Download Analysing the Greek health system: a tale of

HEALTH ECONOMICS
Health Econ. 14: S151–S168 (2005)
Published online in Wiley InterScience (www.interscience.wiley.com). DOI:10.1002/hec.1033
Analysing the Greek health system: A tale of fragmentation
and inertia
Elias Mossialos*, Sara Allin and Konstantina Davaki
London School of Economics and Political Science, LSE Health and Social Care, UK
Summary
The Greek health system does not yet offer universal coverage and has fragmented funding and delivery. Funding is
regressive, with a reliance on informal payments, and there are inequities in access, supply and quality of services.
Inefficiencies arise from an over reliance on relatively expensive inputs, as evidenced by the oversupply of specialists
and undersupply of nurses. Resource allocation mechanisms are historical and political with no relation to
performance or output, therefore providers have little incentive to improve productivity. Some options for future
health system reform include focusing on coordinating funding by developing a monopsony purchaser with the aim
of improving quality of services and efficiency in the health system and changing provider incentives to improve
productivity. Copyright # 2005 John Wiley & Sons, Ltd.
Keywords
Greece; health care reform
Introduction
Greece enacted legislation in 1983 that established
a universal health system with the aim to expand
coverage and reduce inequities in the system,
particularly in finance, access and resource allocation. Although efficiency was not high on the 1983
reform agenda, it has become a central aspect of
recent reform initiatives. Yet the current system is
characterised by a high degree of centralisation,
fragmentation of coverage, a regressive system of
funding, inequitable coverage and access to health
services, distortions in the allocation of resources,
perverse incentives for providers, escalating costs,
and heavy reliance on relatively expensive inputs.
This paper offers an evaluation of health system
change in Greece in the last 20 years on the basis
of a number of criteria: distribution of costs and
benefits to the population, allocative and technical
efficiency and health gain. Assessing whether the
reform has achieved the objectives of improving
efficiency and equity is made difficult for several
reasons, not least of which is that the government
has been unwilling to support any evaluative research.
The Greek health system evolved in a fragmented manner, with a political climate unfavourable
for universalistic ideals and strong vested interests
successfully blocking reform attempts [1,2].
Following the Civil War of 1946–1949 and the
defeat of the left-wing party, the Greek economy
suffered, there was strong political polarisation,
and significant population groups were left inadequately insured for health care. Furthermore, with
no definable period of industrialisation nor the
development of a middle class (rather a proliferation of small firms employing mainly unskilled
labour in the 1950s–1960s), there was limited
unionisation and heavy state control of the few
existing trade unions. During this time, some
white-collared trade unions gained more comprehensive insurance coverage, which, coupled with
*Correspondence to: London School of Economics and Political Science, LSE Health and Social Care, Cowdray House, Houghton
Street, London WC2A 2AE, UK. E-mail: [email protected]
Copyright # 2005 John Wiley & Sons, Ltd.
S152
clientelistic relations between certain social groups
and the state, exacerbated the unequal distribution
of privileges.
Historical institutionalist perspectives shed
some light on why the fragmented Greek health
system is difficult to reform. Moreover, rational
choice institutionalism offers insights on the role of
powerful stakeholders who view major reform
plans as a zero sum game. The incomplete
implementation of the 1983 National Health
System (NHS) reform attempting to universalise
the system and the 2000 reform that had similar
objectives have been discussed elsewhere [1,2]. To
summarise, in 1984 unification of the insurance
funds was abandoned and the focus shifted to
hospital sector expansion. The health system was
not universalised, benefiting several groups, for
example hospital doctors and staff, and privileged
insurance funds who had access to an expanded
hospital sector without bearing the full costs
because of governmental subsidies. The 2000
reform attempted to alter the institutional setting
of the health system and coordinate the purchasing
activities of the insurance funds, threatening to
reduce many interest groups’ privileges. Overall, it
is important to consider the political, economic
and cultural context of the Greek health system
when analysing reform efforts and posing suggestions for future policies. Specifically, the influence
of stakeholders, the presence of clientelistic relationships between the political party in power and
certain groups, and fiscal constraints (significant
national debt) that prevent health care from being
placed high on the political agenda pose significant
barriers to health system reform [1,2].
The next section describes the organisation of
the Greek health system in terms of financing and
delivery, and addresses the following areas: levels
of population coverage, sources of revenue for
health care, and trends in health expenditure.
Following this, the paper highlights the methods
of resource allocation at the macro level
(budget allocation) and micro level (payment of
providers). Next, the degree of equity of access to
care, outputs and health outcomes is discussed.
Finally, some suggestions are posed for future
policy developments.
Structure of the Greek health system
The Greek health system has a mix of public and
private funding and delivery. The system is highly
Copyright # 2005 John Wiley & Sons, Ltd.
E. Mossialos et al.
centralised. The Ministry of Health and Welfare
(MoH) is responsible for the NHS. The Ministry
of Labour and Social Insurance is responsible for
the insurance funds, which play a significant role
in financing and providing health services. The
Ministry of Finance (MoF) is responsible for
retrospectively subsidising the NHS and health
insurance funds (HIFs) and so far, has not shown
any interest in playing a more significant role.
Figure 1 depicts health care funding and delivery in Greece. Public financing consists of
taxation (for NHS staff salaries and NHS and
health insurance fund deficits) and social insurance, but entitlements are defined through occupationally based insurance fund membership and
not on the basis of citizenship. Also, private
financing plays a significant role in the health
system, particularly in the form of direct and
informal payments, and less so, private medical
insurance (PMI).
Health care provision can be described as
tripartite: the NHS provides public hospitals,
public primary health centres and rural posts;
one insurance fund (IKA, that covers about 45%
of the population) provides 242 urban primary
health centres and a few hospitals; and the private
sector is either contracted by the health insurance
funds (for hospitals, physicians, and diagnostic
centres) or directly provides services to the
population (private consultations, diagnostic tests,
hospitalisation).
The NHS law of 1983 (implemented in 1985)
primarily addressed the delivery side of the health
system by expanding the public hospital sector
(nationalising not-for-profit hospitals), and improving primary health care by initiating the
establishment of about 200 rural and semi-urban
primary care centres coordinated by the MoH.
Coverage of pharmaceutical care was extended,
mainly for the agricultural population. Also, the
NHS law aimed to unify the social insurance funds
into a single purchasing body; however this was
never implemented as a result of considerable resistance by the trade unions of the privileged social
groups who enjoy better coverage and good links with
political parties. Since then, several small insurance
funds have been merged with IKA, but there are still
about 30 funds and the largest ones and other
stakeholders continue to resist increased coordination,
as it has been viewed as a first step towards
establishing a universal system [2].
In theory, the MoH is responsible for managing
and organising hospital and rural primary health
Health Econ. 14: S151–S168 (2005)
S153
Analysing the Greek Health System
Private Doctors
(contracted by
Health Insurance
Funds)
N
NHS Hospitals &
Semi-urban and
Rural Primary
Care Centres &
Rural Posts
IKA
Primary
Care
Centres
*
f-f-s
Direct
payments or
surcharges on
f-f-s paid by
HIFs
Private
Hospital
Services
f-f-s
Capitation
Per
diem
Diagnostic
Centres
f-f-s
PMI
Per
Subsidies & diem
Staff Salaries
IKA
OGA OAEE Other Funds
Contributions
for group
contracts
f-f-s
Health Insurance Funds
Informal
Payments
Subsidies
Taxes
Contributions
Formal
Private
Payments
Enterprises
Population
(not for OAEE, OGA,
self-employed, or liberal
professions)
*OGA contracts private doctors for repeat prescriptions
Note: f-f-s refers to payment by fee-for-service
Figure 1. Organisation of the Greek health system: financing flows and delivery of health services
care services and the insurance funds are responsible for their financing. However, insurance funds
actually pay about half of the hospital costs, while
the MoH and MoF cover the deficits through taxation. Because of ideological reasons, the Socialist
government of the 1980s wanted to restrict private
sector provision by prohibiting the establishment of
new private hospitals, and preventing existing
private hospitals from changing their functions.
To further restrict private sector activity the MoH
introduced regulation equalising private and public
hospital prices, while keeping public hospital prices
low. As a result, huge deficits were created in the
public hospitals, and there was a reorientation of
private activity from hospitals to more profitable
investments (diagnostic centres which were, and still
are, unregulated).
