In just over a decade, many high-income health systems around the world have faced two major shocks – the recession following the 2008 financial crisis and the Covid-19 pandemic. A shock can be defined as a sudden change that creates significant acute demands on a health system, differing from chronic challenges and enduring health system stressors such as population ageing [1,2]. Although different types of shocks have distinct footprints on health systems, all disrupt the existing interaction between supply and demand, either by expanding the need for care or reducing the resources available to deliver care, and sometimes both [3]. Furthermore, each shock leaves a legacy on the health system [4] with the prospect then that there is a dynamic effect from one shock to the next. Health system resilience thus involves addressing the long-run effects of past shocks as well any new shock to the health system.

This paper contrasts the Irish experience of the economic crisis and the Covid-19 pandemic, and the health system responses to these shocks, from the perspective of national and international health leaders who had experience of both periods. Exploring these experiences creates an opportunity to understand the impact of each crisis on the health system, explore options for addressing legacy issues and consider practical steps to improve system performance. Lessons from the Irish response to these two crises provide a case study for exploring appropriate policy responses and re-examining the nature of shock legacy.

The economic crisis of 2008 acted as a profound shock to health systems around the world. At the time, Ireland was one of the five European countries to receive a bailout from the Troika (the EU, the IMF and the European Central Bank). The Troika played a significant role in guiding Irish decision-making and determining financial parameters. These restrictive fiscal policies had a direct impact on national health policy and service delivery, with external agents closely monitoring adherence to cost reduction and efficiency measures [3], which included sharp reductions in real health spending per capita [5]. These cuts had significant ramifications on infrastructure, service delivery and workforce capabilities [3]. For example, hospital bed numbers decreased substantially, with 4.85 beds per 1000 population in 2008 versus 2.83 in 2009 [6]. Financial cuts led to fewer services, poorer access and a greater financial burden on households already experiencing the negative impact of the financial crisis [5]. The austerity budgets occurred within the context of a system that has been historically underfunded, with inconsistent and inequitable access to services a persistent feature of healthcare provision in Ireland [7].

In contrast, Ireland's response to Covid-19 was supported through the release of funds at a national level and further aided by the lifting of fiscal regulations at an EU level [8]. Furthermore, additional funding for the health sector was made available beyond the additional needs of the pandemic, particularly around investment in the health system capacity [8]. This was to support the implementation of Sláintecare, the government's 10-year programme for reform, which aims to introduce Universal Health Coverage (UHC), strengthen primary care capacity, address inequitable access and decentralise population planning and decision-making [9]. In Budget 2021, over €1 billion in funding was released for additional beds, community services and a scheme to reduce long waiting times. This funding also provided for the proposed introduction of the Sláintecare public-only Consultant Contract. Additional funds of €425 million were also allocated to shifting care from hospitals to community settings [8]. These additional funds thus supported reforms that were co-aligned with the immediate pandemic response, as well as long-term reform commitments made by the government [9].