VENETIA NOTARA M S c , RNT 1, SOTIRIOS A. KOUPIDIS MD, MS c , PhDs 2, ELISSAVET VAGA MSc 1 and ILIAS A. GRAMMATIKOPOULOS MD, MPH, PhDc 3,4 1Lecturer, Clinical Nursing Unit-Health Visiting Department, Technological Educational Institute of Athens (T.E.I. – Athens), Athens, 2Senior Lecturer in Public Health and PhD student, Athens University Medical School, Athens and 3SHO Psychiatrist, 2nd University Psychiatric Clinic, Aristotle University of Thessaloniki, Thessaloniki and 4Research Assistant, Clinic of Social and Family Medicine, University of Crete, Crete, Greece
Greek healthcare system
The Greek health care system is characterized by the coexistence of the National Health Service (called ESY), a compulsory social insurance and a voluntary private health insurance system. The ESY provides universal coverage to the population and operates on the principles of equity, equal access to health services for all and social cohesion. In addition, 97% of the population is covered by approximately 35 different social insurance funds (compulsory social insurance), whereas 8% of the population maintains complementary voluntary health insurance coverage bought on the private insurance market (WHO Regional Office for Europe 2006).
Correspondence Venetia Notara Clinical Nursing Unit-Health Visiting Department Technological Educational Institute of Athens (T.E.I. – Athens) Thivon Av. 274 Athens Greece E-mail: firstname.lastname@example.org NOTARA V . , KOUPIDIS S.A. , VAGA E. & GRAMMATIKOPOULOS I .A. (2010) Journal of Nursing Management 18, 501–504
Economic crisis and challenges for the Greek healthcare system: the emergent role of nursing management Background Despite several reform efforts, the Greek health care system still faces problems related to misdistribution of trained health staff and finance between geographical areas. Aim The objectives of the present study were to describe the current situation of the delivery of the healthcare service in Greece, to explore the basic implications of the economic crisis from a nursing management perspective and to examine future practices opening a debate in policy developments.
Key issue The principal finding of this study was the serious shortage of trained nurses, the imbalances in nursing personnel, an excess of doctors and the complete absence of a Primary Healthcare System in civil areas provided by general doctors.
Conclusion It is important that health care policy makers become aware and seriously consider rearranging the Health Care System to become more effective and efficient for the population (client). Special attention should be paid to strengthening areas such as primary health care, public health and health promotion in the direction of minimizing the demand of hospital services. Implications for nursing management Any implementation of major health care reforms should consider seriously the role of the nursing management which formulates the substantial link between the health services and the patient. Keywords: Greece, health care, nursing management
Accepted for publication: 6 May 2010 Journal of Nursing Management, 2010, 18, 501–504 DOI: 10.1111/j.1365-2834.2010.01119.x ª 2010 The Authors. Journal compilation ª 2010 Blackwell Publishing Ltd 501
Health services in Greece are funded almost equally through public and private sources. Public expenditure is financed by both taxes (direct and indirect) and compulsory health insurance contributions (by employers and insured people). Voluntary payments by individuals or employers represent a very high percentage of the total health expenditure (more than 42% in 2002), making Greeces health care system one of the most privatized among the European Union countries (WHO Regional Office for Europe 2006). Greece is one of the Organization for Economic Cooperation and Development (OECD) countries with the highest healthcare spending as a percentage of Gross Domestic Product (9.1% of GDP in 2006) (OECD 2009, Siantou et al. 2009). The GDP growth change was –1.8% and the public debt as percentage of GDP was 96.5% for 2009, while unemployment reached 8.6% the same year.
Greece has launched or introduced tax cuts for their lower- and middle-income groups and is also promoting private–public partnerships in its infrastructure investment initiative (which includes hospitals) but public funding for these initiatives is limited (WHO Regional Office for Europe 2009). Background of the key issue Greece presents one of the highest rates of physicians per residents (1 : 260) among the OECD countries.
Contrary to the high number of physicians there is a relative lack of trained nurses, the ratio of nurse to physicians being two to three. In 2001, there were 4.5 practising physicians per 1000 inhabitants, one of the highest concentrations in the European Union. Meanwhile, despite concerted efforts to increase the ratio of nurses to inhabitants, Greece still has one of the lowest in Europe. The majority of Greek physicians are specialized, and half of them work in the private sector and primary health care (WHO Regional Office for Europe 2009).
The Greek health care system is highly centralized and regulated. Thus, while exercising strong regulatory control over insurance funds and public hospitals, it is not involved in ongoing planning activities in numerous areas, including ensuring a minimum level of benefits to be provided by insurance funds; provision of health care services and facilities using needs-based criteria; planning of health care manpower; determining priorities with respect to patterns of care to be provided; determining priorities across regions; or allocating resources according to specific criteria.
Despite several changes since its establishment, the overall objectives of the Greek health care system have remained relatively impervious. Yet the current system is characterized by a high decree of centralization, fragmentation of coverage, a regressive system of funding, distortions in the allocation of resources, perverse incentives for providers and heavy reliance on expensive inputs. However, despite the favourable political conditions, health reform was only partially implemented. Expansion of public expenditure on health care focused primarily on the construction of rural health centres and a number of hospitals which improved access to health services especially for the rural population.