The insurance funds incurred significant deficits
after 1993 for two reasons: the government
increased hospital prices to address the public
hospital deficits; and prices for diagnostic services,
Copyright # 2005 John Wiley & Sons, Ltd.
which are almost fully private, were very high. Put
together, there was considerable financial pressure
on the insurance funds and therefore the government intervened and subsidised their deficits. The
government has been reluctant to allow insurance
contributions to rise because of the potential
labour market implications that would result from
rising labour costs to compensate for high
insurance premiums. Although one would expect
the government to put pressure on the insurance
funds to improve efficiency by limiting or ceasing
their subsidies that cover funds’ deficits, this
option remains politically unfeasible.
Health services coverage, funding and conditions of access
Two main types of coverage are available to the
population: the health insurance funds and private
Health Econ. 14: S151–S168 (2005)
S154
E. Mossialos et al.
medical insurance. Indirectly, the NHS offers a
third type of coverage to the population, since
anyone can access the public hospitals and rural
and semi-urban primary health centres, even if
they have no insurance or are illegal immigrants
(who are estimated to constitute 4–5% of the
population). Most funding is public from taxation
and social insurance (56.3% of total expenditure),
with payments from private health insurance
accounting for about 2.3% and the remaining
41.4% from out-of-pocket payments, a significant
proportion of which are informal (see Table 1).
At present approximately 30 social health
insurance funds provide coverage to about 95%
of the Greek population. The three largest funds
cover about 80% of the population: the Social
Insurance Organisation (IKA) covers the majority
of the working population; the Agricultural
Insurance Organisation (OGA) covers agricultural
workers, and OAEE covers professionals, small
businesses and merchants. The remainder of the
population is covered by individual funds for the
self-employed, civil servants and military personnel, banking and public utilities. Insurance coverage is compulsory for all of the employed
population and their dependants. The unemployed
are covered through government subsidies, and the
retired population continues to be covered by their
pre-retirement insurers (apart from OAEE, which
shifts its retired population to IKA).
Contributions and benefits are unequal across
insurance funds. For most insurance funds, funding is via proportional employer–employee contributions (with no tax deductions). However, the
government heavily subsidises schemes for civil
Table 1. Sources of revenue for health care in Greece as
% of total revenue (1987, 1992 and 2000) (OECD
estimates in brackets)
1987
General taxes
Social insurance
Total public
1992
2000
33.7
33.3
30.4
25.4
24.1
25.9
59.1 (59.9) 57.4 (54.6) 56.3 (53.9)
Private insurance
Na
2.1
2.3
Direct payments
40.9*
40.4
41.4
Total private
40.9 (40.1) 42.6 (45.4) 43.7 (46.1)
Total
100
100
100
Source: Authors’ estimates, Sissouras et al. [6], and Ministry of
Health unpublished data.
n
Including PMI.
Copyright # 2005 John Wiley & Sons, Ltd.
servants (OPAD), military personnel, and agricultural workers (OGA). Furthermore, contribution
rates are lowest for the self-employed as they have
an incentive to under-report their income. Generally the benefits received by the members of
OPAD, OAEE and of banking, public utility
sector funds and professionals exceed those
provided by IKA and OGA, particularly regarding
freedom of choice of primary care providers
(including private providers) and improved access
to private hospitals (Figure 1).
In 2000, taxation and social insurance accounted for 30.4 and 25.9%, respectively, of total
health expenditure [3]. Tax revenues are mainly
indirect taxes on goods and services (58.4% of
total tax revenue) and direct taxes (41.6% of total
tax revenue), with taxes on income representing a
much smaller proportion (39.3% of direct taxes,
16.3% of total tax revenue).
Approximately 8% of the population has PMI
which covers services in the private sector. Policies
tend to be selective in nature – targeting young and
healthy people – and lack comprehensiveness [4].
PMI coverage remains low despite high direct
payments. One reason for this may be a reluctance
of individuals to pay a third party, in addition to
cultural and historical factors. When people are
accustomed to paying their doctor or hospital
directly, the transfer of money to a third party may
be seen as an unnecessary erosion of the patient–
doctor relationship and reduces the assurance of
quality of care [5].
Out-of-pocket payments, mostly in the form of
direct and informal payments, are the highest in
the European Union (EU). There are several
reasons for the high level of this form of private
expenditure. The way primary health care provision is structured and financed forces patients to
use both public and private services concurrently
[6]. Doctors are able to transfer patients from
social insurance funds, where they work part-time,
to their private practices [7]. In a health interview
and utilisation survey in the area of Patras, it was
shown that 30% of insured patients used both
social insurance funds and private doctors’ services
in the same period [8]. Similar trends were found in
surveys of IKA patients [9].
Although private practice for public hospital
doctors has been forbidden since 1983 (except for
university hospital doctors and doctors working
for the army), many doctors have illegal private
practices or ask for informal payments. However,
there is no available evidence on the size of
Health Econ. 14: S151–S168 (2005)
S155
Analysing the Greek Health System
informal payments as no reliable surveys have yet
been conducted in this area. Since 2002 the
government has attempted to legalise limited
private practice for hospital based doctors in order
to formalise some informal payments. However,
few physicians have taken up this practice, though
the number is increasing. Although there has been
no formal evaluation of this measure, there are
several possible explanations for its limited uptake
so far: some physicians are ideologically opposed
to private practice and refuse to accept payments;
surgeons have no incentive to take part in this
partial private practice since the level of fees are
the same across all specialisations and are thought
to be much lower than the informal payments;
physicians prefer to continue accepting informal
payments rather than to legitimise these payments
and hence pay taxes on them; and given the
oversupply of specialists in Greece, some physicians may not have had the opportunity to attract
private patients.
Despite the efforts to diminish the private sector
involvement in health care provision, there has
been significant private sector expansion in the
area of diagnostic services. Other areas with
significant private sector involvement include:
gynaecology (due to cultural reasons, the preference among Greek women for high quality
hospital amenities); mental health (due to the
substandard quality of public sector psychiatric
hospitals); and elective surgery (due to long
waiting lists in the public sector).
A summary of the public–private mix in health
care is depicted in Box 1. The vertical division is
between public and private providers and the
horizontal division separates the public and
private sources of funding.
The rural population is insured by OGA and has
access to rural health centres and rural doctors.
There are now about 200 rural health centres
staffed with GPs and specialists and 1311 rural
health posts staffed with medical graduates without clinical experience.
The entire population has access to the outpatient departments of hospitals in urban centres.
In the urban centres, IKA operates its own
network of primary health centres, a few hospitals,
and contracted doctors to which their patients
Box 1. Summary of the mix of public and private funding and provision of health care in Greece
Funding
Public
Public Provision
Private
NHS: Public hospitals and health centres
provide services (almost) free at the point of
use, however there are informal payments.
Social Insurance (IKA): Private medical services, e.g. laboratories, radiology and pathology, are reimbursed (fee-for-service) for
services provided to patients.
Social Insurance (OGA): Same as IKA, but
also contracts doctors for repeat prescriptions.
Social Insurance (other funds): reimburse
contracted providers (fee-for-service, or capitation for OAEE) for private medical consultations, medical services obtained in the
private sector and services provided by private
clinics and hospitals.
Social Insurance: In theory should reimburse
NHS for use of hospital services by members.
IKA (covering 45% of the population) directly
employ doctors to provide primary care
services to members.
OGA members (25% of the population) use
free-of-charge NHS rural health centres and
surgeries.
Private
Private health insurance: In theory should
reimburse NHS for use of public services by
enrolees. In practice this never happens.
Out of pocket payments: Direct payments by
patients to cover co-payments in the NHS for
hospital outpatients consultations (rarely collected), and pharmaceuticals. Most self-employed pay 25% for diagnostic tests and
therapeutic procedures. Additional fees (fixed
fee-for-service) for private consultations by
specialists in NHS hospitals.
Copyright # 2005 John Wiley & Sons, Ltd.
Private health insurance: reimburses enrolees
for fees paid for consultations, services and
inpatient care provided by the private sector.
Out of pocket payments: direct payments by
patients for private consultations and other
medical services (e.g. hospital and diagnostics).
Health Econ. 14: S151–S168 (2005)
S156
have access free at the point of use. The other
funds contract doctors to provide services to their
members. Several funds, such as OAEE, OPAD,
and funds for banking, public utilities and professionals offer freedom of choice of private doctors.
Office-based specialists are usually the first point
of contact and people have direct access to
secondary care as there is no gatekeeping system.
