It ’ s the economy , stupid ! When economics and politics override health policy goals – the case of tax reliefs to build private hospitals in Ireland in the early 2000 s

To analyse the policy process that led to changes to the Finance Objectives: Acts in 2001 and 2002 that gave tax-reliefs to build private hospitals in Ireland. Qualitative research methods of documentary analysis and in-depth Methods: semi-structured interviews with elites involved in the policy processes, were used and examined through a conceptual framework devised for this research. This research found a highly politicised and personalised policy Results: making process where policy entrepreneurs, namely private sector interests, had significant impact on the policy process. Effective private sector lobbying encouraged the Minister of Finance to introduce the tax-reliefs for building private hospitals despite advice against this policy measure from his own officials, officials in the Department of Health and the health minister. The Finance Acts in 2001 and 2002 introduced tax-reliefs for building private hospitals, without any public or political scrutiny or consensus. The changes to the Finance Acts to give tax-reliefs to build private Conclusion: hospitals in 2001 and private for-profit hospitals 2002 is an example of a closed, personalised policy making process. It is an example of a politically imposed policy by the finance minister, where economic policy goals overrode health policy goals. The documentary analysis and elite interviews examined through a conceptual framework enabled an in-depth analysis of this specific policy making process. These methods and the framework may be useful to other policy making analyses.


Introduction
For fifteen years up to 2008, Ireland experienced exceptional economic growth and was regarded as a model for economic development (Kirby, 2010). By 2010, Ireland was experiencing the worst economic decline of any high income country since the Second World War and was described by the International Monetary Fund (IMF) as 'perhaps the most over-heated of all advanced economies' (Department of Finance, 2010). From 1997 to 2007, Fianna Fáil, the dominant Irish political party, was in a coalition government with a small laissez-faire liberal party -the Progressive Democrats (Gallagher & Marsh, 2007).
During this period of economic growth, Ireland's Department of Health developed a new national health strategy, which had 121 commitments, including an increase in hospital bed provision by 3,000, the majority of which were planned for public hospitals (Department of Health, 2001). Simultaneously, the Department of Finance established tax breaks for developers to build private-for-profit hospitals (Wren, 2003).
This research provides an in-depth exploration into the policy processes that led to the introduction of tax breaks to build private hospitals in Ireland during 2001 and 2002 and their impact on the hospital landscape. It seeks to understand why the changes to the Finance Act were made even though they were contrary to the health strategy commitments.
While there is much written about increased privatisation of hospital care and blurring between public and private providers, there is little research on what influences these policy processes and choices (Maarse & Normand, 2009). This research utilised the Irish context, where the private sector component of the public private mix is unusually strong for Northern Europe, with a view to informing policy making processes and policy analysis research, nationally and internationally.
The aim of this research is to provide an in-depth analysis of this specific policy making process in order to better understand health and public policy making processes.
Irish economic, political and health policy context Economic context. Throughout the 1990s and the first years of the early twenty first century , Ireland e xperienced e xceptional economic growth with annual growth rates of 7.5%, which in some years exceeded 10% (Kirby, 2010). For fifteen years up to 2008, Ireland's growth rates were over three times the European average (Kirby, 2010). This expansion, which was subsequently found to be unsustainable, was driven by a pro-cyclical economic policy, largely dependent on Foreign Direct Investment; and a property boom fuelled by government tax-reliefs and over-generous, unsound lending practices by banks (Kirby, 2010). These factors, combined with low interest rates, which were predetermined by Ireland's Eurozone membership, fed 'an orgy of borrowing and consumption' (Kirby, 2010 : 4).
Irish economic growth came to a sudden end in 2007/8, at the onset of the global financial crisis. By 2010, borrowing rates were unsustainable and Ireland entered an EU/IMF/ECB (European Central Bank) bailout (Department of Finance, 2010).
Political context. Two national political parties, Fianna Fáil and the Progressive Democrats (PDs), were in power continually from 1997 to 2007(Leahy, 2009. Fianna Fáil, which was selfstyled as the 'republican party', was the largest, oldest, dominant party in Ireland, characterised by a working-class base and conservative policies (Ferriter, 2004).
Popularly known as the PDs, the Progressive Democrats party, which was formed in the late 1980s by a group that split from Fianna Fáil, pursued economically conservative policies with a strong low-tax, pro-business and pro-market focus (Collins, 2005). Although the minority party in government for ten years from 1997, they had considerable influence over government policy, especially economic policy (Leahy, 2009). Their leader, Mary Harney, was Tánaiste (deputy prime minister) and from 2004 until 2010 she was the Minister for Health. In government, the PDs held considerable influence over health policy even before occupying the health ministry (Wren, 2003).
The Minister for Finance from 1997 to 2004, Charlie McCreevy, was a senior Fianna Fáil member closely allied with the PDs and their leader. Together, they had significant influence over Government policy (Collins, 2005;Leahy, 2009).

