In our Q&A: Eighth Amendment Referendum series, we are answering questions our readers have submitted in relation to the upcoming vote on 25 May.
THE QUESTION
One common question we received was related to the cost of terminations under the government’s plans and who would pay for them.
Some of those queries were:
THE ANSWER
In looking at this question, we asked both the government and the HSE for responses, looked at the Health Minister Simon Harris’s previous statements in the Dáil and also to the evidence that was presented before the Oireachtas Committee on the Eighth Amendment.
Firstly, it is worth pointing out again that the termination of pregnancy is already currently legal in certain circumstances, those outlined under the Protection of Life During Pregnancy Act.
Figures from the Department of Health for 2016 showed that 25 legally-permitted abortions were carried out during that 12 month period. In 2015, 26 terminations were carried out. Figures for 2017 have not yet been released by the department.
The minister and the Department of Health are made aware of all terminations that take place but the HSE has pointed out that they would have only details of those which take place in the public system.
The cost of terminations may be borne either privately or by the public system depending on the patient and this is likely to be the case under any future expanded system.
“I think you could make that deduction and I think that you wouldn’t be wrong. Even though it’s not exactly clear yet,” a spokesperson for the Minister for Health told TheJournal.ie.
Resources
It has been acknowledged by the government that, if its proposals for abortion are made a reality, additional resources will be required to provide such services.
Fine Gael has said that Health Minister Simon Harris is committed to meeting this additional need with adequate resources.
Details of exactly how this would be achieved have not yet been discussed but the government has said that these conversations would happen involving health bodies and providers as the government prepares legislation in the event of a Yes vote.
The government has published its General Scheme of the Bill to Regulate the Termination of Pregnancy but any final legislation would first have to go through all the usual stages of the Oireachtas.
“What he’s done in advance of all that is he’s absolutely committed to making sure that the resources are in place. What he’s saying is whatever is needed will [be] provided by way of resources,” the spokesperson added.
Last month, Harris was asked a number of questions on these issues by Fianna Fáil’s Éamon Ó Cuív TD.
Among the questions he was asked related to “the cost and staffing implications” of abortion services and “if these will take place in registered maternity hospitals or in specially provided facilities”.
In his response, the minister said that such issues would be addressed if the referendum was passed.
“In the event that the proposed referendum on Article 40.3.3 is passed by the people, the government would seek to give effect to legislation regulating the termination of pregnancy in Ireland,” Harris said.
In such circumstances, the Department of Health would, in considering any such legislation, consult with representative bodies of all relevant medical practitioners on the details of the legislative proposals and possible service implications, as is usually the case in developing legislation.
The cost implications of the wider introduction of abortion services into Ireland was an issue that was discussed during the Oireachtas Committee on the Eighth Amendment.
Fine Gael Senator Jerry Buttimer asked Dr Ronald Johnson of the World Health Organisation what proportion of a State’s health budget would usually go towards abortion.
Johnson said that it would not be possible to provide such an estimate, stating:
I cannot answer the question about costs. The cost of an abortion varies across the world from being free to $1,000. Women in New Zealand and the United Kingdom receive a free service. The cost of an illegal abortion can be astronomical.
“There are so many technicalities in estimating the cost for a particular system and we do not have the information necessary to process it, but we could certainly sit down and work with the committee on that issue.”
Johnson was also asked how long it would take to finalise the system so that terminations could take place. He said it would depend on people being “willing to implement the change” but that it need not take long.
“If there are people here who are committed to implementing it, it should be easy. It is simple. Abortion is simple. Adding it to the health service would be very simple, but there have to be the personnel who are enthusiastic about doing it,” Johnson told the committee.
Training and hospitals
During the committee, the medical skills necessary for terminations to take place were also discussed and the question of the need for additional training was raised.
Both Dr Meabh Ni Bhuinneain and Dr Peter Boylan of the Institute of Obstetricians and Gynaecologists said that obstetricians and gynaecologists already have the skills required to carry out a termination.
They stated that little or no additional training would be required but that additional resources would be.
“The skill sets for the medical and safe surgical procedures in relation to termination of pregnancy already exist in obstetrics and gynaecology and women’s health services in Ireland,” Ni Bhuinneain said, adding that they exist in GP settings, or in pregnancy or maternal care units throughout the country.
Boylan stated:
The skill levels required in termination of pregnancy, every trained obstetrician possesses, so we are more into resources and so on. It is well-known that the Irish maternity services are under-resourced – that is no secret. In a broad sense, yes, we would require more investment, more personnel and so on.
“The skill sets are there already. Early terminations with tablets can be done through GPs’ surgeries and clinics, and by nurses who are certified to prescribe,” he added.
As with other primary care services, prescriptions and services from GPs are covered for medical card holders and the spokesperson said that early terminations with tablets would also likely be covered.
Abortion pills and clinics
That latter point raised by Boylan highlights that abortion pills are now commonly used in medical terminations up to 12 weeks of pregnancy.
It is proposed that abortion would be made available without restriction up to 12 weeks of pregnancy and it is envisaged that this would take place in most cases in a GP setting.
In terms of the cost of such terminations, it would depend on the deals struck for the supply of the medication and the committee heard that this would be cheaper if carried out by the State.
“Misoprostol is a generic drug and very inexpensive, the price is cents per tablet. Mifepristone is now also very inexpensive. It can be sourced in bulk for approximately $3.50 per tablet. There are models in the world in which ministries of health procure it directly from the manufacturers. That is the cheapest model,” Dr Ronald Johnson said.
As soon as it is run through the private sector, there are import taxes and a mark-up at approximately five places along the way. It should be and can be cheap, but it is not always.
To provide an example of the cost of abortion pills in private abortion facilities, UK-based provider Maria Stopes provides a list of its fees.
The company says that private fees for a medical abortion using abortion pills is £560.
It also notes that it offers discounted fees for women travelling from the Republic of Ireland, providing a medical abortion up to 9 weeks and 3 days of pregnancy for €470.
The extent to which private abortion clinics would be part of Ireland’s future provision of services is unclear, but there is no reason to believe they will not be present.
Harris was asked by Mattie McGrath TD in the Dáil last month “if public monies will go towards private abortion clinics” but the minister declined to speculate beyond the referendum vote.
“In the event that the proposed Referendum on Article 40.3.3 is passed by the people, the government would seek to give effect to legislation regulating the termination of pregnancy in Ireland. Any necessary planning would take place at that stage,” Harris said.
[Update 21 May: Taoiseach Leo Varadkar gave more detail on this question in an interview with Seán O'Rourke on RTÉ radio on 18 May. He echoed his Tánaiste's words when he said there would not be abortion clinics in Ireland. He explained that hospitals would have to apply for licenses to carry out the procedures. He added:
"There will be a licensing regime so really only hospitals will carry out surgical procedures. There’s no provision for abortion clinics in the draft legislation."
Speaking to TheJournal.ie, Peter Boylan welcomed the intervention from Coveney, saying it was "reassuring".
Asked how a GP-led system would work practically, he said:
"If you look at the numbers, if only 100 GPs in the country were to provide this service, they would see maybe two cases every fortnight or every month. The numbers are not great when they're spread out over the year, and they're also in every single county across Ireland."]
If you have another question, please send it to referendum@thejournal.ie.
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