Exploring health care reform in a changing Europe: Lessons from Greece

Abstract

The economic crisis is the major theme in the Eurozone and its impact on public health and outcomes is largely discussed. Under this pressure, concerns of further inequalities exist that may have an impact on the burden of several diseases in certain European countries. In this context, Greece is currently an issue of top interest in any international economic discussion. Although the background of the recession has been largely discussed as a political crisis, its health effects on the population, as well as the key role of primary care and general practice/family medicine in health care reform remain to be explored. Serving both the worldwide trend of orienting health care systems towards strengthened primary care and the inner need for minimizing the demand and lessening the burden from the dysfunctional and costly hospital-care system, the economic crisis sets the perfect timing for prioritizing primary health care. In this article a unique window of opportunity for health care reform in Greece is examined, attempting to establish the axes of an example of how health care system can be reshaped amidst the economic crisis. Equity, quality, value framework, medical professionalism, information technology and decentralization emerge as topics of central interest. There is no doubt that Europe is transitioning under challenging social, economic and public health perspectives. However, taking Greece as an example, the current economic situation sets a good timing for health care reform and the key messages of this paper could be used by other countries facing similar problems.

Keywords::

• Greece
• economic crisis
• quality
• equity
• health care system reform
• primary care

KEY MESSAGE:

• The economic crisis sets the timing to shift to a primary care system in Greece

• Apart from health care, Greece should focus on general changes, primarily decentralization and education

• In a changing Europe, approaches on health care reform via primary care in settings similar to Greece could be discussed and explored

INTRODUCTION

Nowadays, Europe is facing unprecedented social, demographic and epidemiologic transitions mainly because of the economic crisis that has affected Greece and other countries, at a global level. Despite the attempts to maintain a calm face, it is becoming increasingly clear that European countries are in front of even more ominous challenges. Undermining of the common currency, social unrest and spreading of the infection from the most vulnerable countries to the once considered impervious economies frame today's picture and threaten Europe's core. Under the pressure of known economic and social determinants on health (1), each government should assume responsibility not to leave further income inequalities impact different health outcomes (2).

In this context, Greece is currently an issue of top interest in any international economic discussion. The country, which had taken advantage of the possibility to borrow promiscuously due to the lower interest rates its government bonds could attain, led by particular political parties for decades, built up €300 000 million in debt after the predictable strike of the global financial recession. Unable to stand up to its financial responsibilities, it reached the edge of bankruptcy and, facing the fiscal debacle, resorted to social cost-cutting measures and heavy taxation, especially after the bailout proposal of the international leaders (3).

Meanwhile, Greek health care lacks the setting of common targets delineated years ago. Greece's system is a mixture of public integrated, contract and reimbursement models, comprising elements from both the public and private sectors and incorporating principles of different organizational patterns. Access to services is based on citizenship and occupational status. The system is financed by the state budget, social insurance contributions and private payments (4). Unlike its initial design, the system had evolved in a fragmented manner until today's inequitable access to health services, conflicting incentives for providers and escalating costs. However, the economic crisis came to aggravate the situation further (5) and certain proposals about a more rational, evidence-based, and integrated system has failed (6). The health effects of this political and socioeconomic crisis have started to be published in international literature (7); we are herein underlying the increased burden in both communicable and non-communicable diseases.

Serving both the worldwide trend of orienting the health care systems towards strengthened primary care (8) and the inner need for minimizing the demand and lessening the burden from the dysfunctional and costly hospital-care system, the economic crisis sets the most suitable timing for shifting to primary care as a priority (6,9,10). Primary care, critical for decreasing costs while improving quality of health care services (6,11), seems like the answer to the challenges of the changing world, under the concept of ‘glocalization’ (i.e. think globally, act locally) and the emerging non-communicable disease crisis, as well as the revisited communicable diseases (12,13). Although this is a recognized priority, Greece is still contemplating what direction a national policy favourable to primary care should follow.

This article attempts to examine a unique window of opportunity for health care reform in Greece, highlighting the axes of an example of how the primary health care system can be reshaped amidst the economic crisis. Its approach was based on an existent SWOT analysis from four continents, according to which for each system it is important to monitor the impact on: equity (access, reducing social inequalities in health); quality (both process and outcome); and health outcomes on morbidity and mortality (12). These issues, as well as value framework, medical professionalism, information technology, health management with a focus on decentralization, cost-effectiveness and patient experience within a strong primary care, emerge in this article as topics of central interest (Figure 1); and the economic crisis can be suitable to focus on these issues (10).

