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Kathi Apostolidis: Demolishing the Greek national healthcare system the amateur way

22 Dec, 11 | by BMJ Group

It takes vision, passion for healthcare, compassion for those who suffer, knowledge, a dedicated team of experts, commitment from all stakeholders, and experience of what it means to be a patient to plan a new strategy for the healthcare sector. These are all missing from what the Greek Ministry of Health has done for the last two years.

What the Ministry of Health has achieved up until now are just separate agreements with different interest groups of the healthcare sector, each fighting fiercely to safeguard their own benefits. Thus, pharmacists have successfully safeguarded their profession, and doctors are allowed to continue practising privately.
 All the negotiations were made separately with each interest group, and of course, in the absence of the least used resource in healthcare: the patient. None of the numerous committees, task force groups, or consulting bodies, which proposed measures for the healthcare reform included patient participants.

Patients have a vested interest in healthcare policies as both taxpayers and insurance payers. They have not been consulted at all so far, and there is no sign that the situation will change. The reform of the healthcare system could be very different, if the Ministry had invited all “partners in health” to sit around a table, discuss the problems, and jointly decide what measures should be taken to safeguard the public and social character of the Greek national healthcare system.

The healthcare system and the social insurance system were far from rational, but they managed to function and cover, even partially, the needs of large groups of the population. However two years of economic hardship have destroyed both of these systems due to excessive expenditure, budget cuts, and piecemeal measures.  

The national healthcare system suffers from many disparities, under the table payments, overpricing, carelessness, and unwarranted variations in practice. There is an over-concentration of healthcare providers in the large cities which host medical schools, leaving the rest of the country with minimum or inadequate healthcare services. Everybody agreed that the healthcare system needed profound reform, but instead of reform what patients experience is the complete abolition of healthcare and social insurance.

We have a saying in Greek that goes: if your head aches, cut it. This is the approach that the Ministry of Health has taken so far in reforming healthcare. Is the minister of health a good accountant? Yes, he is and by the standards of the “big three” (IMF, ECT, EU), he seems to be more efficient than his colleagues in other sectors of the economy.

But, I can see only a population drawn in despair waiting for the inevitable. Today, after just two years of economic decline, there are 500,000 households in which no one earns an income. The number of unemployed exceeds 900,000, according to data from the Labor Institute of GSEE. The economy is crumbling, and the banks have stopped all financing. 14 billion euros have been taken out of Greece in the last month alone. More than 60 billion euros have gone since 2010, according to the Governor of the Bank of Greece. The government has practically stopped working since last summer. There is hardly enough state money for salaries and pensions. Shops and businesses close one after the other, there are whole streets where all the shops are closed.

But did these drastic taxation measures and other healthcare budget cuts have a positive impact on the state deficit? Did they improve the healthcare services offered to Greek taxpayers? Have the health outcomes of Greek people improved in the last two years of drastic taxation increases, and salary, pension and healthcare budget cuts? This recent article in the Lancet, “Health effects of financial crisis: omens of a Greek tragedy” is very explicit on this matter.

Let’s take a concrete look at the economics of a typical Greek household: we assume it to be a family with three children, a mortgage, healthcare expenses, school fees for one child, and cost of living expenses.

The annual income of the family was 32,000 Euros in 2010, and we assume that this family is among the very very lucky to retain this income in 2012 -2013 (they won’t because at the time of writing this article more salary and pension cuts were announced for 2012).  Let’s now see how their taxation will evolve in these three years with the already announced taxation for 2012, but without the additional measures that have just been voted in to the 2012 state budget, nor those that are expected as a result of the new EU loan agreement.

What is unconceivable is that the taxation is higher for families with children. The more children a family has, the higher the taxation, and it is higher percentage wise for those with lower rather than those with higher incomes. Children have become a proof of wealth and they are taxed.