In general, access to first level, primary care
providers is free at the point of use. However,
patients usually visit a doctor contracted by their
insurance fund or another doctor on a private
basis, either for a second opinion (for which
patients do not have to pay) or because of
unsatisfactory public services.
Moreover, there is no national regulation
specifying the standards of services required by
contracted providers and the overall amount they
will be reimbursed. As prices do not vary according to the standard of service, providers have little
incentive to improve quality. Long waiting times
at health centres encourage people to go directly to
hospital emergency departments. As much of this
demand is for non-urgent treatment, emergency
services are used to treat minor health complaints.
Inefficiencies also arise from the lack of a gatekeeping system resulting in poor information
transfer and loss of continuity between ambulatory care and secondary care and incomplete
patient information and medical records which
causes a repetition of tests and prescriptions [10].
Fairness of the financing system
The continual dependence on indirect taxation
coupled with the high level of private expenditure
in the form of direct payments and unequal social
health insurance contributions that favour the
wealthier population groups suggests that the
financing system is regressive. Moreover, analyses
of the Greek Household Budget surveys have
shown that between 1981 and 1994, private
expenditure increased for all socio-economic
groups, but the relative and absolute increase
among low income groups was higher than for
middle-to high income families [4,11,12].
There is significant social security contribution
evasion in Greece at the equivalent of 15–20% of
the total income of most social insurance funds,
and 30% in the case of IKA, which further
compromises fairness [13]. The situation is exacerbated by a significant informal economy
Copyright # 2005 John Wiley & Sons, Ltd.
E. Mossialos et al.
accounting for 28.5% of GDP in 2001/2 (an
increase of 26.1% from 1989/90) and a workforce
with a large share of self-employed (32.5% of total
employment in Greece, compared to the EU
average of 14.7%) [13,14]. According to Bronchi,
horizontal and vertical equity (defined respectively
as the principles that taxpayers with the same
income should pay the same tax; and those with
different levels of income should pay different
taxes) are undermined through an ever-increasing
number of exemptions to certain social groups
(particularly the self-employed) irrespective of
their ability to pay, and a reliance on indirect
taxation [15]. Although Bronchi estimated that
personal income taxes in Greece were relatively
progressive, this crude measure of progressivity
does not account for tax deductions which
compromise progressivity because higher income
groups have larger allowances [16].
In a recent analysis of equity of finance in the
Greek system the funding system in 1998 was
found to be regressive [17]. In other words, lowincome households paid a higher proportion of
their income towards health care than the rich.
The WHO index of financial contribution and
financial risk protection, for which a value of 1
indicates equity of financing, was estimated to be
0.930 (no uncertainty interval was reported)
compared with the WHO estimate based on
experts’ views of 0.963 (uncertainty interval
0.946–0.978) in 1997 [18]. These figures should be
treated with caution, however, because data from
the household budget surveys (HHBS) were
matched with taxation data reported by the
MoF. Overall, it appears that low income groups
bear a disproportionately large share of the health
care funding burden. Furthermore, because of
more comprehensive social health insurance coverage in some ‘privileged’ funds, one study found
that OPAD members, who are better covered, are
less likely to seek private health care than IKA
members [12].
Health care delivery
Following the 1983 reform, the next noteworthy
development was the establishment of regional
directorates (PESYs) in 2001. The legal status of
each individual hospital was abolished with
PESYs acting as intermediaries between the
MoH and the hospitals. Regional directors would
be able to influence personnel allocation, for
Health Econ. 14: S151–S168 (2005)
Analysing the Greek Health System
example, by allowing personnel to move across
hospital departments and across hospitals, where
previously there had been considerable rigidity,
with personnel being tied to particular departments and hospitals. Because this change represented a shift in power away from both the MoH
and the hospitals (doctors and civil servants) and
towards the regions, there was significant opposition from both fronts. Although the potential
effect of the 2001 reform on the efficiency of health
care delivery may be limited by the regions’ lack of
purchasing powers over providers, to date there
has been no formal evaluation of its impact.
The proportion of different services provided in
the public system or by private providers is not
known but most primary care consultations are
provided by contracted office-based doctors and
dentists. This is also the case with laboratory tests
and imaging techniques (X-rays, nuclear medicine). The integrated model of health service
provision, where the government or social insurance funds are both the financer and provider of
health services, exists in the NHS for hospital
inpatient care, GP and specialist services in NHS
and IKA health centres and health posts in rural
areas [19].
Public health. Reforms of the health sector have
largely neglected public health. However, there are
some important weaknesses in public health
system in Greece: there is no national public
health policy, no national screening programme,
no population health survey, no information
system to gather and organise public health data,
and no career path for public health professionals.
Although the district-level has public health
directors, their responsibilities are mainly limited
to inspection of health facilities and hygiene,
rather than developing and implementing public
health strategies.
Hospitals. Following the establishment of the
NHS, many medical facilities previously operated
by non-profit institutions and the social welfare
system were brought under the ownership and
control of the NHS through a process of
‘nationalisation’. Between 1983 and 1985, 8347
beds that belonged to the non-profit hospital
sector were nationalised, representing about 9%
of total beds. Subsequently there was a reduction
in bed numbers throughout the 1980s and 1990s,
mainly in the psychiatric sector. Also there was a
significant decline in private beds due to the
Copyright # 2005 John Wiley & Sons, Ltd.
S157
closure of many small clinics and hospitals
resulting from their fees being linked to the low
public sector fees.
In 1997, there were 350 hospitals in Greece
providing a total of 52 474 beds, with about 71.2%
belonging to the NHS. This is equivalent to a ratio
of 5 beds per 1000 inhabitants, compared to the
EU average of 7.4. However, the average occupancy rate in Greek hospitals is very low (65% in
1998 compared to the EU average of 80.9%),
suggesting that availability of beds is not a
problem. Average occupancy rate masks the
problem of large discrepancies within hospital
departments and across hospitals in different
regions in Greece, favouring the urban centres.
Among 896 departments of NHS hospitals in
1997, 34.3% of hospital departments had a very
low occupancy ratio (under 50%), while 60.1%
had an occupancy ratio of up to 100% [20]. The
remaining 5.6% had an occupancy ratio of above
100%, reflecting the use of extra ‘stretcher’ beds in
the wards of urban general hospitals (mainly
cardiology and general surgery).
The wide variation in occupancy results from
the policy of allocating an equivalent number of
beds to each clinic within the hospital, irrespective
of variation in production. The situation is further
exacerbated by the policy of allocating personnel
to hospitals on the basis of hospital bed numbers
rather than outputs. Hospitals with low output but
a high number of beds will be allocated more staff
than needed.
Health care professionals. By 2002 there were
about 47 944 doctors, 12 394 dentists, 41 151
nurses and 8977 pharmacists in Greece [21]. Less
than 2% of the doctors are general practitioners, a
specialty that is not highly esteemed and, compared to specialists, are not as well paid. Because
of the lack of organised primary health care
coupled with a limited encouragement to produce
more general practitioners, there is no system of
referral.
The oversupply of doctors, dentists and pharmacists and the under-supply of nurses is revealed
through comparisons with other EU countries.
Greece has the highest ratio of doctors (4.5),
specialists (3.0) and dentists (1.2) per 1000
inhabitants [21]. Greece’s ratio of pharmacists
per 1000 population is ranked 4th. Conversely,
Greece had one of the lowest ratios of nurses per
1000 inhabitants (3.9) in 1999, less than half the
EU average. The supply of nurses is low because of
Health Econ. 14: S151–S168 (2005)
S158
low salaries and the oversupply of doctors, who
are substituting for, and taking on many of the
responsibilities typically allocated to nurses. Thus
Greece is relying on expensive inputs to deliver
health care.
Equipment and technology. There is an active
private sector in the provision of diagnostic and
therapeutic services (i.e. clinical pathology, radiology and computerised tomography, MRIs and
haemodialysis). The main implications of the 1983
NHS restrictions on private hospitals were a
change in the focus of private investment, and a
rapid development of private diagnostic centres:
84.4% of radiology laboratories, 74.9% of nuclear
medicine laboratories, 80% of MRI scanners and
68% of CT scanners are in the private sector. The
number of CT scanners per million population in
Greece in 2002 was 17.7, higher than in the UK
(5.8), France (9.0 in 2001), Denmark (13.2),
Germany (13.3), Finland (13.7), Spain (12.8) and
the US (12.8 in 2001) [21].