Health policy context
As public finances expanded significantly, the Irish public health budget quadrupled between 1997 and 2007, rising from €4 billion to €16 billion (Department of Health, 2010). This rise reflected the economic growth and increased expenditure across spending departments, especially on wages. Much of this investment was making up for decades of under-spending, when Ireland spent well below the OECD average on health (Wren, 2003). Ireland's average health spending per capita between 1995 and 2008 came seventeenth of 25 OECD countries (McDonnell & McCarthy, 2010).
While public spending on health increased in the 1990s, there were few attempts to reform the financing or inequitable structure of the Irish health system. Ireland's inequitable and inefficient public private mix of healthcare is well documented, characterised particularly by the absence of a universal primary care system and inequality in access to the public hospital system, in that those with private insurance get preferential (quicker) access to public, as well as private, hospital beds (Burke, 2009).
In 2001, a new health strategy 'Quality and Fairness' was published, which outlined 121 actions in a seven year reform programme (Department of Health, 2001). The Strategy proposed many measures, of which few were achieved, as most reform efforts went into restructuring the health system from eleven old health boards into one Health Service Executive in 2005 (Burke, 2009). Throughout the last decade, public hospitals have been under increasing pressure to treat more public patients, to reduce waiting times as well as meet the demand for those with private health insurance (Burke et al., 2014). In 2000, there were limited numbers of private hospital beds with some parts of the country without any private hospitals (Wren, 2003).

Methods
Qualitative research methods were used, combining detailed documentary analysis with topic-guided, semi-structured in-depth interviews with policy elites. The following databases were searched: However, very few Irish specific documents were found; therefore snowballing methods were used to source relevant documents referenced in other reports and grey literature. Freedom of Information requests were used to obtain documents not in the public domain, as well as asking each interviewee for documents relevant to the research. This yielded dozens of documents, so only those directly relevant to the changes to finance acts were included. The interviews were conducted in person. Questions asked are in Supplementary File 1.
Thirty-six primary and secondary documents were analysed in order to trace relevant policy developments. These are listed in Supplementary File 2. The primary documents related directly to the Finance Acts while the secondary documents provided background for political, health and economic policy developments. Twenty one in-depth interviews were carried out with policy elites involved in the policy processes. The lead author did the interviews, with over a decade of experience of interviewing people for health policy/services research.
Elite interviews are with 'individuals considered influential, prominent, and well informed' (Marshall & Rossman, 2011). Everyone interviewed for this research were 'elite', in that they were senior ministers, political advisors, senior departmental and health services officials; owners or chief executives of private hospitals; senior medical personnel or representing the interests of private hospitals. Snowball and purposive sampling were used to identify and recruit the interviewees (Marshall & Rossman, 2011). The research protocol and instruments were approved by Trinity College Dublin, School of Medicine's Ethics Committee. The participant information leaflet and informed consent form are in Supplementary File 3 and Supplementary File 4.
Two key interviewees turned down the request for interview. In order to mitigate against bias, i.e. those who gave interviews were more favourable to the research, in instances where just one person or a small minority of people made a point, this is made clear in the analysis. Also triangulation of findings from the documents was used to support and check-up points made by interviewees.
The strengths of the methods are the in-depth analysis of the policy making process, which allows not only a description of what happened, but also allows for an analysis of what explains what happened. The limitations of the case is that it is just one case that may be atypical of policy making processes.