  2010 2011 2012
Income (€) 32,000 32,000 32,000
Tax(€) 390 5,560 6,200
Income after tax(€) 31,610 26,440 25,800

As well as taxes this family will have to pay from the income above (that will be further reduced by new taxation and salary cuts in 2012) social insurance contributions, healthcare beyond the minimum offered by EOPYY (the new umbrella organization under which all social insurance funds are mandatorily hosted), increased utilities, heating costs, transportation, and other living expenses.

The measures taken so far, solely aimed at cutting down healthcare expenditure, will only broaden healthcare disparities, and will increase the gap between those who can afford high quality, reliable private healthcare, and those unemployed or at subsistence level for whom the only resort will be a public hospital.

The list of new reductions in healthcare benefits grows every day. Those with insurance and the population in general are not informed what these measures will really mean for their access to the public healthcare system, their health outcomes, or the impact of these measures on their already substantially reduced income. The financial possibility that large population groups had until now to use private healthcare for emergency cases or for the treatment of serious diseases is gone forever, due to the drastic taxation imposed, and the concurrent salaries, and pensions cuts.

Greeks live under continuous uncertainty about the future, with depression becoming a national disease. Daily changes, and the reduction or abolition of their long established and directly contributed social insurance benefits, and their eligibility for healthcare services create anxiety, anger, and confusion. Hospitals are working without basic supplies, low quality disposables that tear off before being used, a lack of basic foods in hospital kitchens, and expensive hospital equipment that is broken and not maintained. Patients have to bring their medicine to hospital themselves. Doctors are working unpaid overtime. There are very long waiting times to get a medical appointment, or to schedule an operation. The e-prescription application often crashes, and is not able to cope with even the small number of people who use it. This is now the reality for healthcare professionals and patients in Greece.

Kathi Apostolidis is a public affairs consultant, Athens.

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  • atsapas

    Shocking and demoralising it may sound, however, it is indeed a realistic, precise and objective description of healthcare in Greece today! Thank you Kathi for sharing this excellent post!

  • http://twitter.com/kgapo Kathi Apostolidis

    some recent articles from the local english language press for those wishing to learn more ….
    1. More Greeks turn to Doctors of the World – http://bit.ly/tIhxgx
    2. More patients turning to state hospitals –   http:/http://bit.ly/rY28eg  
    3. Work stoppages in health and public services – http://bit.ly/tBTiDT
    4. Doctors warn that health service might collapse – http://bit.ly/t6LRF1
    5. How the new measures change our lives – http://bit.ly/s1O73f
    6. Doctors in orthopaedic supplies scandal told to repay €2m – http://bit.ly/vu0KHB 

    and a lot more in the political dailies…
    ,,,,,,,,

  • Robert J Reynolds

    We live in a system with ‘moral tolerance’ – even requirement – for ‘uncertainty and depression’ from inequality and unemployment.

    Ruled by Conflict of Interest, there is – top to bottom – no escape from corruption, unconscious-subtle to deliberate-outrageous.

    Corruption extends to the professions, even to medicine, inviting ‘public trust’ but failing to endorse democratic determination of the aims of healthcare.

    Making a virtue out of necessity, our myth-makers have come to trumpet the cause of the individual, not just for aristocracies but across the whole population: we are thereby made hypocrites.

    Though we see that no equality of ‘opportunity’ can survive in a casino-culture, we affect shock at the persistence of ‘disparity’ in healthcare and outcomes, across ‘classes’ as across castes, in fact across incomes spectra and between nations with different degrees of inequality.

    So great is the fall in ‘economic command’ now being faced in the West, adequate control of our aggregate spending power – enabling industry to meet domestic and export targets – requires national rationing of income.

    Those who should lead, the professions included, hang-back in thrall to petty fears, failing to advocate Equality for Democracy, perhaps in hope ‘we might still come out on top’, prepared as ever to ride the coat-tails of Mammon, discounting direct and opportunity costs for the children of all.

    Our ‘choice’ of healthcare outcomes, starts with our ‘choice’ of income-distribution: if not in good times, and not in hard-times, when might we ‘settle’ for Equal Democracy? Just before ‘deserved’ extinction may be too late.
     