In 1994, the Minister of Health invited an international committee to examine the reform options for the health care system and to make recommendations for change. The committee found the health system in Greece to be largely curative and that it made excessive use of hospital out-patient departments. On top of all this, there was a misdistribution of trained health staff and finance between geographical areas (Abel-Smith et al. 1994).
While there was an excess of doctors, hardly any were trained to practice family medicine. There was a serious shortage of trained nurses, so that inpatients frequently employed untrained staff to care for them at night. Primary care was almost always provided by specialists. The health care system in Greece is currently characterized by a public–private mix for both funding and delivery. As mentioned above, in Greece three main types of coverage are available to the population: the National Health Service (NHS), health insurance funds (insurance based on occupation) and private health insurance (Mossialos et al. 2005). In the late 1980s, in order to attract more clients, companies developed a health insurance product of comprehensive hospital coverage without ceilings or cost-sharing.
Companies signed contracts with preferred private hospitals and gave their clients the opportunity to obtain unlimited inpatient care. In contrast with reimbursement policies, companies paid the providers directly. The result was an increase in admission rates, check-ups, laboratory tests and overall hospital expenditure. Companies undertook strict control and evaluation of the claims made by private hospitals (the control of tariffs and the necessity of check-ups and laboratory tests).
Furthermore, in the early 1990s they also introduced ceilings on expenditure and deductibles, which is the amount you pay out of your own pocket before the insurance company begins picking up any of the costs of health care. V. Notara et al. 502 ª 2010 The Authors. Journal compilation ª 2010 Blackwell Publishing Ltd, Journal of Nursing Management, 18, 501–504 Current health care crisis
The health care system in Greece is financed in almost equal proportions by public and private sources. Private expenditure consists mostly of out-of-pocket and underthe- table payments. Such payments strongly suggest dissatisfaction with the public system, as a result of under financing during the past 25 years (Siskou et al. 2009). A very high percentage of informal payments are made in order to gain access to public hospitals and to receive a higher quality of services.
Despite near universal coverage of the population by public health insurance, informal payments are widespread and a major source of inequity and inefficiency in the Greek health care system (Liaropoulos et al. 2008). The health system in Greece has for many years been in a state of continuous crisis.
The basic aspects of this crisis involve: a fragmented administrative framework; low level of public expenditure; a significant private sector; inadequate hospitals; skewed manpower; and a low level of primary care. As a result, several ambitious reform plans have failed repeatedly owing to an array of interrelated economic, political and social factors that channel potential changes toward the trodden path. This constellation creates unfavourable conditions for the introduction and implementation of major reforms (Davaki & Mossialos 2005).
The 200 reform measures announced in 2001 including changes aiming at: the decentralization of the ESY, the creation of a unified financing system for the social insurance funds, a new management structure in public hospitals, the organization of a Primary Health System in urban areas, and the strengthening of Public Health and Health Promotion (Tountas et al. 2002) are still in their infancy. Recently a Health Care Reform Act seeking quality improvement and coordination of outpatient and hospital services at the Regional level, through the enhancement of primary care, has been approved, integrating the health system in the primary care system with a major focus on equity, quality and outcomes (Souliotis & Lionis 2005), but the evidence of the follow- up and audit are still lacking.
Implications into practice Even if it is accepted that good health prevails in Greece, slower economic growth rates, an ageing population and continuous immigration will place increasing pressure on healthcare resources and will necessitate a more rational use of these resources. Health economic evaluation, by weighing benefits against costs, therefore, has an important role to play (Rovithis 2006). Demand pressures will also be heightened by an ageing population, which is expected to be more pronounced in Greece than for the average of the other OECD countries. Hospital patients during the next 30– 40 years will largely come from the baby boomer generation.
As these individuals grow older they will have a greater need for healthcare and will frequently have multiple problems. They also may be having elective procedures and a general expectation of a higher level of care, including spa-like amenities. Obesity also will be a factor among patients. A key finding which arises from a study conducted by Lionis and colleagues is that the long-standing dominance of medical perspectives in Greek health policy has been paving the way towards vertical integration, pushing aside any discussions about horizontal or comprehensive integration of care (Lionis et al. 2009). Meanwhile, the nursing shortage will continue and existing nurses will age, making professional caregivers scarce and tasks more strenuous. This creates concern for staff and patient safety.
Systematic overview of skill deficits in relation to skill requirements should be implemented by regional health authorities to enhance delivery of on-the-job training targeting group-specific, local needs (Markaki et al. 2009). It is also recommended for undergraduate medical students, the teaching of communication skills within primary care doctor–patient encounters, the exploration of new ways of teaching the doctor-patient relationship and that students and young doctors be encouraged to prioritize quality over quantity (Soler et al. 2007), proposals that should be encouraged also for the nursing training programmes.