The dispersion of high technology equipment in
the private sector over which the state has very
weak controls, combined with strict controls over
procurement in the NHS has led to wide discrepancies in the availability of equipment. Because of undersupply in the public sector, the NHS
or social insurance funds pay the private sector for
any use patients make of these services. Moreover,
it is likely that many NHS and insurance fund
doctors receive informal payments from private
centres to channel patients for CT and MRI scans.
Therefore, the current organisation of medical
technologies in Greece and lack of regulation leads
to inflated costs and consumption.
Mental health policy. There has been some effort
to reform mental health care in Greece, with
some improvements; however, the situation is still
far from satisfactory [10]. A psychiatric reform
programme has been in effect since 1984 focussing
on decentralising mental health services, deinstitutionalising long-stay mental health patients, and
training mental health personnel [22]. An analysis
of the impact of this reform up to 1996 suggests
that although some improvements were seen such
as an increase in community-based services,
significant regional disparities were found favouring urban areas, particularly those with higher
levels of socioeconomic development [23]. For
instance, in urban centres there has been more
development of community-based alternatives to
Copyright # 2005 John Wiley & Sons, Ltd.
E. Mossialos et al.
hospital care and increased number of mental
health care staff and services than rural and
disadvantaged areas [23]. Therefore, despite some
efforts at deinstitutionalisation, many mental
health patients remain in psychiatric hospitals
with poor conditions.
Expenditure trends
Greece spends a significant proportion of its
wealth on health care and is heavily dependent
on private expenditure. Greece spent 9.4% of its
GDP on health care in 2001 (up from 5.6% in
1970), 4th highest among EU countries.
Public sources of funding accounted for 52.9%
of total health expenditure in 2002, which was the
lowest in the EU [21]. Private health expenditure in
Greece has grown faster than GDP, while public
expenditure has grown less quickly than private
expenditure, as shown in Table 1. Private expenditure increased from 3.4% of GDP in 1990 to
4.5% in 2002 whereas in the same period public
expenditure rose from 4.0 to 5.0% [21]. Increases
in private expenditure may be explained by the
undersupply of diagnostics and technology in the
public sector, disorganised primary care, increasing informal payments in the public sector, and
limited coverage of dental care. Also, there have
been pressures to reduce public expenditure,
despite economic growth, during the period prior
to qualifying for membership of European Monetary Union in 2000.
Table 2 outlines the expenditure of different
categories of health service provision in 1990 and
1998. Public expenditure includes taxation and
social health insurance, while private expenditure
includes PMI and out-of-pocket payments. In
1998, inpatient care accounted for the largest
proportion of health care expenditure, followed by
ambulatory care, pharmaceuticals and dental care
[22]. Inpatient care accounted for 37.1% of total
expenditure in 1998, a decline from 40.1% in 1990.
Ambulatory care accounted for 26.5% of expenditure compared to 24.1% in 1990. Pharmaceuticals consume a growing proportion of health
expenditure, increased from 14.4% in 1990 to
15.6% in 1998. Expenditure on dental care
exceeded that of pharmaceuticals in 1998
(15.6%), representing 1.4% of GDP. Public
expenditure exceeds private expenditure in the
hospital sector; the opposite is seen in the
Health Econ. 14: S151–S168 (2005)
S159
Analysing the Greek Health System
Table 2. Health care expenditure by categories and public–private mix in Greece as % of total expenditure on health
care, 1990 and 1998
1990
Inpatient care
Ambulatory care
Dental care
Pharmaceuticals
Other
Total
1998
Public
Private
Total
Public
Private
Total
54.90
22.18
1.36
12.32
9.24
100
15.30
27.26
34.10
17.07
5.37
100
40.13
24.07
13.57
14.43
7.79
100
55.91
22.85
1.23
15.82
4.19
100
12.36
31.36
33.98
15.38
6.92
100
37.11
26.52
15.37
15.63
5.37
100
Source: Souliotis [24].
ambulatory and dental care sector, and they are
equally divided in the pharmaceutical sector.
Resource allocation
Budget allocation (the macro level)
In Greece there is no pooling of health resources
and there are large geographical inequalities in
service provision. Social health insurance contributions are collected and retained by the insurance
funds, but there is poor co-ordination of the
insurance funds’ purchasing activities. Pursuing
equity and efficiency objectives requires allocating
resources according to health care need. However,
in Greece, resources are allocated on the basis of
historical precedent and political negotiation. This
patchy approach to health care financing compromises equity and efficiency by hindering the
effective application of budget ceilings, reducing
the negotiating power of the MoH, MoF and
social insurance funds, and impeding cross-subsidisation amongst insurance funds.
A recent study that applied the UK Resource
Allocation Working Party resource allocation
method in Greece confirmed that there are
significant regional inequalities in resource allocation and suggests that there is a need to transfer
resources between regions, particularly away from
the urban centres of Athens and Central Macedonia towards the Peloponnese, Western Macedonia,
Thessalia, Central Greece and the islands [25].
However, with continuing urbanisation and depopulation of rural areas, whereby young adults
migrate from rural to urban areas (mainly Athens
and Central Macedonia), there may be a shift in
Copyright # 2005 John Wiley & Sons, Ltd.
demand for health services (particularly as the
migrants age) to the urban and away from rural
areas and thus current patterns of resource allocation may be more closely aligned with future needs.
A soft budget for public health expenditure
financed by the MoF and MoH is established
within the annual national budget. The Regional
Health Systems (PESYs) have been, in theory,
responsible for co-ordinating NHS hospitals.
However, they have no powers regarding major
capital investments or paying providers, which
remain under the control of the MoH.
The insurance funds are, in theory, responsible
for determining budgets for primary health care,
pharmaceutical care and hospital services provided
to their members. Budgets are mainly calculated
on a historical basis. In reality, these budgets do
not set expenditure limits as the expenditure of the
social insurance organisations is demand-led; i.e.
the social insurance funds reimburse all providers’
claims, without regulating and monitoring activities. Both the hospital deficits, and the social
insurance fund deficits are not dealt with in a
rational or effective way. Deficits are retrospectively covered through subsidies, thus providing
no incentive to economise or to improve efficiency.
In 2001 the then Minister of Health was
planning to introduce a coordinating body for
the insurance funds to develop the contracting of
clinical services. The plan was to establish contracts with public or private bodies, individuals or
collectives as long as efficiency objectives were
upheld in the delivery of care. However, in 2002
these plans were shelved due to widespread
resistance from the medical profession, civil
servants, and by the trade unions of sectors
covered by the privileged insurance funds. It is
unlikely that a coherent resource allocation
mechanism will be established in the near future.
Health Econ. 14: S151–S168 (2005)
S160
Furthermore, the powers of the MoH and
insurance funds are currently quite limited due to
the lack of information systems providing details
of provider activities and insufficient leverage over
providers.
Paying providers (the micro level)
The payment of providers is complex due to the
public–private mix of provision and funding.
Private providers include for-profit institutions
such as private hospitals and clinics as well as
independent solo providers (doctors, dentists and
pharmacists).
Payment of hospitals. In NHS hospitals the
historical budgets reinforce established inequities
in the funding and provision of health care
services. Hospitals are still paid per day of care,
and although this system is administratively
simple, it does not offer incentives to economise.
Private providers are used by health insurance
funds and private medical insurance funds and are
paid either by fee-per-item or per diem for their
services. Insurance funds reimburse the providers
retrospectively.
Staff in public hospitals are employed as civil
servants, as are most NHS doctors. Non-clinical
services, e.g. maintenance, security, catering,
laundry and incineration, are generally contracted
out to the private sector. Since many private
hospitals are contracted by more than one fund it
is very difficult to know the number of privately
contracted hospital beds and data is not available
in a consolidated format.
Patients can choose any public or private
contracted hospital and they often choose to travel
to Athens or to visit the large University hospitals
outside Athens, by-passing their local district
hospitals. There are a number of reasons for the
significant inter-regional flow of hospital patients.
For example, the NHS reform was mainly
hospital-focused and trade unions in the hospital
sector are based in the two urban centres, Athens
and Thessaloniki; therefore, more resources were
directed there. Thus, local district hospitals are
often understaffed and have poor capital infrastructure. Due to the lack of a referral system,
patients can choose the hospitals themselves and
as a result, they prefer to be hospitalised in
institutions offering expensive, high technology
services delivered by reputable doctors. Although
Copyright # 2005 John Wiley & Sons, Ltd.