Conceptual framework
All interviews were transcribed and coded using NVivo 9 under themes identified in a conceptual framework specifically devised for this research. The conceptual framework was derived from relevant literature in the public policy, health policy and political economy fields. The framework drew on Kingdon's multiple streams research, policy analysis work of Walt and Gilson, Grindle and Thomas's empirical work on the political economy of health reform, Reich's work on political priorities for health policy, as well as Touhy's and Wilson's comparative health systems analyses (Grindle & Thomas, 1991;Kingdon, 1995;Reich, 1995;Touhy, 1999;Walt & Gilson, 1994;Wilsford, 1994).
Kingdon's classic work on why policy issues rise onto and fall off governments' agendas, identified the problem, policy and political streams that come together at a certain moment in time to form a policy window, which is often opened by a policy entrepreneur (Kingdon, 1995). While this research does not utilise Kingdon's multiple streams, it draws on Kingdon's focus on how alternatives to government proposals are generated, as the Finance Act changes emerged as alternatives to original health policy intent. Kingdon's concepts of policy windows and policy entrepreneurs are explicitly utilised in the framework.
Kingdon defines 'policy entrepreneurs' as 'advocates who are willing to invest their resources -time, energy, reputation, money -to promote a position, in return for future gain' (Kingdon, 1995: 179). Kingdon identifies how policy entrepreneurs are 'not only responsible for prompting important people to pay attention, but also for coupling both problems and solutions to politics'. (Kingdon, 1995: 18). Kingdon also points out how there is no single formal or informal position for policy entrepreneurs, they can be a cabinet secretary, lobbyist, civil servant or academic.
Touhy's comparative work on how windows of opportunity were more likely to be created by events in the political realm, rather than in healthcare, and Wilsford's work on path dependency, also influenced the conceptual framework (Touhy, 1999;Wilsford, 1994).
The conceptual framework developed for this research was devised by merging and combining aspects of the work referenced. All material was then analysed using this conceptual framework with the themes and variables outlined in Table 1.

Results
This research sought to explain the policy making process behind the changes to the Finance Act in 2001 and 2002 that gave tax-reliefs to developers to build private hospitals, which was

Ideas for intervention
The proposed policy 'solution', the degree of agreement on solution, origins of 'solution' including policy transfer, opposition and alternative solutions to problem

Guiding institutions
The role of key institutions and the degree of priority given to the issue

The role of policy entrepreneurs
The role and influence of policy entrepreneurs, particularly strong champions of the policy, in the policy-making process

Political ideology/ institutions
The degree that contextual (historical, economic and political) and political institutions influence the policy choice

