Gregory Roumeliotis, MPhil
General Manager Cryo Save Balcanica
Vice President of GHSMA
Stefanos Chronis, MSc
Polyclinic Health Unit SA
current structure of Greek healthcare services:
Greece covers an area of 131 957 km2 with hundreds of scattered islands around its coastline. The country is divided into 13 administrative regions.
Over the last 15 years, a great many economic immigrants – some legal, others not - have been entering the country. According to official statistics, the population (in 2005) stood at 11 120 000 people. Women make up 50,5% of the total population. In 2005, the workforce amounted to 4 850 000, and unemployment was at 9,6%.
Greece is a parliamentary democracy. The capital is Athens with 4 million inhabitants; Thessalonica is called the “capital of north” is. The official language is Greek (98%). Other languages are spoken in border zones (2%).
In 2005, the GDP was 181 billion ( 16 277 per capita), with an annual growth rate of 3.7%. In 2004 health
expenditure was 10% of the GDP; estimates showed that it would increase to 10.3% by the end of 2006. Life expectancy at birth is 82 years for women and 78 years for men (in 2005).
The current Greek healthcare system was established by Law 1397/1983, on which the Greek National Health System (GNHS) was founded. The principles of law include:
• Equity in delivering and financing healthcare services
• Primary health care development
• A new public-private mix in the service provision
• Responsibility of the state for the provision of healthcare services
• Decentralisation in the planning process, improvements and community participation
• Establishment of new payments methods for healthcare providers As a result of this law, all hospitals that had been subsidised by the State became public; the employees all became civil servants; and the establishment of new private clinics was prohibited. (This prohibition was suppressed nine years later.)
Initially, vast numbers of doctors andother health professionals wereappointed in the public sector, andmany new hospitals and more than 200 rural health centres were built.
Interestingly enough, numerous legal provisions have not yet been enforced such as decentralising the system, organising primary healthcare and modernising administrative and economic processes in the public health sector.
The Greek healthcare system is mixed, having elements of both the Bismarck and Beveridge models.
Health expenditure is covered by:
• State budget
• Social insurance funds
• Private insurance companies
• Official out-of-pocket payments by patients
• Non-official payments by patients
The total health expenditure is covered (2005) by:
• State and social funds: 52%
• Private payments of patients: 48% (Private insurance covers about 2%.)
GNHS hospitals receive funds to pay all personnel directly from the State budget. Also, they receive one daily fee for each patient from the social insurance funds, which is low, bearing in mind the real cost of hospitalisation. Therefore, they often face substantial deficits, which are afterwards covered by the State budget.
However, in many cases patients have to pay doctors in public hospitals some money “under the table” to
minimise waiting time or because they think this will ensure better medical care.
In private hospitals (clinics) hospital fees and doctors’ salaries are higher, as these are paid by private insurance companies, or directly by patients. Patients who have social insurance prefer to stay in private clinics, as this guarantees fast service and more luxurious conditions.
The main problems in the Greek healthcare sector can be summarised as follows:
• The number of doctors per capita is very high, bearing the size of the population in mind. Experts estimated that the country needs 27 000 to 30 000 doctors. However, currently there are more than 68 000 doctors; in other words, 1 doctor for every 136 inhabitants. Some doctors supplement their income in rather unorthodox ways, resulting in unjustifiable increases in healthcare.
In contrast, there are few registered nurses – one nurse for every 250 inhabitants – because this profession does not offer much in terms of social reward. As a result, hospitals employ nurses’ assistants to deal with the workload. Unfortunately, these assistants are not sufficiently trained.
• Primary healthcare is not organised by a central body, especially in urban areas. General practitioners represent less than 2% of the total number of doctors. Hospitals offer their services covering both secondary and primary healthcare. As a result, there is increase in patients waiting lists, a tendency to direct patients to the private sector or patients engage in unethical out-of-pocket payments.
• The fact that GNHS staff have a job for life and the lack of active HR evaluation and incentives are negative factors that impact on the productivity and effectiveness of the system. In a lot of cases, problems arise in the supply chain of technological equipment, sanitary materials and medicines, resulting in financial loss for public hospitals.
• Modern management methods and cost control systems, such as global budgets and DRGs, have yet to be applied in GNHS hospitals.
Regarding the establishment of modern and integrated Health Information Systems and despite the generous EU funding, absorption rates are very low, application has been very slow and therefore the system cannot have powerful and accurate tools to achieve optimum operation and planning, or perform financial and clinical audits.
In November 2006, the Minister of Health and Social Solidarity announced that he would propose three new bills to Parliament regarding the (i) central procurement of hospital supplies; (ii) administrative reengineering of the GNHS; and (iii) organisation of primary healthcare.