Figure 1. Fishbone diagram presenting the major suggestions for substantial changes in the health care system in Greece, a country facing economic crisis. PAF, prevention-appraisal-failure.

FOCUS ON EQUITY

Lack of equity of access to health care has been long described as a fundamental problem of Greek health care (5). Although primary care services were accessible to all Greeks before the economic crisis, today certain problems have been recognized after the introduction of contact fees. However, equity demands redesigning primary care into an integrated model.(6) The integration of primary care providers, the establishment of a multidisciplinary team and the legislation for the family (personal) doctor institution seem to be essential for continuous and efficient health care (6 11). To that direction, we should seek for measures of doctors’ control to explore interventions in the organizations and delivery of health services, with the main aim to identify effective interventions to improve performance, production, efficiency and equity should be sought (14).

Patient-centred care

Faulty organizational structure and lack of control and coordinated care in Greece has led to physicians failing to accept joint responsibility for outcomes (15). Even in rural primary care centres, medical directors who have been assigned with management responsibilities are still requesting formal training and support, as a recent qualitative study reported (16). It is generally accepted that medical professionalism is facing a crisis enhanced by the lack of mechanisms to control doctors’ performance. It is not certain to what extent the growing commercialization of the health care system or the growing influence of the pharmaceutical industry on medical practice, are accountable for the decline of professional values. Therefore, the rebuilding of a patient-centred system is a sine qua non condition in order to remedy these matters (6). The issue of the doctor-patient relationship is central and medical education should be enhanced with this concept. Especially as Greek medical students show a strong tendency towards specialization, and away from primary care and traditional specialties which include human contact (17).

The aforementioned challenged doctor-patient relationship during the period of crisis also calls for an effective use of voluntary and charitable organizations, within the concept of compassion towards the patient. This is more crucial now than ever before, particularly in countries in similar situations to Greece, where the financial crisis is expected to have an enormous effect on health and social care (18). Even though voluntarism seems a luxury within an economic recession, volunteers in the community could be attracted if they were given the prestige of an administrative position. Simple, inexpensive, questionnaire-based, research among potential volunteers would provide clues of who can be more effective in which position. Moreover, a cost-effective way to sensitize students towards patient-centred practice would be to favour their participation in non-profit charitable organizations which address medical needs. An encouraging message has been received after the first evaluation of a course on ‘compassionate care’ in the University of Crete. This elective confirmed that students value the opportunity to increase their awareness on the concept of compassion and health care (19). All in all, voluntarism and compassionate care require more coordinated actions; regional authorities and municipalities, perhaps in conjunction with regional health care centres, could undertake simple actions to promote them.

Decentralization

Above all, with many forsaken jobs and villages, the once lucrative Greek province is now neglected. Athens seems the most obvious choice for today's youth; therefore, accumulating large numbers of unemployed (20), most of which are pushed away from their country seeking better prospects (17). Therefore, the most important and direct way to reform the society, restore its smooth running and secure equity of access to health care is decentralization of population; and relevant government incentives are sought.

A health care system, decentralized politically, financially and operationally, may be characterized by expenditure control, reasonable positive development in productivity and a high degree of patient and citizen satisfaction (21). Health has been recognized as a beneficiary of sustainable development (22). However, regional health planning is still discussed separately from other sections of development, even though it could invest in primary care with some existing evidence from previous efforts undertaken in Crete (23). Major changes could be gradually achieved in the Greek society and economy through: (i) revitalizing townships with new job openings (primarily in the fields of education and medicine, thus also providing occupation to the growing surfeit of new physicians); (ii) supplying peripheral hospitals with accountable to the population health needs; (iii) establishing integrated primary health care; (iv) promoting proper student education accountable to the patients’ needs with better career orientation and guidance; (v) promoting intersectoral cooperation with the health care services towards sustainable development. This process could aid in the solution of the fact, recognized by the Organisation for Economic Co-Operation and Development (OECD) that Greece faces an over-supply of doctors and undersupply of nurses, resulting in inefficient allocation of resources (24). Decentralization, focused on sustainable development, should be approached under the framework that it is not an end in itself, but rather should be designed and evaluated for its ability to achieve broader objectives of health reform: equity, efficiency, quality, financial soundness (21).

