Restore Policy Briefs

How International Health System Austerity Responses to the 2008 Financial Crisis Impacted Health System and Workforce Resilience - A Realist Review.

Building Health System Resilience Through Policy Development in Response to COVID-19 in Ireland: From Shock to Reform.

Implication for Health System Reform, Workforce Recovery and Rebuilding in the Context of the Great Recession and COVID-19: a Case Study of Workforce Trends in Ireland 2008-2021.

Barriers to Resilience Among Healthcare Staff in Ireland in the Post-Austerity Period. A Secondary Data Analysis.


March 2023

The RESTORE team hosted its annual research seminar, entitled Transforming Health System Resilience into Health Reform, on 29 March 2023.

International health policy experts George Wharton from the London School of Economics and Dr Ewout van Ginneken from the European Observatory on Health Systems and Policies joined the RESTORE team to launch the PRESTO Report: An analysis of resilience and sustainability in the Irish health system.

Prof Colin Doherty, head of the School of Medicine, TCD, provided the welcoming speech and Dr Annalisa Montesanti, lead programme manager for the Health Research Board, which funds the RESTORE project, provided closing remarks.

The PRESTO report suggests that Covid-19 provided a profound stress test for the Irish health system. Going into the pandemic, the Irish system had low capacity, with very long waiting lists for acute and community care. The pandemic itself then created unprecedented demands on services and the workforce, placing huge strain on a system already under pressure.
However, the PRESTO report also shows that the Covid-10 pandemic provided opportunities to bring in reforms outlined in Sláintecare ahead of schedule. These included free healthcare for Covid testing and diagnostics, as well as new pathways of care in the community and online.

The report also highlights the central role the healthcare workforce plays in the delivery of services, and the important role of engagement and communication in staff retention.
The PRESTO report is the result of a collaboration between researchers from the Centre’s RESTORE team and the global Partnership for Health System Sustainability and Resilience (PHSSR). The PHSSR was established in 2020 by the London School of Economics, the World Economic Forum, and AstraZeneca.

Welcome address and RESTORE update


Session 1 Health system resilience – From COVID to Cost of Living


Session 2 Understanding Shocks and Catalysing System Reform


Session 3 Panel Discussion and Closing remarks


October 2022

Key metrics of health system resilience within the Irish context

Graph image

The inpatient and day case waiting list numbers greatly increased in 2014, with the effects of the austerity years beginning to have a major impact. The numbers on the waiting list have still not recovered, with the figures from 2014 to 2021 at far higher levels than the 2008 to 2013 period, along with having much longer waiting times. This is despite a recovering economy and increased budget spend in health from 2014. Total numbers on the waiting list reached a peak in 2017 and began to improve in 2018 and 2019 before the figures began to increase again in 2020 due to the COVID-19 pandemic. In the first months of 2021, numbers waiting over 12 months were at the highest level they have ever been.

Source: PRESTO Report. Link pending publication.

Graph of HSE staff turnover

HSCP-Health and Social Care Professionals. PCC-Primary Care Centres

There has been a general upward trend in staff turnover rates during the 2018 to 2021 period. While staff turnover rates had increased between 2018 and 2019, the COVID-19 pandemic appears to have caused a greater increase in turnover in 2021. The turnover is at its highest rate in 2021 in all staff categories except PCC (although PCC is much higher in 2020 and 2021 compared to 2018 and 2019) The highest turnover rates are seen in Medical Staff (9.8%) and in HSCP (9.6%) (Health and Social Care Professions) in 2021. While the lowest turnover rates were seen in General Support staff, Management/Admin and Primary Care Centres, all three of these categories experienced a substantial increase in turnover in 2021, compared to 2018 and 2019 levels. In 2020, there was initially a slightly lower turnover in most staff categories compared to 2019, as people may have felt the need to stay and help the response to COVID-19 at the early stages of the pandemic. As the pandemic prolonged, people may have also begun to feel burnout, leading to higher turnover in 2021.

Source: PRESTO Report. Link pending publication.

