many actors in the health policy arena. Health policymaking, as they argue, has become an increasingly technocratic process, and their analysis raises significant questions about the implications of neoliberal modes of government in the context of the three documents’ acknowledgement of persistent health inequalities in the State.

Governing organ donation: the dead body, the individual and the limits of medicine

This chapter focuses on governmental dilemmas and practices around the dead body in recent political debates about organ donation. Drawing on a public consultation process initiated by the Joint Committee on Health and Children in 2013 on a proposal to change the organ donation system in Ireland from one based on ‘opting in’, to one based on ‘presumed consent’, this chapter explores the political rationalities that underpinned the construction of organ donation as a ‘problem’, and the ways in which the Irish state has sought to act through its citizens to transform the prevailing cultural attitude to organ donation. The chapter reveals how governmental shaping of people’s subjectivities and dispositions in relation to organ donation was necessarily complex and messy, reflected in the different rationalities articulated in public hearings which invoked ideas about the dead body, the rights of the individual and the family, and the limits to medicine. The chapter draws attention to the significance of counter conducts or forms of resistance in defining and articulating policy problems: thus, whilst the overriding construction of the organ donation problem by the government was one of a scarcity of organs and a low donation rate, counter-discourses pointed to an ineffective and poorly-resourced health system.

When health means illness: analysing mental health discourses and practices in Ireland

This chapter focuses on the area of mental health policy as an arena in which expert systems, in the form of biomedical discourses and psychiatry, have played a central role in constituting mental health ‘subjects’. The analysis focuses on the discourses emerging from recent mental health policy documents, including Ireland’s main mental health strategy, A Vision for Change. Drawing on Dean’s ideas about fields of visibility and valued knowledge, this chapter suggests that despite a broadening of understanding of mental health beyond medicalised discourses, seen most recently in health promotion campaigns and suicide prevention strategies, in practice, the focus remains on the mental health service user, and the provision of services for those who are mentally ‘ill’. Attempts to reconfigure mental health as something which affects ‘all of us’, and moves beyond mental ‘illness’ – which, it is argued, may have the potential to open up less stigmatising modes of understanding about mental health – are hampered by the continuing dominance of the biomedical frameworks of understanding.

Doing the ‘right thing’? Children, families and fatness in Ireland

Set up against the background of increasing concerns in the Irish media and government discourses around a childhood obesity epidemic since the 2000s, this chapter critically unpicks the ways in which particular truths are created about childhood obesity by a complex range of institutional actors, and become the basis for interventions and actions targeted at particular groups. Specifically, it explores how data from the National Longitudinal Study of Children, Growing up in Ireland (GUI) has been used to construct a particular reality of the ‘problem’ of childhood obesity, grounded in an uncritical acceptance of medical norms and instruments (such as the Body Mass Index). This chapter points to the sheer complexity of both the institutional actors (medical and social scientists, policy makers, and the media), and types of knowledges, invoked in the problematisation of obesity, whilst also highlighting the limits of interventions that place responsibility for tackling the ‘risk’ of obesity at the feet of children, parents (and most specifically, mothers), and schools through individualised interventions to act on the behaviours and bodies of children.

Assessment of Need as a technology of government in Ireland’s Disability Act 2005

This chapter is concerned with exploring a specific governmental technology – the Assessment of Need (AoN) process in the Disability Act 2005 – which has initiated a new system of categorising children with disabilities in the Irish state. Subject to significant controversy, the AoN exposes not just the way in which governmental rationalities and strategies seek to bring new categories of individuals into being, but also how these projects are often incomplete and fraught with tension, insofar as they are played out within and across institutional and professional boundaries and forms of expertise. In particular, the chapter is concerned with documenting how those charged with working within the health system interpret, make sense and sometimes subvert, the categorisations and obligations which the AoN process places upon them, thereby pointing to the messy realities of governing which are sometimes absent from governmentality-inspired analyses of policy programmes.