E. Mossialos et al.
admission to a hospital depends on individual
clinicians, it is unlikely that a patient would not be
admitted if they offer to pay informally, whereas
those who cannot afford to pay may be delayed
with longer waiting times.
Payment of doctors. Currently, the medical care
payment system does not provide doctors with
incentives to improve efficiency and quality.
Specialist doctors working in public hospitals
and health centres (both NHS and IKA) are paid
on a salaried basis, and contracted doctors in
ambulatory settings on a fee-for-service basis.
Public hospital doctors until recently were not
allowed to see patients privately for fees, although,
as previously mentioned, in practice many did so.
Many insurance fund doctors work part time. For
instance, in the IKA primary care centres, doctors
are often contracted on a part-time basis, but most
of them work even fewer hours than those for
which they are contracted. There are powerful
financial incentives to minimise the time and effort
devoted to salaried institutional practice, and to
spend time instead in private work, whether
permitted or not.
Medical associations in Greece usually argue
that informal payments exist in the public sector
because of the low payments to specialists. In
1985, in an attempt to attract doctors to NHS
hospitals and reduce informal payments, the
government offered higher salaries (up to 250%
increases) in return for them ceasing private
practice [26]. However, this policy failed and many
senior doctors who were enjoying significant
privileges in hospitals (mainly because of dual
practices in the public and private sectors) resigned
from government service (and most other NHS
doctors ignored the rules). Moreover, in 1992 the
Conservative government permitted NHS employment on a full-time or part-time basis. There was
limited uptake of this partial private practice (less
than 2% of doctors). It seems, therefore, that in a
culture of informal markets doctors do not
increase their NHS productivity because of salary
increases and do not respond to offers to work
part-time and practice privately. It is likely that
informal activity will continue to take place within
the system as doctors’ performance is not recorded
and their payments are not related to performance.
Apart from OAEE, IKA and OGA, primary
care doctors (mainly specialists) contracted by
insurance funds are paid on a fee-for-service basis.
Anecdotal evidence suggests that physician fees
Health Econ. 14: S151–S168 (2005)
S161
Analysing the Greek Health System
are set relatively low, and physicians inflate their
claims by adding false consultations in order to
generate more income, and that they increase
referrals to private diagnostic centres for which
they are given referral fees. OAEE pays its
contracted doctors on a capitation basis and
IKA doctors are salaried, but many work parttime. Paradoxically, OGA patients have access to
salaried NHS doctors and health centres as well as
a network of 8000 specialists who are contracted,
but are not paid by the fund to prescribe
pharmaceuticals to its members. Rather, OGA
members pay for non-NHS consultations out of
pocket, although there is anecdotal evidence
suggesting that these specialists may be sponsored
by the pharmaceutical industry.
The different physician payment methods appear to impact insurance funds’ primary care
expenditure. For example, the per capita health
expenditure (including formal out-of-pocket payments) of OPAD, where physicians are paid feefor-service, is around three times that of OAEE,
where physicians are paid capitation, and twice
that of IKA, which has salaried physicians [9].
This finding should be interpreted with caution,
because the retired population of OAEE is insured
by IKA, and IKA engages in cost-shifting to
private providers.
In the NHS and insurance funds, pay scales are
rigid and there is limited ability for local management to reward good service or discipline those
who neglect their work. There is a lack of
incentives for almost all grades of staff, except
the incentive to leave early for other work. There is
limited professional satisfaction for doctors or
patient satisfaction because of the lack of continuity of care, limited user friendliness and
inconvenience, particularly in the over-crowded
hospital outpatient departments which often lack
separate accident and emergency departments [10].
Paying pharmacists, drug pricing and reimbursement. There is no formal health technology
assessment (HTA) policy in Greece. The state is
involved in price setting and reimbursement of
pharmaceuticals. Until recently, pharmaceutical
prices could not exceed the three lowest prices in
the EU, which shifted to the lowest price.
Subsequently, the High Court declared this
process unfair for the industry and requested it
to be changed. It is currently unclear how the
pricing system will be changed.
Copyright # 2005 John Wiley & Sons, Ltd.
Pricing and reimbursement decision-making is
currently fragmented. The Ministry of Trade is
responsible for pricing, and the MoH (specifically
the National Medicines Organisation) for market
authorisation. The health insurance funds (under
the Ministry of Labour) finance the pharmaceuticals, and are also jointly involved with the MoH
in defining the positive list. First, the price is
established, then, without any formal HTA, the
decision for reimbursement is made. Therefore, the
prices and decisions to reimburse are made separately, making coordination of these procedures
extremely difficult. In theory, if reimbursement is
denied, companies can negotiate a lower price, but
in practice, almost all products are reimbursed.
Following the introduction of extended patent
periods in 1998, the government has decided that
when a patent expires, products maintain their
original patent price, and generic products’ prices
are fixed with a discount of only 20%. The fixed
pricing of all products means that there is no room
for generics to compete on price with the original
brand and amongst themselves. This practice certainly does not create an environment that encourages consumption in the generic market [27].
All the attempted pharmaceutical policy
changes have focused to date on supply side
measures, but there have been no efficiencyimproving measures targeting physicians or pharmacists such as budgets to influence doctors’
prescribing habits, substitution rights for pharmacists, or prescribing guidelines to facilitate costeffective prescribing. The criterion for inclusion in
the recently introduced positive list is only a
product’s average daily treatment cost, with no
consideration of clinical or cost effectiveness.
The distribution margins set by the government
give the wholesaler 7.8% (without VAT) and the
pharmacy 35% of the retail price, which does not
provide any incentive for pharmacists to dispense
cheaper alternatives. Rather, the high profit
margins encourage the sale of more expensive
drugs and sustain a large number of pharmacies,
fuelling the excessive consumption of pharmaceuticals. It is questionable whether so many pharmacies are needed to ensure high quality
pharmaceutical care [28].
Appropriateness of care
There is no system in place to assess the quality or
appropriateness of services [10]. Additionally,
Health Econ. 14: S151–S168 (2005)
S162
there are no effective systems of organising and
coordinating medical records, measuring how
health resources are used, and measuring and
monitoring the outcome of care. This problem is
exacerbated by the fact that most doctors do not
keep medical records in private practice even if
they are contracted by health insurance funds, and
if they do, they are inaccessible [10].
There are no practice guidelines, and prescribing
patterns are idiosyncratic. It appears that most
Greek doctors do not prescribe according to
evidence-based practice [29]. A recent study of
the prescribing patterns of office-based doctors in
Larissa in central Greece showed that many
doctors are poorly equipped for asthma management and mainly carry out asthma treatment after
recommendations from a pulmonologist or internist, which are also incompatible with established
treatment guidelines [30]. In 1997 Greece had the
highest number of antibiotic prescriptions per
1000 population amongst 13 EU member states
[31].
In addition, studies have shown that Greece has
a very high, and growing, rate of caesarean section
deliveries, which is unlikely to reflect need [32,33].
The results of a recent study of the predictors of
caesarean sections in three Greek hospitals suggest
that physicians are motivated to perform caesarean sections for financial incentives (due to high
informal payments or PMI) and convenience
(ability to plan the time of delivery) as opposed
to medical necessity [34].
Dental care is an area where appropriateness of
care has been questioned. It is likely that because
of the high number of dentists, and high dental
care expenditure, dentists are providing excessive
services. A recent study of patients’ expectations
and perceptions of the quality of dental care
revealed that despite the high number of dentists,
there was a gap between expected and perceived
quality and responsiveness [35].
Access, outputs and health outcomes
Equity of access
It appears that there may be inequities in access in
Greece arising from supply-side variation, different entitlements and benefits coverage across
insurance funds, and high informal and direct
Copyright # 2005 John Wiley & Sons, Ltd.
E. Mossialos et al.
payments. Although there is limited evidence on
how informal payments affect access and utilisation of health services, it is clear that patients who
cannot afford to pay cannot access the same level
of services or have to wait longer for care [10].
Three studies have attempted to estimate equity
of utilisation of health services in Greece. The
studies were based on estimates of self-reported
visits to health services, with no comparison with
other surveys or official statistics. They all focused
on demand side factors. The first study found
significant horizontal inequities in utilisation of
total doctor visits, but with disaggregated data,
only specialist service use was inequitable, favouring the rich [36]. Furthermore, the study found
PMI coverage and regional disparities slightly
reduced equity in doctor visits. The survey
questions separated specialist and GP visits, and
since there are so few GPs in Greece yet a high
number of GP visits were reported, the results
should be treated with caution.
