Greek crisis fallout is an opportunity for health
Greece’s health reform – born of the 2008 economic crisis – may fall short of expectations. Aris Sissouras tells Menelaos Tzafalias why.
Aris Sissouras has advised governments on health sector affairs and promoted research for health-care services in Europe for more than two decades. From 2011 to 2012 he was the chair of the independent Expert Committee for the reform of the country’s National Health Services. He is a professor of operational research and the director of the Health Policy and Operational Management and Planning unit at the University of Patras, Greece. Sissouras has worked on committees and working groups at the World Health Organization as well as a project to develop health indicators in the European Union (EU), and he was a member of the High Level Committee on Health of the EU. He was in the team that developed the plan in 1983 for the creation of today’s Greek National Health System (NHS).
Bulletin of the World Health Organization 2014;92:8-9. doi: http://dx.doi.org/10.2471/BLT.14.030114
Q: How has the economic crisis affected health in Greece?
A: The prevalence of clinical depression and of suicide has increased over the last three years. Also, the prevalence of HIV infection is increasing, perhaps because injection drug use has grown and programmes supporting people who are dependent on such drugs have been slashed. Access to the health services has been reduced and pressure on the public services is greater. People can no longer afford private health care and are going to public hospitals. Hospital admissions have been increased by 28% to 2.2 million in 2013 from 1.6 million admissions in 2009. Many people with health problems, who lack the money, are not seeking health care at all. In addition to poor access, an increase in co-payments for medicines and the imposition of other user chargers have compounded these problems. Hospital budgets are continually being cut, resulting in shortages of medical materials, particularly laboratory materials, undermining the quality of care. People’s health and the health system have both suffered.
Q: What is being done to protect people from financial ruin and make health services more accessible?
A: Unemployment is increasing every year and, today, 27% of the adult population, nearly 1.5 million people, is unemployed. About 18% of the overall population (11 million) no longer has health insurance coverage, as people who become unemployed now lose this after one to two years. This has grave social implications. To address the problem, the government is issuing health vouchers for certain groups, such as low-income families and the disabled. Local governments and the Greek Orthodox Church are also trying to establish “solidarity centres” that would provide basic health services and medicines to those in need. In addition, nongovernmental organizations, which used to attend to immigrant populations, are now providing free health services to Greeks as well.
Q: Was the reform long overdue or is it a desperate attempt to address the current budget deficit?
A: Our current health policy and any changes to the health sector are determined mainly by the crisis and, in many ways, dictated by the memoranda of the Troika [representatives of Greece’s official lenders: the EU, the European Central Bank and the International Monetary Fund]. The fact is that Greece has taken out loans and that obliges us to fulfil certain conditions.
Q: Given the anti-Troika demonstrations in Greece in recent years, does it help that the terms of your country’s health sector reform are dictated from abroad?
A: While there is unease about this situation in Greece, a large part of our society recognizes that the health-care system had reached the point of unsustainability and was in urgent need of reform. Many people are understandably inclined to be negative and say that our health policy is being manipulated by outside forces. But, while the broader terms are being dictated by the Troika – i.e. by how much certain spending should be cut – we have a certain degree of freedom to decide how to implement these cuts and certain policies that were long overdue are now being implemented.
Q: If all the cuts stipulated by the Troika are made, can the Greek health system function properly, within the budget foreseen by the memoranda?
A: No, not at the moment, because the health system lacks the structural elements needed to allocate and control the money in a more efficient and rational way. It’s a paradox. On the one hand, we accept that there was a lot of ‘fat’ in the health sector, which had to be eliminated, i.e. a lot of unnecessary expenditure that had no effect on the quality of health care. But, on the other hand, these cuts have brought health services and outcomes to a lower level than before, because the structural changes that should have been in place have not been instituted. It’s a vicious circle of the need and will for reform on the one hand and the inability of the system to proceed with the required changes, on the other hand.
Q: One of the key problems highlighted by the Troika and in your independent experts’ report was the failure of the Greek health system to contain pharmaceutical spending over the past 10 years. Why?
A: This is partly because of over-prescription, which is a common problem in many countries, but it is mainly because the health system never developed mechanisms to control expenditure by evaluating new medicines and medical devices. The underlying reason is that, unlike other countries, e.g. Germany, the United Kingdom and Scandinavian countries, Greece does not have a health technology assessment agency whose role is to evaluate new technology and decide which products should be made available and reimbursed through the NHS, because strong pressure groups working for the “medico-technology complex” persuaded our politicians to reject plans for such an agency – not just once, but three times – in the past.