Policy process/window
The process through which the policy was made and the moment when the political, policy and problem streams comes together inconsistent with and appeared to have undermined the stated health strategy aim of expanding public hospital beds. The results are outlined using the themes and variables identified in the conceptual framework, drawing on findings from the documentary analysis and interviews interspersed.
Policy characteristic Severity of problem. By 2000, there was widespread agreement inside and outside the health system that the shortage of public hospital beds and the associated long waits for public patients in emergency departments and for hospital admission for elective treatment was one of the major challenges facing the Irish health system (Department of Health, 2001). Simultaneously, there were increasing numbers with private health insurance without much choice in private hospital options. By 2001, over 47% of the population had private health insurance, which facilitated faster access to care in public as well as private hospitals (HIA, 2013). Yet, private health insurance contributed towards less than 7% of overall health expenditure in the early 2000s (OECD, 2004).
While there was agreement about the shortage of public beds and long waiting times experienced by public patients, there was significant disagreement as to the causes. Government decisions had closed large numbers of public hospital beds in Ireland during the 1980s economic crisis. By 2000, in line with international trends, there was an expectation of a falling need for hospital beds facilitated by advances in medical technology, shorter lengths of hospital stays and increased numbers of day cases.
Since the 1990s, government policy stipulated that a maximum of 20% of patients treated in public hospitals can be private patients (Wren, 2003). In 2002, after this policy was restated in Quality and Fairness, 25% of public hospital discharges were found to be private and in some hospitals up to 40-50% of patients were private (Comptroller and Auditor General, 2003). This high demand for private treatment in public hospitals, combined with incentives, encouraged doctors and hospitals to prioritise private patients over public patients and exacerbated two-tier access to hospital care (Burke, 2009).
The main explanation given by interviewees for the shortage of public hospital beds was the failure to invest in the capital public health budget.
Ideas for intervention. The long waits for public patients needing admission to public hospitals emerged as a central issue in the 2001 national health strategy (Department of Health, 2001). As a response, a key proposal was to increase the numbers of hospital beds by 3,000, 650 of which were due to come on stream in year one, 450 of which would be public (Department of Health, 2001).
There are arguments for and against whether private hospital capacity assisted in alleviating public hospital capacity. Given that the majority of citizens do not have access to private hospitals and that more complex care takes place in the public system, meeting the needs of the whole population could be best addressed through investment in the public system (Department of Health, 2010).
In parallel, in 2000, the Department of Finance was developing the annual Finance Act, which is the primary legislation that brings the provision for the national budget into effect. In the national budgets in the years up to 2001, there had been a proliferation of tax-reliefs, which gave tax breaks to developers to build hotels, houses, apartments, car parks, and shopping centres (Commission on Taxation, 2009).
Tax-reliefs were a central instrument of government policy, which fuelled the economy and a construction industry boom, which in turn generated huge tax revenues for successive governments. Tax In response, a Department of Health official said: I agree with your arguments against introducing a tax based scheme to support the creation of hospitals. Such a scheme would be totally contrary to 'the orderly development of hospital facilities'. It might also create excess capacity which would be inflationary from the point of view of insurers. It would also reduce the possibility of more efficiencies in the hospital sector (Department of Health, 2000).
These findings were reinforced by the interview data (selected quotes are in Table 2), which show that senior civil servants in both government departments and the Minister for Health's position was overridden by the Minister for Finance.
The role of policy entrepreneurs. Two policy entrepreneurs emerge clearly from the documents. In the first year that health institutions were included for tax-reliefs, James Sheehan, a surgeon and co-owner of Ireland's first stand-alone private hospital, lobbied finance minister McCreevy seeking tax breaks for hospitals.
In November 2000, Sheehan wrote: My reason for writing is to make representation to you in the hope that some tax incentives could be provided for acute [hospital] facilities (Sheehan, 2000).
In 2002, a representative of private hospitals, Michael Heavey, lobbied the government that the tax-reliefs be extended to forprofit hospitals.

Political ideology/ institutions
The point of all this… is that it was a much more politically saleable way of putting expensive public services in place (IV 1).

So I approached Charlie McCreevy on that basis … and I said, 'Look is there any chance you could extend it [tax reliefs] to the health situation?' He said, he'd look at it, he'd put me in touch with his officials in the department. I went with a submission, he met me and he was very helpful They asked me for my views and we drafted it together…. And I sat down with them and we wrote the Finance Bill … (IV 15)
a Interviewees were guaranteed anonymity and confidentiality. Given the small size of Ireland and the policy making community, interviewees (IVs) are referred to by numbers, as saying they are a departmental official or a minister or an advisor could make them identifiable. One interviewee is identified in the text as he published a memoir subsequent to the interview where he retold what he had told me in the interview and therefore it is now in the public domain.
Policy process/window. Two separate policy processes were in train while tax-reliefs to build private hospitals were introduced.