  • Stavros Saripanidis

    I would like to quote here my relative electronic Letters to the Editor of the BMJ:

    http://www.bmj.com/content/342

    http://www.bmj.com/content/343

    http://www.bmj.com/content/343

    http://www.bmj.com/content/342

    http://www.bmj.com/content/343

    http://www.bmj.com/rapid-respo

    http://www.bmj.com/content/339

    Stavros Saripanidis, Consultant in Obstetrics and Gynaecology

  • http://twitter.com/kgapo Kathi Apostolidis

    Thank you for your insightful comments!

    “Our 'choice' of healthcare outcomes, starts with our 'choice' of income-distribution: if not in good times, and not in hard-times, when might we 'settle' for Equal Democracy? Just before 'deserved' extinction may be too late.”

    You are right with what you say above, because it is at  the roots  of the spectacular growth of the parallel private healthcare sector in Greece…Income decides for health outcomes… and will continue to do more and more  in the years to come with the impoverishment of larger social classes and the limitation of healthcare services offered by the public healthcare systems… I hear similar messages from fellow patients from many European countries…

  • marinic

    Dear Dr. Saripanidis,
    Thank you for sharing your contributions  in  the healthcare discussion! I had a  look into the topics dealt with in your attachments and they are indeed among the problems of the ailing Greek ESY (national healthcare system). I would particularly mention the ghost-writing that afflicts the Greek scientific community…

  • marinic

    Dear Mr. Tsapas,Thank you very much for your comments! I have tried to go beyond the personal stories with a healthcare system in deep trouble and look at the way the really acute condition of the Greek healthcare was treated…. We have by now seen that the ad hoc unilateral agreements with the various healthcare interest groups instead of improving the  services of the public healthcare system, have on the contrary highlighted all its weaknesses…No reform whatsoever can be effective if the general public interest is not the key element and if agreements are made with few powerful groups, leaving out the key stakeholders,  in this case THE PATIENTS, who are also the payers of  the system as taxpayers and social insurance payers, but also the least used resource in healthcare!The patients, as  the actual users of the healthcare system, do know well from personal experience with their specific disease the problems in  that particular part of healthcare, something that the other stakeholders, will not know until in their turn become patients….LET PATIENTS HEAL HEALTHCAREThe above message was first heard by Dave deBronkart (aka @epatient|Dave), former Chair and currently Board Chairperson of the Society of Participatory Medicine in the USA, when he testified before the health authorities, and  this year in at the TEDxMaastricht in Europe, when his presentation “The Year of Patients Rising” went viral with more than 300.000views in just 8months!Wonder if we will ever see Greek patients participate equally in healthcare policy making but till that time health professionals will have to learn how to cooperate with their patients, listen to them and really share with them information and  decisions about their care. You might be interested to read about The Salzburg Statement  published here in BMJ, of which I am honored to be a co-signatory, that was agreed upon by the 58 participants from 18 countries of  the Salzburg Global Seminar in December 2010, to consider the role patients can and should play in healthcare decisions and how both could work together as co-producers of health.

  • Robert J Reynolds

    Greece is not alone in its afflictions. Others should not think to desert but rather make common cause. History can help us at last to define and address what underlies our alleged 'failures of democracy', in healthcare as in all other fields.

    In the UK, General Medical Practitioners fought for independent business status in the National Health Service of 1948; and NHS Hospital Consultants were allowed up to two sessions a week in Private Practice, making NHS Elective Surgery the realm of the less-demanding less-well-off two-thirds.

    Not surprisingly, long NHS waiting-lists developed, Private Hospitals flourished, and the NHS concept took the blame, address of waiting times even by Blair's New Labour resorting to and strengthening Private Provision. Winter bed crises have at times made increased NHS investment unavoidable, to the frustration of tax-cutting hopes amongst politicians. Temptation to starve the NHS, and to use NHS funds for political patronage, offers some explanation of policy over recent decades.