The second study was based on a survey in 2001
on health care access in Greece [17]. This study
found that there were no regional differences in
access to health services. Also, several factors were
associated with higher use of office-based doctors,
as opposed to specialists: low income, worse health
status and low educational level. The results of this
study suggested a pro-poor bias; worse selfreported health status, low educational level and
lack of insurance coverage for primary health care
are correlated with higher use of hospital care.
Caution is needed when interpreting these results,
as the study methodology had many limitations
including a very low response rate (less than 40%)
to the mailed surveys.
The third study using Eurobarometer data from
1996 found that income was a determinant of
utilisation of health services in Greece (with the
exception of hospital stays and hearing tests)
where higher income groups appear to have better
access than lower income groups [37]. The effect of
income on diagnostic service use was particularly
strong. As shown in some other countries, it is
possible that low income groups may compensate
for their under utilisation of non-hospital services
by using more hospital services [38]. Nonetheless,
these findings should be treated with some caution
since income data in the Eurobarometer surveys
are not carefully collected, and the study did not
distinguish between GPs and specialists [36].
Overall, the evidence is by no means comprehensive and is somewhat contradictory, owing to
Health Econ. 14: S151–S168 (2005)
Analysing the Greek Health System
study limitations. Although some studies did not
find significant regional inequities in access, they
did not consider cross-boundary flows (mainly
people travelling to urban centres) or private
payments, therefore neglecting potentially significant time and financial costs, which could create
barriers to access.
Outputs
The only updated indicators of hospital performance are fairly crude measures of process outcomes such as length of stay, occupancy rate and
admission rate (not including psychiatric hospitals) from 1997. Accounting systems play a
marginal role in the NHS because the system
favours overtly political evaluation criteria of
organisational and individual performance [39].
There was a reduction in hospital occupancy rates
from 69% in 1980 to 65% in 1997. The percentage
of admissions to public hospitals increased from
77.82% in 1987 to 81% in 1997. The average
length of stay for acute treatment hospitals has
declined from 11 days in 1980 to 6 days in 1997
and has been accompanied by an increase in
admission rates from 1134 per 1000 population in
1980 to 1516 per 1000 population in 1997. These
figures show similar trends to other European
countries and, taken together with the reduction in
bed numbers, suggest a higher throughput. It is
likely that the decrease in length of stay can be
attributed to new pharmaceutical treatments and
medical technologies, as opposed to health policy
efforts; however, it is unclear whether the increase
in admissions is a reflection of population ageing.
There is some evidence, although relatively
dated, that significant inefficiencies exist. One
study using data envelope analysis (comparing
total costs with four outputs: number of inpatient
days in medical and surgical care, outpatient visits,
and ancillary services) estimated that in 1992
hospital inefficiency amounted to about 20% of
total costs, thus suggesting a potential to reduce
hospital spending [40]. The study also reports that
the difference between the actual and most efficient
costs was 27% for general hospitals and 16% for
teaching hospitals. These findings highlight the
variation in performance across Greek hospitals,
favouring the urban, teaching hospitals. Aletras
found similar results using a sample of 91 general
public hospitals in 1992 and estimated that the
average hospital X-inefficiency was 20–34% of
Copyright # 2005 John Wiley & Sons, Ltd.
S163
observed hospital costs [41]. Athanassopoulos
et al. found that in 1992 urban hospitals exhibited
very high output slacks, which suggests an
opportunity to increase the number of patients
they serve [42]. Athanassopoulos and Gounaris
estimated that 10–18% of hospital expenditure
could have been saved in 1992 [43].
Similarly, Prezerakos used 1995 data from 106
public hospitals and measured technical efficiency
by employing data envelope analysis. His analysis
suggested that 58.4% of the sample hospitals had
an efficiency deficit which was, on average, 20%
less efficient than the most efficient hospitals.
However, the most efficient hospitals included
many small hospitals (with less than 40 beds)
operating at a high efficiency level possibly because
they function as transhipment points for health
services that are then provided in the large scale
urban hospitals [44].
One study indicated that hospitals with between
250 and 400 beds operated more efficiently than
both smaller and larger hospitals, as measured by
general cost analysis (comparing total costs and
revenues per day across hospitals) [45]; however,
these results could be questioned since the
hospitals used in the sample appeared to overinvest in beds [42]. Not all of these reported
inefficiencies can be translated into cost savings,
however, because of potential differences across
hospitals in levels of slack in their operations, and
equity considerations that may allow some hospitals to operate below capacity.
The evidence regarding the performance of IKA
and NHS primary care centres is very limited.
Among 133 IKA primary care centres, it appears
that those with the technological infrastructure to
perform laboratory and/or radiographic examinations are more efficient [46]. Also, Sissouras et al.
examined the efficiency of 24 NHS primary care
centres in rural and semi-urban areas in 1996 and
found that most health centres were inefficient and
the lowest cost-efficiency was revealed to be in
health centres located close to hospitals, perhaps
because without an organised system of primary
care, people bypass local health centres and go
directly to hospitals [47].
In the pharmaceutical sector, the evidence
suggests that expenditure is rising as a result of
expensive new products. Between 1994 and 2000,
although relative drug prices (i.e. prices of the
drugs available in 1994) fell by 17% and the
number of prescriptions rose by only 16.34%, drug
expenditure at current prices increased by
Health Econ. 14: S151–S168 (2005)
S164
204.36%. Most of the cost increase was attributed
to new, costly, but not necessarily innovative
products [48]. Similarly, a recent study modelling
the increase in outpatient antibiotic expenditures
found that new expensive products account for
much of the non-rational acceleration in pharmaceutical expenditures [49]. Two studies found that
the positive list resulted in a one-off reduction (for
only one year) of the growth rate of the market.
The velocity of growth increased sharply afterwards suggesting that, since consumption remained stable between 1999 and 2000, there has
been a shift in prescription behaviour towards
more expensive drugs [50,51].
Overall, the evidence reveals significant inefficiencies in the hospital sector, and continuous
rapid increase in pharmaceutical expenditure,
perhaps as a result of the lack of a coherent
regulatory framework in the pharmaceutical sector.
Health outcomes
Life expectancy at birth in Greece has been
consistently increasing since the 1950s and is
currently 80.7 years for women and 75.4 years
for men [21]. In 2001, Greece ranked 9th for both
male and female life expectancy in the EU [21].
Between 1990 and 2000, male and female life
expectancy at birth increased at a slower pace than
the preceding 10 year period. Moreover, there was
a slight reduction in male and female life
expectancy between 1997 and 1998, which was
the only year since the early 1950s that a reduction
has been reported [52]. Nonetheless, these crude
measures of health outcome simply indicate the
existence of an effect, but say nothing about its
causes.
Much of the gains in life expectancy from 1970
to 1998 can be attributed to a reduction of infant
mortality [53]. Gains in the 1980s can partly be
attributed to improvements in pharmacological
treatments (mainly for breast cancer and cardiovascular diseases), Mediterranean diet, and possibly income improvements, a reduction of socioeconomic inequalities and improved access to
hospital care with the establishment of the NHS
[53,54]. However, gains in the 1990s have been
much lower due to increasing mortality from
traffic accidents, rising rates of obesity and
smoking related diseases (lung cancer and respiratory diseases) [53].
Copyright # 2005 John Wiley & Sons, Ltd.
E. Mossialos et al.
Furthermore, the adult probability of death
(ages 15–59) has increased for males since the
1970s whereas it has continuously declined for
females, but at a slower pace in the last 10 years.
Overall, against a background of continuous rises
in health expenditure and significant increases in
expensive health care inputs life expectancy in
Greece shows signs of slowing down, particularly
for women [53].
Amenable mortality has been used as an
alternative measure of health outcome, and one
that, unlike more crude measures such as life
expectancy, specifically attributes health outcome
to the health system [55]. Disability-adjusted life
expectancy in Greece has been reported by the
WHO to be 72.5 [56] (which is inflated due to
methodological limitations [55]), which places
Greece 5th in the EU; however, when comparing
amenable mortality, Greece falls to 8th place in the
EU [55].
Most improvements in life expectancy in the
1980s and 1990s were due to reductions in
amenable mortality, indicating that the NHS likely
had a positive effect on health outcomes. In the
1980s, at least 70% of the total improvements in
life expectancy were due to falling amenable
mortality in both sexes, about half of which was
due to falling infant mortality, consistent with
other studies [53]. Also during the 1980s, ischemic
heart disease increased among men and women,
which slightly reduced the effect of health care on
amenable mortality during this time. In the 1990s,
amenable mortality explained two-thirds of the
total increase in life expectancy. Falling infant
mortality was again the most important driver of
this improvement, explaining 36% of the increase
in female and 47% in male life expectancy.