Discussion
The documents and interviews clearly show that the changes to the Finance Act were political decisions, made by the finance minister who was effectively lobbied by private hospital interests, who persuaded him to apply tax-reliefs to the health arena. Even though there was an extensive national health policy developed at this time, with different policy commitments, the wishes of the finance minister over rode the opposition of finance and health officials as well as the health minister.
This reflects findings in international health policy literature where economic policy goals usually over ride health policy aims (McIntyre et al., 2004). The power struggle between the Departments of Health and Finance emerges clearly from this casestudy. This is probably true for most elected governments, in that ultimately it is the Department of Finance that holds the purse strings and therefore the power.
Recent research trying to explain the policy decisions that led to the Irish economic crisis, refers to Ireland's policy environment as one of 'emergent neo-liberalism', where 'much of policy transformations of the Celtic Tiger era movements were, then, to an extent the outcome of a certain political pragmatismdoing what was necessary at the time to satisfy the needs of various sectors of the voting public -rather than being characterised by clearly delineated periods of 'roll back' and 'roll out' neoliberalism ' (Kitchin et al., 2012).
Political ideology emerges, generally and in this study, as one of the strongest influences on the policy processes, in health as in other policy arenas. In this case, political ideology was served by the political institutions, in pursuit of a particular economic policy pursued by the government. The smaller coalition party had disproportionate influence over government policy. This was enabled by close alignment of the finance minister to the ideology and policies of the junior partner, which emerged as one of the most robust findings in this research.
Touhy's work found that episodes of health policy change were brought about by windows of opportunity created by events in the broader political arena, not in healthcare per se (Touhy, 1999). She found that when governments had a majority, which 'were swept into power by broad current opinion, that establishes the broad outlines for change ' (Touhy, 1999: 114). Touhy concluded that it was these 'accidental logics that drive the dynamics of change' (Touhy, 1999: 239). This resonates strongly with the findings in this research, in that these policies were born out of the political ideology of the time, which drove a specific economic policy agenda that included tax breaks, not out of an analysis of their potential effects on health policy.
Touhy also emphasises the importance of national context, in which the legacy of past policy failures condition policy makers to adopt an incremental approach which can sow the seeds of future policy failures (1999). This emerged as a finding from the interviews, in that the existence of Ireland's unique publicprivate mix of healthcare allowed the justification of adding more layers to it with the introduction of tax-reliefs to build hospitals.
This finding bears out the work of David Wilsford and others on 'path dependency' (Wilsford, 1994). 'Path dependency' is a term used when a set of decisions for any given circumstance is limited by the decisions made in the past, even though past circumstances may no longer be relevant. For Wilsford, 'a path dependent sequence of political changes is one that is tied to previous decisions and existing institutions' (Wilsford, 1994: 252).
Wilsford sought to explain policy change by seeking to explain a path-dependent model where 'actors are hemmed in by existing institutions and structures that channel them along established policy paths' (Wilsford, 1994: 251). When path dependency is influencing health policy reform, structural forces dominate and therefore major change is unlikely and policy development is more likely to be incremental (Wilsford, 1994). The vast majority of change in Ireland's health policy occurred in an incremental manner (Burke, 2009;Wren, 2003). Here, the path dependency of the long institutionalised public private mix in healthcare, as well as the application of tax-reliefs to the health sector, was the dominant force of change. This is evident in the rapid growth of private hospital beds and low numbers of additional public hospital beds.

Conclusions
The introduction of tax-reliefs in Ireland for private hospitals in 2001 and 2002 is a clear example of a politically driven economic policy, which came from outside of the health arena and had a significant impact on healthcare provision. Even though 1 While anonymity and confidentiality was guaranteed to all interviewees, Sheehan subsequently wrote a memoir which included reference to his direct role in drafting the initial changes to the Finance Act (Sheehan, J, Life Close to the Bone, 2013).
there was a much larger, health policy development process, the zeal of the finance minister for tax-reliefs for health over-rode the opposition of his own officials, the health minister and department officials.
The research clearly reveals that a small number of people involved in private hospitals lobbied the Minister for Finance for the changes to be introduced. This demonstrates politicised and personalised nature of these policy-making processes. The result of which was increasing the numbers of private beds, instead of investing in the public health system. As the majority of the population do not have access to private hospitals, this exacerbated existing inequalities in access to hospital care in Ireland.