    Long-apparent NHS under-provision in staff and education is on-going, despite the recurrent surfacing of 'headline scandals'.  NHS time, energy and money has been poured into often destructive proliferation of 'management', diversion from care and education in burdensome tick-box exercises, excessive installation of computer infrastructure, fabulously-paid work-experience for 'support' industries, patient-pricing and desperate deal-making in experimental internal markets, preparing the way for 'off-our-books' privatisation, patients once more to be at the mercy of fortune and fine-print insurance, our government, taxpayers and charities once more at the mercy of private contractors and 'lowest-bid public duty'.

    None with evil intent, leaders in professions, in business and in politics, all have laboured with a fatal combination of weaknesses: inevitable ignorance, inability to trust others, and incapacity to hold the trust of others. Despite knowledge however great, no individual can know all: leaders need, as well as humility, the objective basis of faith in the integrity of advice from others.  Others, in turn, need to know the objective basis of trust in leaders, their equal status in the markets that together we shape. Knowing all others to be subject to Conflict of Interest, it become acceptable – 'just sensible' – to look to the interests of self and family and class and profession.

    Without a context of full employment, and equal shares in whatever together we produce, rigid pursuit of 'efficiency' is necessarily callous. Those required or employed to wield hatchets will, naturally, tend to draw the line at self-sacrifice, at immediate harm to their own families. So, the well-placed prosper, and others come to 'know their place' as once the unconsidered poor, now the unconsidered 90-99-100%. Mammon is running all into the ground.

  • marinic

    “We need to include patients as we listen, learn, and redesign our current systems of care with them and for them.” Dr. John Krueger- Τhe   Patient Will See You Now-Journal of Participatory Medicine-
    http://www.jopm.org/perspectiv

  • http://twitter.com/kgapo Kathi Apostolidis

    Dear Mr. Reynolds, Thank you for your understanding of the difficult times the hard working Greek people are going through. You do not only have an  understanding of what is going on here,  but it seems you have too a thorough knowledge of the situation.

  • Stavros Saripanidis

    Severe humanitarian crisis in Greece due to inefficiency of the public
    healthcare system

    The condition of the public Greek healthcare
    system is rapidly deteriorating following the Country’s economic failure.

    Greeks skip prescriptions or self-medicate
    because they do not have money to pay their minimal participation to
    pharmacists or doctors.  [4]

    State
    Hospitals turn away parturient women without job or insurance and small income
    if they can’t pay in advance.  [6]

    Greek
    patients visit free NGO street clinics that were set for illegal
    immigrants.  [7][8]

    Doctors
    working in public Hospitals report that health services are collapsing.  [5][13]

    Greek
    Health Minister agrees!  [14]

    Only two in 10 Greek women
    regularly have a Pap test, or cervical smear. 
    [3]

    Greek schools are faced with
    malnourished children that faint in class. 
    [1][2]

    References

    [1]  http://www.athensnews.gr/porta

    [2]  http://www.athensnews.gr/porta

    [3] 
    http://www.ekathimerini.com/4d

    [4] 
    http://www.ekathimerini.com/4d

    [5] 
    http://www.ekathimerini.com/4d

    [6] 
    http://www.allvoices.com/contr

    [7] 
    http://greece.greekreporter.co

    [8] 
    http://www.ekathimerini.com/4d

    [9]  http://www.guardian.co.uk/worl

    [10]  http://www.bbc.co.uk/news/heal

    [11]  doi:10.1016/S0140-6736(11)61556-0

    http://www.thelancet.com/journ

    [12]  doi:10.1016/S0140-6736(11)61152-5

    http://www.thelancet.com/journ

    [13]  Overburdened public hospitals are facing
    acute shortages of everything from syringes to bandages because of budget cuts:

    http://www.washingtonpost.com/

    [14]  Greek National Health System will collapse
    within months, says Health Minister:

    http://www.ekathimerini.com/4d

    Stavros Saripanidis, Consultant in Obstetrics and Gynaecology 

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