FOCUS ON QUALITY

Inappropriate undergraduate medical education, lack of interdisciplinary collaboration, lack of quality assurance measurements and lack of standards (5), remain the most important barriers relevant to a health care reform based on quality performance in Greece. However, outcomes are still expected from the appropriate utilization of the funding from the National Strategic Reference Framework 2007–2013. To what extent all these missing auditing procedures are due to the system's inability to control performance or an issue of lacking transparency is still questionable.

Cost-of-quality

Specific directions should be followed for the evaluation of quality costs in health care, an approach not utilized in Greek programmes (25). Systems which adopt a cost-of-quality concept seem to be successful in reducing quality costs and improving quality of health care services for their customers. Cost-of-quality is usually understood as the sum of conformance (the price paid for prevention of poor quality), plus non-conformance (cost of poor quality caused by product and service failure) costs. A most easily implemented, classical prevention-appraisal-failure model must suit the situation (insurances); the environment (hospital, primary care centre); the purpose (cure); and the needs (workforce, infrastructure) of the system in order to have a chance to become a successful systematic tool in a quality management programme (26). Cost-of-quality approaches within scientific context can improve the decision making of health managers even in a resource-limited environment, but require strong political decision (27). For example, the OECD points out a lack of regulation in the purchasing of computed tomography scanners and magnetic resonance imaging. Greece is still a 'champion’ in operating capacity that disproportionally corresponds to the patients health needs (24). The current situation calls for a tighter control of both budgets and quality as well as patients’ safety in clinical practice.

Information technology

Information Technology (IT), which is associated with improved processes and outcomes in primary care (28), still needs to be organized properly in Greece. There are certain reports which link health IT with the improvement of quality and efficiency (28). Therefore, health-care professionals should be efficiently aided, by existent research, to effectively use health IT and especially electronic health record systems, which, if implemented under a robust organization, may also be cost-effective (28,29). However, current results from a national electronic patient record system based on episode care are very disappointing. In addition to these, current modern approaches using proficient technologies, like near- patient testing, that, have on many occasions proved to potentially have economic benefits (30), are still out of the agenda of health care authorities in Greece.

Economic value framework

As far as value is concerned, the failure to measure and prioritise value improvement in Greek health care delivery suppresses innovation, leads to inadequate cost containment and encourages micromanagement of physicians’ practices, all imposing substantial costs (15). Value, which has received a prompt attention in current literature (15,31), should always be defined around the customer and in a well-functioning, either tertiary or primary, health care system the creation of value for patients should determine the rewards for all other actors in the system. This, while developing a regime to systematically measure the aspects of the outcome hierarchy for each medical condition hospitals provide services. Although the definition of value framework varies across different settings and cultures, its concept includes the creation of a context for improvement, for every physician and provider group to try to be better this year than it was last year. Value can be enhanced by improving one or more outcomes without compromising others or by reducing the costs required to achieve the same levels of outcomes. A comparing analysis between total costs of a patient's entire care cycle and the outcome will enable structural cost reduction, through steps such as: re-allocation of spending among types of services, elimination of non-value-adding services, better use of capacity, shortening of cycle time, provision of services in the appropriate settings (15).

FOCUS ON HEALTH OUTCOMES

Life expectancy in Greece remains lower than in a number of OECD countries (24) and a negative trend has been observed even before the austerity period. Reducing morbidity and mortality and improving quality of life for the patients also demands, among other measurements, health-care system interventions (32), but it is uncertain to what extent it can be achieved in a country under austerity. However, interventions that address to human resources on both medical providers and patients’ behaviour seem to be a challenging priority. A country seeking an amelioration of its morbidity and mortality reports should build upon a solid educational system; thus, a system linked to the market, the society's needs and the changing medical aspects (in our case especially the orientation towards family medicine). Efforts to train the primary care practitioners to use appropriate non-pharmacological and patient behaviours modifications intervention is of high priority at the moment in Greece. In addition, adherence to clinical guidelines, encouraging of research and innovation, creation of national health databases and introduction to the up-to-date technological advances in health care delivery should be attempted.