Data availability
There were two main sources of data for this research articledocuments and interviews. The documents are listed in Supplementary File 2. It is not possible to provide the transcripts of interviews, given the nature of the interviews -interviewees were given guarantee of complete confidentiality and anonymity in their informed consent forms, it is not possible to provide them as source data. Their availability, even if anonymised, would break the agreements with interviewees and the approval received from the research ethics committee in the School of Medicine in Trinity College Dublin. Any breach of it would be detrimental to the trust built with this research team. Given the small size of the policy community in Ireland, then and now, the interviewees would be recognisable to people working in health policy in Ireland.

Introduction
The significance of the quadrupling of the heath budget in a decade is hugely significant. The expansion opens up new actors and policy options; taken-for-granted assumptions about finance and service delivery may no longer apply as strongly. The authors could delve into this further, drawing on documentary and/or interview data more clearly.

Methods
The issue of anonymity is described well although this does present some uncertainty in terms of corroboration. The authors do offer some data triangulation. Given the elapsed time between the period in question and this publication, it is important that the authors add the year/date of interviews to provide temporal context. There is a danger of recall bias and post-hoc rationalisation.

Conceptual framework
The authors draw on a reasonably wide selection of concepts for an article of this length. It shows that the article is drawn from a broader study. A narrower focus would provide greater conceptual clarity. It is hard to trace how the framework (used by the authors) was devised since Kingdon's model is one of two outlined on page 4, and yet the authors state "this research does not utilise Kingdon's multiple streams" but "Kingdon's concepts of policy windows and policy entrepreneurs are explicitly utilised in the framework." In my opinion, Kingdon's (entire) model would indeed be suitable for this study. In any case, citation of other studies (which used Kingdon's or Touhy's approaches) would be merited.

Findings
Findings • more evidence from interviews/documents could have been provided to substantiate the Severity: claims being made. In particular, evidence from sources outside political/policy networks (eg. media reports, public opinion) would be highly relevant (given Touhy's argument). The percentage of population with PHI appears significant given growth of hospital beds in this sector seems to have been seen as a viable option.
• the feasibility of increasing bed numbers by 3,000 (including 650 in one year) does not Intervention: seem to have been addressed. Although the implications of the proliferation of tax breaks in other areas of the economy/society (including health care) were apparent, it was not clear how a consensus about application of tax breaks to health care was achieved. More detailed would be required, for example (eg. para.1, page 6 "They were a politically acceptable alternative to public sector investment"). This would include a comparison of how alternatives (drawn from Kingdon's `primeval soup') were considered and apparently rejected.
• this section provides a good sense of the policy process and change over time. The Actor power: authors note the potential imbalance between anonymised and named sources. Although this gives a somewhat tendentious perspective, it is transparent. I have an equivocal view of the table on page 7 regarding the role of policy entrepreneur; it is overly simplistic but it does address the elements of the framework. The article does point towards the inter-connections between elements but needs to be elaborated better (ideally in a longer assessment) to gain a thorough assessment of the data and the application of the conceptual framework to the data.

Discussion
This section does cover new and intriguing perspectives on `Accidental logics' and `Path dependency.' These could have been described better at the outset and then a more nuanced assessment offered in the Discussion section. Equally, the Discussion does not address Kingdon's multiple streams.
Overall, the article attempts to trace the process relating to a significant change in policy (between espoused policy and actual implementation). Whilst the conceptual and empirical sections offer interesting and relevant material, I feel that the article is under-developed in the sense of substantial contributions to theoretical perspectives. Some of the empirical data are cursory and more depth could have been provided. The interpretation of the data in relation theoretical framework needs further development. Much of this comment might be due to the nature/structure of the article (eg. Word length); in which case, I would suggest a more focused remit of the article, drawing on one aspect of the conceptual framework and exploring the relevant data associated with it.