A recent review of perinatal mortality compares
the quality of care provided in 10 different
European regions [57]. Compared to the other
countries, Greece had the highest perinatal mortality rate (around 9 per 1000). Greece also had
one of the highest percentages of perinatal deaths
that were associated with ‘suboptimal factors’ (e.g.
failure to detect severe intrauterine growth retardation) contributing to the fatal outcome. This
study suggests that the high perinatal mortality
rate in Greece may be explained in part by
suboptimal quality of care.
The literature in the area of health inequalities
in Greece is practically nonexistent. One study
reviewed socioeconomic inequalities (measured by
income and education) in health among the
Health Econ. 14: S151–S168 (2005)
Analysing the Greek Health System
European elderly [58]. The study showed that
Greece has one of the largest absolute and relative
inequalities in health among men and women.
The future
The NHS Law outlined its fundamental principles
of universal coverage and equitable access to
health care. More recently efficiency considerations have been highlighted. However, analysis of
the current system demonstrates that these principles have not been met. Funding has become more
regressive since 1980 with a shift towards private
sources. Unequal coverage results from a fragmented financing system, varying contribution
rates and differing benefits packages across insurance funds. Patients face significant direct costs or
have to purchase services in the private sector.
Although access to primary care appears equitable, or even pro-poor, access to specialists favours
high income groups. Resource allocation is based
on a historical and political basis and, although
the evidence is unclear, it appears there are
regional inequalities in the quantity and quality
of services provided. Finally, there is considerable
incoherence in mental and public health policy,
with much improvement needed in the quality of
mental health services, and developing public
health infrastructure, specifically information systems for monitoring, evaluating health trends in
addition to developing coherent prevention strategies. In future reform initiatives, it will become
increasingly important to emphasise preventive
health policies [10].
Furthermore, there is an over reliance on
expensive inputs. There is an excess of heavy
medical equipment particularly in the private
sector which remains unregulated, coupled with
an excessive use of emergency departments for
non-emergency treatments. There is an excess of
doctors and dentists and a serious shortage of
nurses. High pharmacy profit margins on pharmaceutical sales, the lack of generic price competition, a lack of generic substitution and a lack of
formal HTA contribute to pharmaceutical cost
escalation. Although formal HTA has been
criticised in the UK due to the observed inflationary pressure on health expenditure [59], since
almost all pharmaceutical and medical products in
Greece are reimbursed, formal HTA could play a
role in rationalising resource allocation; drug
Copyright # 2005 John Wiley & Sons, Ltd.
S165
pricing and reimbursement decisions could be
linked with the therapeutic value and cost-effectiveness of new medicines.
Overall, Greece has not yet fully established a
comprehensive and universal health care service
free at the point of use and health gains appear to
have reached their limit. Future health system
reform should consider focusing on funding, HTA,
purchasing mechanisms, and quality of care. This
proposed agenda is far from complete, however, as
it does not account for the fragmented character of
the Greek health system. It would be unrealistic
and ineffective to apply solutions used in other
health systems, as one cannot ignore the history of
health reform in Greece, its highly politicised
system, cultural idiosyncrasies and the vested
interests involved in policy development [2].
In terms of funding, a potential strategy is to
pool all resources through taxation and social
health insurance into a coordinated fund, in order
to establish a public sector monopsony purchasing
structure. With coordinated purchasing, there may
be pressures placed on providers to improve
efficiency, with appropriate monitoring systems
in place. This proposal will equalise benefits (hence
access to care) only under the condition that public
spending increases, and resources are distributed
to the less privileged funds. In the case that
benefits are similar, it would be possible to move
from the current system of entitlements based on
occupation to one based on citizenship. Furthermore, with a monopsony purchaser, regional
resource allocation methods could be introduced,
as well as a formal HTA policy for pricing and
reimbursement decisions. However, creating a
single purchaser with concentrated public resources is not the only way to improve efficiency.
It is important that providers have incentives to
be productive and improve quality. The hospital
payment system is currently on a per diem basis.
Therefore, a revised pricing system is needed based
on a combination of DRGs, in order to account
for hospitals’ activities, and annual budgets to put
a limit on expenditure. Payment of hospital
doctors is currently salaried and uniform across
specialties. The introduction of a fee-for-service
payment for hospital specialists, coupled with an
annual expenditure ceiling (to curb the inflationary
tendencies of a fee-for-service payment system),
could improve the efficiency of the NHS. A feefor-service payment system would require the
establishment of a fee schedule and a corresponding reporting system. Such a payment system may
Health Econ. 14: S151–S168 (2005)
S166
place indirect pressure on hospital managements
to move patients through faster without compromising patients’ health.
To improve primary health care, since a GP
system is impractical due to the high number of
specialists and relative lack of GPs, the coordinated purchaser could encourage group specialist
practices that function as a referral system to
hospitals and maintain a medical records system.
Currently doctors take advantage of the system
that allows different contract arrangements with
different funds. Therefore, a standardised contract
in addition to payment by capitation, as opposed
to fee-for-service, will improve primary care and
remove the incentive for specialists to inflate health
expenditure. Furthermore, a better coordinated
primary care system could contribute to an
improvement of quality and appropriateness of
care for people with chronic health conditions [60].
It is unclear, however, whether specialists would
accept new roles without the appropriate incentives in place. In the long term, given the high
number of physicians in Greece, group practices
with specialists paid individually on a capitated
basis may be an attractive approach, but much will
depend on the development of a coordinated
purchaser.
Because the reform of 2000–2002 failed to move
towards this suggested direction, it is unclear how
future government plans will evolve. Politicians
might be cautious to attempt a major reform that
will aim at increasing equity of finance and
rationalising delivery. It is more likely that for
the foreseeable future no major changes will take
place.
References
1. Mossialos E, Allin S. Interest groups and health
system reform in Greece. West Eur Polit 2005; 28(2):
420–444.
2. Davaki K, Mossialos E. Plus ça change: health
sector reforms in Greece. J Health Policy Polit Law
2005; 30(1–2): 143–168.
3. Hellenic General Accounting Office. Annual Report
of Revenues and Expenditure for 2000, vol. 1, Part 1:
Central Government. Hellenic General Accounting
Office: Athens, 2001.
4. Liaropoulos L. Health services financing in Greece:
a role for private health insurance. Health Policy
1995; 34(1): 53–62.
5. Mossialos E, Thomson S. Voluntary health insurance in the EU. Int J Health Serv 2002; 32(1): 19–88.
Copyright # 2005 John Wiley & Sons, Ltd.
E. Mossialos et al.
6. Sissouras A, Karokis A, Mossialos E. Health care
and cost containment in Greece. In Health Care
and Cost Containment in the European Union,
Mossialos E, Le Grand J (eds). Ashgate: Aldershot,
1999.
7. Deligianni Y, Kalomenidis K, Karokis A, Mitropoulos J. Report on the Health Status of the
Population of Patras. University of Patras: Patras,
1995 (in Greek).
8. Karokis A. Demand for primary health care and the
creation of the unified fund in Greece. Proceedings
of the 5th Hellenic Conference on Health Economics:
The Prospects for a Unified Fund in Greece, 11th
June 1996, Athens (in Greek).
9. Theodorou M. Primary Health Care in IKA.
IMOSY: Athens, 1993 (in Greek).
10. Abel-Smith B, Calltorp J, Dixon M et al. Report on
the Greek Health Services. Ministry of Health and
Social Welfare of Greece, Pharmetrica, Athens,
1994.
11. National Statistical Service. Household Budget
Survey 1998/99. National Statistical Service: Athens,
2002.
12. Matsaganis M, Mitrakos T. Determinants of household expenditure in Greece. Econ Policy Stud 1999;
5: 19–48 (in Greek).
13. European industrial relations observatory. Greece:
thematic feature – industrial relations and undeclared work. European foundation for the improvement of living and working conditions: Dublin,
Ireland,
2004.
http://www.eiro.eurofound.eu.
int/2004/06/tfeature/gr0406104t.html [4 November
2004].
14. Schneider F. The size and development of the shadow
economies of 22 transition and 21 OECD countries.