Graph of health funding sources

The proportion of total health funding coming from government spending increased from 72.7% in 2016 to 74.6% in 2019. The COVID-19 pandemic gave rise to greater expansion, with government spending reaching 79% of health funding in 2020. In 2021, estimates place this figure somewhat lower at 78.4%. The pandemic has brought Ireland closer to the EU average of 80% of total health funding coming from the government. It remains to be seen if this higher level will be maintained after the COVID-19 pandemic, with 2021 already estimated to be lower than the 2020 figure.

Source: PRESTO Report. Link pending publication.

Trends in acute and community public-only staffing levels 2008 – August 2021

Graph image

Before the financial crisis, there were considerably more public-only WTE (Whole Time Equivalent) staff based in community services compared to acute settings (a difference of 4,485, 4%). While all staff numbers dropped during the Recession period, the decline was sharper in community-based services. From 2014 to 2019, the greatest staff gains were within acute settings, increasing by over a third from the beginning of the Recovery period (n=17,354, 33.5%), compared to a 18.2% increase for community services over the same period (n=8,548). This gap accelerated during the COVID-19 period. By August 2021, the gap had tripled with 13,645 more WTEs in acute settings compared to community, a complete reverse of the 2008 situation, when the numbers were weighted in favour of community settings.

Source: Fleming et al. (2022)

March 2022

The RESTORE team have summarised, into a two-page policy brief, the findings from an extensive systematic review due to be published soon titled: Metrics and Indicators Used to Assess Health System Resilience in Response to Shocks to Health Systems in High Income Countries - A Systematic Review. This policy brief draws together the main findings of the review, which categorises how health system resilience has been assessed and reported over the past two decades. The reported metrics are classified according to the WHO Health System Functions of Governance, Resources, Finance and Service Delivery and the four-stage shock cycle framework: 1. Preparedness, 2. Onset and Alert, 3. Impact and Management and 4. Learning and Legacy. Click here for the full policy brief.

Image of policy brief on Health System Resilience Metrics and Indicators

November 2021

The RESTORE research team hosted the 1st annual workshop on November 16th, 2021: Measuring and Building Health System Resilience. Following a welcoming address from Mairead O’Driscoll, Chief Executive the Health Research Board, Prof Steve Thomas outlined evolving thinking about health system resilience over the last decade alongside current challenges. Dr Pádraic Fleming, of the RESTORE project team, presented findings of two reviews of international evidence: one examining the measurement of resilience across different shocks and the other a realist review tracing the legacy of the economic crisis on the response to COVID 19. In addition, Prof Thomas highlighted early indicators of resilience metrics within the Irish context, identifying both strengths and weaknesses of the response to COVID 19. These presentations were supplemented by a presentation from Dr. Sara Burke, showcasing a recent Lancet publication - a policy analysis of how Slaintecare development has been enhanced by the response to COVID-19.

Two keynotes were presented by Anna Sagan, from the European Observatory of Health Systems and Policies, outlining lessons learned across Europe during the COVID-19 pandemic and how health systems can ‘build back better’. The second keynote came from Dr. Liina-Kaisia Tynkkynen of Tampere University Finland, identifying key themes from managers of their experience of crisis preparedness and governance of COVID-19 in four regions in Finland.

Finally, Prof Thomas and the keynote speakers were joined by Muiris O’Connor, Assistant Secretary General from the Department of Health, reflecting on the presentations of the day alongside the future direction of the reform agenda in Ireland and how momentum from the COVID-19 response can be harnessed to implement reform in an intentional way at pace.

“I liked the kind of wry observation that's it's worth focusing on legacy because you leave one anyway. And I think I've always said for years around Slaintecare, a greater intentionality around where we're going and what we're doing is really vital in in health and social care and in reform.” – Muiris O’Connor, Department of Health

Recordings of the full webinar, alongside PDFs of the presentations can be viewed at the following links:


Welcome and Introduction to RESTORE


Session 1


Session 2


Panel Discussion