Are sufficient details of methods and analysis provided to allow replication by others? Partly
If applicable, is the statistical analysis and its interpretation appropriate? Not applicable Introduction This issue is now dealt with more extensively in a section on the health policy context. This draws on the broader health policy and relevant Irish literature, which was not a specific focus of the interviews. For example, in order to explain the increase in health budget, we have added the following text: Analysis on the differences in health expenditure across 30 OCED countries in the early 2000s found that 90% related to GDP per capita (Department of Health, 2010). Analysis of this period of increased spending, undertaken by an Irish government commissioned expert group on resource allocation and financing, stated: 'In terms of economic sustainability, while Irish healthcare expenditure as a proportion of gross national income (GNI) increased from 7.3 per cent in 2000 to 9.0 per cent in 2007, health expenditure as a proportion of GNI has also risen across the EU and OECD, with the result that in 2007 Ireland still ranked among the low spenders on health in terms of health expenditure as a proportion of GN'I (P 65, (Brick A 2010) (OECD 2017).

Methods
The year/dates of the interviews and greater clarification on how material was verified are now provided.

Conceptual framework
As the reviewer has correctly identified, this paper came from a broader study -the PhD of the lead author. As detailed in the overall response to reviewers, there is now much more detail on the literature drawn on, including a new text in the conceptual framework section explaining the rationale and literature from where each of the variables was derived. This is specified in a more developed table and in the text in longer methods, findings and discussion sections.

Findings
More quotes are added as suggested to substantiate points made. Other sources not originally analysed in the research are not used. Intervention: The points made here have been clarified in the body of the text. The research found that while there was political support for tax breaks in general, there was no consensus on their introduction into Health. In fact, it was the result of private sector lobbying, together with the positive response by the Minister for Finance to the lobbying at the time that brought about the policy change. Actor Power: The table of quotes has been discarded as a table and these and other quotes are now provided throughout the text. The interconnections between the elements are dealt with in the discussion section where they are now weaved into the relevant literature and in a new section entitled 'Reflections on the conceptual framework and methods'. Discussion: These issues are now addressed in a longer text in particular in the new section on conceptual framework Page ? , an extended findings (Page ? -?) and discussion sections (Page ? -?) with some sections largely rewritten.
No competing interests were disclosed. Competing Interests: 1.

5.
This is an interesting paper, that could be much more convincing if it were revised to take account of what I see as a number of problems.
This could be set up better. It is not clear, except for the innuendo, that the policy was necessarily bad. I think the paper would be improved if it didn't try to assess the policy, and instead looked at how the policy was made, and what explains the policy choice. It is asserted that the chosen policy went against the Department of Health strategy -this is the key to the framing of the paper -but I think it would be more convincing if we could see that strategy, and show this more clearly.
There are also some problems with the argument. There had been the quadrupling of the budget when the 'neo-liberal' agenda was in place, this hardly suggests libertarian ideology at the centre of the government. It might be more interesting to look at why this was concentrated on current spending and not capital spending.
There is not a strong basis for the analysis in the literature cited. The empirical evidence appears to point to interest-based politics, and or ideology. The multiple streams framework doesn't really add anything. There is a literature, I'm working on, that looks at policy failures as a result of institutions (which can incorportate path dependency), interests and ideology. It seeks to explain how these interact to reduce/ target the flow of information to policy makers. I can see how this would add to the explanation here. As it is written, there are assertions made in the Discussion that don't really stand up to scrutiny, or at least aren't well supported in the text, f.i. there's nothing here that suggests that path depdendency is important. That doesn't mean it is not, just that the case hasn't been made.
There was no discussion of how Finance Bills are produced and negotiated. This would be useful.
The empirical evidence is dealt with in a somewhat patchy manner. The most damning bit of evidence evidence seems to be the claim that James Sheehan wrote the relevant section of the Finance Bill. Is this true? I'd be disinclined to believe everyone's claims. I'd prefer if the authors used process tracing techniques -it would make the paper much longer, but more convincing.
Other small stuff. There are no page numbers for references that are clearly page specific. Some references are to edited books, not the individual chapter that claim is drawn from, e.g. Gallagher and Marsh 2007. There is a reliance on the analysis of Kirby (2010) that is highly contestable, and hardly mainstream. he for instance does not recognise the genuine (and verifiable) increase in wealth, welfare and well-being associated with the Celtic Tiger years. On p.3 there is a misuse of the word conservative.. the authors mean liberal. Typo on top of p. 4, public patients? The methods section read a bit like an MA thesis. Claim on p. 5 that public patients do not have access to private hospitals is not strictly true, and they did through the national treatment Purchase Fund.