Discussion Paper No. 514, Institute of Labour
Studies, Bonn, 2002.
15. Bronchi C. Options for reforming the tax system in
Greece. OECD Economics Department Working
Papers No. 291, OECD, Paris, 2001.
16. Balfoussias A. Administrative Reform and the Greek
Tax System. Centre for Planning and Economic
Research: Athens, 2000.
17. Kyriopoulos J, Gregory S, Economou Ch. Health
and Health Services in Greece. National School of
Public Health: Athens, 2002.
18. Wagstaff A. Reflections on and alternatives to
WHO’s fairness of financial contribution index.
Health Econ 2002; 11: 103–115.
19. OECD. The Reform of Health Care: A Comparative
Analysis of Seven OECD Countries. OECD: Paris,
1992.
20. Polyzos N. An analysis of the hospital sector in
Greece. Ph.D. Thesis, University of Athens, 2001.
21. OECD. OECD Health Data 2004. OECD: Paris,
2004.
22. Madianos M, Yfantopoulos J. Final Monitoring
Report on the Progress of the Implementation of
Health Econ. 14: S151–S168 (2005)
Analysing the Greek Health System
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
the Psychiatric Reform Program in Greece under
Reg(EEC) 815/84. MEMHSU: Athens, 1996.
Madianos MG, Zacharakis C, Tsitsa C, Stefanis C.
The mental health care delivery system in
Greece: regional variation and socioeconomic
correlates.
J Ment Health Policy Econ 1999; 2: 169–176.
Souliotis K. An analysis of health expenditure in
Greece (1989–2000). In Health Expenditure in
Greece, Kyriopoulos J, Souliotis K (eds). Papazisis
Publishers: Athens.
Mitropoulos I, Sissouras A. Geographical Inequalities in Financing Health Care in Greece. University
of Patras: Patra, 2000.
Yfantopoulos J. Health Care Planning in Greece.
National Centre for Social Research: Athens, 1988.
Mrazek M. The impact of differing regulatory
frameworks on post-patent pharmaceutical markets
in the United Kingdom, United States and Germany,
1990–1997. Ph.D. Thesis, The London School of
Economics and Political Science, University of
London, 2001.
Polyzos N. Pharmaceutical care. In Report on the
Planning and Organisation of Health Services,
Theodorou M, Karokis A, Polyzos N et al. (eds).
Ministry of Health: Athens, 1994 (in Greek).
Giannakakis IA, Ioannidis JP. Arabian nights –
1001 tales of how pharmaceutical companies cater
to the material needs of doctors: case report. Br Med
J 2000; 321(7276): 1563–1564.
Gourgoulianis K, Hamos B, Christou K et al.
Prescription of medications by primary care physicians in the light of asthma guidelines. Respiration
1998; 65: 18–20.
Molstard S, Lundborg CS, Karlsson AK et al.
Antibiotic prescription rates very markedly between
13 European Countries. Scand J Infect Diseases
2002; 34(5): 366–371.
Skalkidis Y, Petridou E, Papathoma E et al. Are
operative delivery procedures in Greece socially
conditioned? Int J Quality Health Care 1996; 8:
159–165.
Alran S, Sibony O, Oury JF et al. Differences
in management and results in term-delivery in
nine European referral hospitals: descriptive
study. Eur J Obstet Gynaecol Reprod Biol 2002;
103: 4–13.
Mossialos E, Allin S, Karras K, Davaki K. An
investigation of caesarean sections in three Greek
hospitals: the impact of financial incentives
and convenience. Eur J Public Health 2005; 15:
288–295.
Karydis A, Komboli-Kodovazeniti M, Hatzigeorgiou, Panis V. Expectations and perceptions of
Greek patients regarding the quality of dental
health care. Int J Quality Health Care 2001; 13(5):
409–416.
Copyright # 2005 John Wiley & Sons, Ltd.
S167
36. van Doorslaer E, Koolman X, Puffer F. Equity in
the use of physician visits in OECD countries:
has equal treatment for equal need been achieved?
ECuity II Project Working Paper No. 3: Rotterdam,
2001.
37. Mergoupis T. Access to health care in Greece: a
micro-level analysis. Proceedings of the First Conference of the Hellenic Social Policy Association,
Komotini, 2001.
38. van Doorslaer E, Wagstaff A, van der Burg H
et al. Equity in the delivery of health care in
Europe and the US. J Health Econ 2000; 19(5):
553–583.
39. Ballas A, Tsoukas H. Measuring nothing: the case
of the Greek National Health System. Hum Relat
2004; 57(6): 661–690.
40. Giokas D. Greek Hospitals: how well their
resources are used. Omega 2001; 29: 73–83.
41. Aletras V. Economic analysis of hospital performance: an econometric approach. Ph.D. Thesis,
University of Thessaloniki, Greece, 1999.
42. Athanassopoulos A, Gounaris C, Sissouras A. A
descriptive assessment of the production and cost
efficiency of general hospitals in Greece. Health
Care Manage Sci 1999; 2: 97–106.
43. Athanassopoulos A, Gounaris C. Assessing the
technical and allocative efficiency of hospital
operations in Greece and its resource allocation implications. Eur J Oper Res 2001; 133(2):
416–431.
44. Prezerakos P. Case mix in Greek hospitals. Ph.D.
Thesis, Department of Nursing Studies, University
of Athens, Greece, 1999.
45. Polyzos N. Striving towards efficiency in the Greek
hospitals by reviewing case mix classifications.
Health Policy 2002; 61: 305–328.
46. Zavras A, Tsakos G, Economou C et al. Using DEA
to evaluate efficiency and formulate policy within a
Greek national primary health care network. J Med
Syst 2002; 2694: 285–292.
47. Sissouras A, Mitropoulos I, Gounaris Ch. Evaluating the efficiency of health care units: the case
of the Greek primary care centres. In Proceedings
of the 7th International Conference on System
Science in Health Care, Javor A, Eimeren van E,
Duru G (eds). Conference Tours: Budapest, June
2000.
48. Kontozamanis V. The Greek Pharmaceutical Market. Institute for Industrial and Economic Studies:
Athens, 2001 (in Greek).
49. Zintzaras E, Ionnidis JPA. Modelling of escalating
outpatient antibiotic expenditures. J Antimicrob
Chemotherapy 2003; 52(6): 1001–1004.
50. Karokis A, Christodoulopoulou A, Tsiaras T,
Mossialos E. Pharmaceutical price controls and
positive drug list effects on total and social
insurance pharmaceutical expenditure. Proceedings
Health Econ. 14: S151–S168 (2005)
S168
51.
52.
53.
54.
55.
of the 5th Annual ISPOR Conference, Washington
DC, 21–24 May 2000.
Lopatatzidis A, Hatziandreu E, Nektarios M.
Assessment of the Effects of a Positive Drug List in
Primary Care Prescribing in Greece. Social Security
Fund: Athens, 2001.
Eurostast. Demography Statistics. Eurostat: Luxembourg, 2002.
Florinis D. Life expectancy in Greece: 1950–1999.
M.Sc. Dissertation, London School of Economics
and Political Science, 2002.
Panagiotakos DB, Pitsavos C, Polychronopoulos E,
Chysohoou C, Zampelas A, Trichopoulou A. Can a
Mediterranean diet moderate the development and
clinical progression of coronary heart disease? A
systematic review. Med Sci Monit 2004; 10(8): 193–198.
Nolte E, McKee M. Does Healthcare Save Lives?
Avoidable Mortality Revisited. The Nuffield Trust:
London, 2004.
Copyright # 2005 John Wiley & Sons, Ltd.
E. Mossialos et al.
56. World Health Organization. The World Health
Report 1999: Making a Difference. World Health
Organization: Geneva, 1999.
57. Richardus JH, Graafmans WC, Verloove-Vanhorick SP et al. Differences in perinatal mortality and
suboptimal care between 10 European regions:
results of an international audit. Br J Obstet
Gynaecol 2003; 110: 97–105.
58. Huisman M, Kunst AE, Mackenbach JP. Socioeconomic inequalities in morbidity among the
elderly: a European Overview. Soc Sci Med 2003;
57: 861–873.
59. Raftery J. NICE: faster access to modern treatments? Analysis of guidance on health technologies.
Br Med J 2001; 323: 1300–1303.
60. McKee M, Nolte E. Responding to the challenge of
chronic diseases: ideas from Europe. Clin Med 2004;
4(4): 336–342.
Health Econ. 14: S151–S168 (2005)