Acknowledging the link between research capacity building and developing a strong, autonomous body of capable primary healthcare nurses will be instrumental in achieving discipline recognition throughout Europe (Markaki & Lionis 2008). Conclusions Greek health outcomes compare favourably with the OECD average. However, the health care system is seen as not working well by the general population. One source of dissatisfaction is the high proportion of private household spending on health, including informal payments, while public health spending relative to GDP is one of the lowest in the OECD. This situation leads to inequities in access to certain medical services.
Also, there is a weakening of efficiency of the system, which should be addressed sooner rather than later in view of Challenges for the Greek healthcare system ª 2010 The Authors. Journal compilation ª 2010 Blackwell Publishing Ltd, Journal of Nursing Management, 18, 501–504 503 a rising demand for medical services, which is going to intensify in the coming decades, and the need to keep government health care spending in check. Future health system reform should include the areas below: • reviewing the excessively fragmented structure of the health care system and its governance; • enhancing the quality of public primary health care services; • modernizing hospital administration; • tightening control over pharmaceutical expenditure; • implementing nursing management into healthcare services; • healthcare personnel continuous education and needs assessment evaluation; • audit and total quality management incorporation of the provided services; • improve productivity through incentives; and • capacity building within primary healthcare nursing.
Implications for nursing management The great challenges in the 21st century about healthcare policy and its impact on nursing management include the ageing population, the integration of new technology and new knowledge, the rising expectations for both consumers and professionals from the internet information explosion and the integration of primary care services.
As a result of these challenges, it is necessary in decision-making to use an evidence-based approach to address the issues of nursing management, to build a fair system based on equity, effectiveness and efficacy which will overhaul the way care and support is paid for and provided. Therefore in the 21st century which is the century of the patient and evidence-based patient choice will likely dominate, nursing managers should: • focus on continuous education, • provide patient-oriented guidelines through expert consensus panels, • develop audit mechanisms in everyday clinical practice to increase quality, • involve more people in decision-making, • encourage competition as a stimulus to reduce costs. Conflict of interest The authors declare that they have no competing interests.
References Abel-Smith B., Calltorp J., Dixon M. et al. (1994) Report on the Greek Health Services. Athens: Ministry of Health and Welfare. Davaki K. & Mossialos E. (2005) Plus ca change: health sector reforms in Greece. Journal of Health Politics, Policy and Law 30, 143–167. Liaropoulos L., Siskou O., Kaitelidou D., Theodorou M. & Katostaras T. (2008) Informal payments in public hospitals in Greece. Health Policy 87, 72–81. Lionis C., Symvoulakis E.K., Markaki A. et al. (2009) Integrated primary health care in Greece, a missing issue in the current health policy agenda: a systematic review. International Journal of Integrated Care 9, e88. Markaki A. & Lionis C. (2008) Capacity building within primary healthcare nursing: a current European challenge. Quality in Primary Care 16, 141–143. Markaki A., Alegakis A., Antonakis N., Kalokerinou-Anagnostopoulou A. & Lionis C. (2009) Exploring training needs of nursing staff in rural Cretan primary care settings. Applied Nursing Research 22, 138–143, discussion 144–145. Mossialos E., Allin S. & Davaki K. (2005) Analysing the Greek health system: a tale of fragmentation and inertia. Health Economics 14, S151–S168. OECD (2009) OECD ECONOMIC SURVEYS. GREECE – ISBN 978-92-64-05427-1 – OECD 2009. Rovithis D. (2006) Health economic evaluation in Greece. International Journal of Technology Assessment in Health Care 22, 388–395. Siantou V., Athanasakis K. & Kyriopoulos J. (2009) The Greek healthcare system. World Hospitals and Health Services 45, 32–34. Siskou O., Kaitelidou D., Economou C., Kostagiolas P. & Liaropoulos L. (2009) Private expenditure and the role of private health insurance in Greece: status quo and future trends. The European Journal of Health Economics 10, 467–474. Soler J.K., Carelli F., Lionis C. & Yaman H. (2007) The wind of change: after the European definition – orienting undergraduate medical education towards general practice/family medicine. The European Journal of General Practice 13, 248–251. Souliotis K. & Lionis C. (2005) Creating an integrated health care system in Greece: a primary care perspective. Journal of Medical Systems 29, 187–196. Tountas Y., Karnaki P. & Pavi E. (2002) Reforming the reform: the Greek National Health System in transition. Health Policy 62, 15–29. WHO Regional Office for Europe (2006) Highlights on Health in Greece – 2004, WHO, Copenhagen. Available at: http://
http://www.euro.who.int/document/chh/gre_HIGHLIGHTS.PDF, accessed 8 February 2010. WHO Regional Office for Europe (2009) Health in Times of Global Economic Crisis: Implications for the WHO European Region, WHO, Copenhagen. Available at: http://euro.who.int/ Document/RC59/RC59_edoc07.pdf, accessed 8 February 2010. V. Notara et al. 504 ª 2010 The Authors. Journal compilation ª 2010 Blackwell Publishing Ltd, Journal of Nursing Management, 18, 501–504