Is the work clearly and accurately presented and does it cite the current literature? Partly
Is the study design appropriate and is the work technically sound? Partly

If applicable, is the statistical analysis and its interpretation appropriate?
Not applicable thus providing extra capacity for the treatment of public patients on waiting lists. The private hospital sector will be contracted to provide 200 beds, all for treatment of public patients on waiting lists. (P 102, (Department of Health and Children 2001).
We have taken on-board the reviewer's observation and addressed these points, as much as the data gathered and other relevant sources allowed. In particular, the issue of capital under spending is addressed, along with new text on the context, in the health policy context section. However, while we could have speculated, the empirical data (interview data and documents gathered for this research) did not allow us draw any conclusions or explanations for the focus on current spending over capital spending.
2. These points have been addressed in the extended, revised text. Much more space is given to outlining how the conceptual framework was devised in the text and a significantly amended table details the literature from which they emanated. A whole new section on the conceptual framework is included. Much more empirical evidence is provided in the form of quotes from the interviews to back up the points made in the text. The authors believe that Kingdon's work is relevant especially in terms of policy entrepreneurs, policy alternatives emerging in the policy stream and examination of the policy window. These are made more explicit in the findings and the discussion. This reviewer has shared the literature that he and colleagues are working on in relation to 'institutions, interests and ideology' with the lead author. This has not been utilised here as the authors were keen to present the conceptual framework they devised and used in this research. Interestingly each of these -institutions, interests and ideology, as proposed by the reviewer -are close to the 'interests, ideas and institutions' as proposed by Walt and Gilson (1994) and cited in the text. This Walt and Gilson paper greatly influenced the conceptual framework utilised here, albeit used differently with more variables but three of the variables are 'guiding institutions, private sector interests and political ideology' are similar to those proposed by this reviewer. The rewrite has been careful to make sure that the discussion stands up to scrutiny and is directly drawn from the data and literature we presented, in particular drawing on more empirical data from the original research.
3. Where possible, the interview data and documentary analysis were drawn on to shed some light on the Finance Act development process.
4. More empirical data has been included in the revised text, including citing two FOI documents which verify the Sheehan 'claim'. However, the authors do not see that is as 'damning evidence' or even the strongest finding. What this reveals is a personalised, politicised policy making process that took place behind closed doors, where private sector interests lobbied the Finance Minister which led to a significant policy change. This happened alongside more open, health driven policy process was taking place. This is now the focus of the entire draft.
This is a case study completed as part of a PhD, the authors believe the methods and analysis presented stand up and are the better for this review process. To start now on process tracing would require a complete reworking of the data, or even new data collection.
5. These issues have been addressed, page numbers and specific chapters are now included in the references. The word conservative was replaced with liberal.
More 'mainstream' literature other than Kirby has been cited expect when Kirby's analysis was deemed useful to include.
The methods section is now longer. During this time, most public patients did not have access to