Q: What are the implications?
A: The Greek health-care system as a whole and its total health expenditure, public and private, was more than 9% of the gross national product. On the surface, it looked fine, but – and this is the most important point – we were not getting value for our money: there was no system of controlling expenditure in the public but also the private sector. Pharmaceutical expenditure was excessive and there was no system of rational allocation and efficient use of money for running health services. Greece is not alone. On average across the Organisation for Economic Co-operation and Development (OECD) including Greece, life expectancy at birth could be raised by more than two years – holding health-care spending steady – if all countries were to become as efficient as the best performers, according to a 2010 OECD study.. Now the Troika stipulates that Greek public health sector expenditure should not exceed 6% of gross national product, which is the average level for EU countries.
Q: By how much did pharmaceutical spending increase?
A: In 2000, it was at around 1 billion euros (US$ 1.4 billion), but by 2009 it had reached an unjustified and excessive 5.6 billion euros (US$ 7.6 billion), most of which was covered by public money. That’s why pharmaceutical expenditure was targeted by the Troika that stipulated spending levels should be capped at 2 billion euros (US$ 2.7 billion) last year (2013). Naturally, this has led to policies for rationalizing drug expenditure. A new e-prescription system has been established, generics are to be prescribed whenever possible and a recommended list of medicines with a focus on generics has been reintroduced (it was abolished in 2006). So far, Greece has succeeded in cutting pharmaceutical spending to 2.37 billion euros (US$ 3.2 billion) last year (2013) from the 2009 level of 5.6 billion euros (US$ 7.6 billion). The Troika still insists that Greece should cap the level of this expenditure at 1% of gross domestic product, which is continuously decreasing due to recession.
Q: What other changes have taken place?
A: Although Greece created a national health system in 1983, it is a mixed system of health-care services comprising a large public sector: the NHS and the social health insurance funds; and a private health care sector, which grew as a result of the public sector’s failure to undergo the reforms of the original law. In 2011, we merged the national health system and the four main social health insurance funds into one organization, known as the EOPYY (National Organization for Health care Provision), something we should have done years ago. This new organization purchases services provided by the private sector through contracts and those provided by the now unified public health service.
Q: Has the Troika intervened directly in the reform?
A: The European Commission has created a special Task Force whose role is to provide assistance and know-how outside the Troika’s terms of reference and only in response to requests from Greek ministries. In the health sector, for example, the Task Force has been asked to provide German experts to evaluate the implementation of diagnosis-related groups, which is a system used for costing medical activities and providing unit costs so that we can control health expenditure more efficiently. This provides the unified insurance organization, the EOPYY, with a tool to keep track of expenditure, such as how much is being paid to service providers – the public hospitals, private diagnostic centres and private hospitals – that are contracted to provide health services. But, as I mentioned already, there is a danger that the new structure will be ineffective because of management incapacities and budget deficits.
Q: Is there a consensus within Greece as to the kind of reforms and cuts that are needed?
A: No. Many stakeholders who are directly affected by these reforms are opposed to them, for example, doctors and nurses, who have had their salaries cut. Pharmaceutical companies, pharmacists and the biotechnology industry have no interest in rationalizing drug procurement. Patient groups object to them too, as many people have reduced access to health services and may struggle to pay for these out of pocket. Citizens, as a collective body, lack strong negotiating power in health matters as Greece is one of the few countries in Europe that does not have a national patients’ association. We have at least 16 patient groups for specific diseases, such as for cancer and diabetes, but they do not represent a strong civil society movement. We need a strong national patients’ association as a major actor for achieving consensus on government policies.
Q: What is the outlook for Greece’s health services?
A: The government needs to press on with the reforms. Some effective cost containment measures are in place: we have a new unified public health organization, we are building a health information system to keep track of expenditure and health care and there are signs of more dialogue between ministers, who are listening to scientists and public health experts. This new climate may keep the reform agenda alive. Some people are demoralized, understandably so. But I always see the positive side. We now need a national strategy for primary health care and we should address chronic diseases, which account for 70% of our disease burden. We never had a good strategy for prevention or a system of follow-up, partly because of the lack of primary health care. These should be our priorities. Although the health system is still lacking some essential structural elements, it now has a strong basis on which to build. I am one of those who believe that the crisis has provided Greece with a window of opportunity.