Medical and continuing education

In regards to medical professionalism, recognizing importance of primary care has taken high priority and gives added value to appropriate transformation of the curriculum of medical schools and continuing professional development. With general practice, as an academic and clinical discipline, requiring a more rapid development, interest should be paid to create medical schools working in an interdisciplinary teaching environment, with a curriculum more socially accountable. Clinical research and teaching, full academic recognition and creation of a link between the university and the general practitioners, perhaps through senior students spending time in primary care centres, are the major topics of interest (33). The development of practice-based research networks in general practice are still lacking in Greece with the exception of a rural network on Crete. It may be advisable for nursing and medical students to share some courses in order to advance a healthy relationship on enhanced roles that promote networking and culture exchange. Students and residents should be encouraged to attend regional congresses and international elective programmes which can improve their knowledge and performance with no further costs for their country (34).

Nursing management

Advancing the role of nursing management, through assigning professional health care responsibilities to nurses (35) and other health-allied practitioners, especially in primary care, may improve both chronic ill management and health promotion activities (6). For the time being, it is known that nursing staff in public health care operate within a restricted and task-oriented framework and their educational preparation has little effect in practice role variations and professional need (36). However, it requires structural changes in the university education and an adoption of multidisciplinary approaches in both educational and clinical practices that are still lacking in Greece.

Health promotion In regards to patients’ behaviour, Greek primary care patients are very demanding. Health promotion activities that focus on a healthier lifestyle pattern are an issue of both practitioners and patients (37). Examples are smoking and obesity rates, which are the conditions that will supposedly bring the highest health care costs in the future (24). All these efforts are expected to have an impact on morbidity and disability burden; however, they are strongly associated with the primary care practitioners’ skills relevant to behaviour modification, as underlined before. New issues on the agenda, health human resources and health marketing, should be modulated on the needs of the country's current epidemiological profile.

Sustainability Health outcomes in a period of economic crisis are always discussed jointly with financing issues. These measures raise the problem of sustainability, a value-laden concept comprising many ideals such as equity, choice, compassionate care, confidence and quality. Even though new measures seem to require new financing, we have already analysed all of these sustainability issues within the economic recession concept. A need for new investments would not exist if the money currently in the system could be re-allocated to maximize its value. New models of primary care budgeting and pay-for-performance models could be discussed in the new reform for Greece (38). Not surprisingly, this too requires visionary politicians with a willingness and commitment to make fundamental changes in the way health care is organized and delivered, as we have discussed in our paper, but also fundamental changes in many sectors outside health. Besides, emphasis on primary care can mean more quality health care services at a lower price and we can reasonably expect better economic status when the health of the population, as well as the morbidity and mortality rates, are improved (8).

CONCLUDING THOUGHTS

There is no doubt that we are in front of major changes and truculent challenges globally. Europe is transitioning under social, economic and public health perspectives separately if the current crisis seems to affect initially certain European southern countries. However, taking Greece as an example (Figure 1), the current economic situation sets a good timing for health care reform. We suggest this for a number of reasons that have been illustrated in this opinion paper and are summarized as: (i) it has made both the public and the officials wake to sensitive, previously unhandled, matters; (ii) it favours low-cost, but high-impact, changes, like systematic measuring of value and quality, and variations of medical schools syllabi; (iii) it aids the transfer from the costly and dysfunctional tertiary to the economical and efficient primary care; (iv) even though it restrains a reform from the inside, it helps a country discover suitable models, under a financial perspective, from other countries. In order to offer plausible messages for European health care, and in front of a potentially long-term recession, which might take on characteristics of breakdown or bankruptcy, we have made considerable attempt to discuss every thesis in this paper under the light of a cost-benefit reform.

Every country, irrespective of political or economic status, but especially the developing ones, should be open to learning from others to build relevant and cost-effective systems, while using effectively any learned experiences from empirical research implemented locally (38). Generally, it is not considered wise to translate experience gained from other countries in measuring the domestic situation's expected burden and effect without the appropriate adaptation, in terms of the system. However, it has been suggested that several approaches that have worked well for some countries could probably be adapted to the unique circumstances of others (39).

A final key message from the Greek experience: national health care systems need to look beyond their own doors and explore broader system changes, realizing that the recession's effects will be sizeable and long-term. The current socioeconomic downturn makes it essential to explore broader, system-wide integration and embark on long overdue changes, and may very well be the impetus required to drive dramatic reform, resulting in a far better, more integrated health system.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.