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World Report

Health under austerity in Greece


As Greece nears its exit from the bailout programme initiated 8 years ago, health in Greece has
suffered from the severe austerity measures. Talha Burki reports.

It is almost 8 years since Greece by a fifth over 2010–11, and by more crisis and the policy response to it had
accepted its first bailout from the than half over 2011–12. By 2014, Greek devastating consequences for public
European Central Bank, European public spending on health was lower health—the burden of evidence on this
Commission, and the International than any of the pre-2004 EU members. is just too high to disregard”, confirms
Monetary Fund. The country had debts Alexander Kentikelenis, junior research
of €301 billion and was on the verge “‘People are not prioritising their fellow in Politics at Trinity College,
of bankruptcy. A second bailout of health...They only try to access University of Oxford, UK.
€130 billion was agreed in 2012, and a health care when their situation The first years of austerity saw
third of €86 billion in 2015. On Jan 22, becomes unmanageable.’” increases in mental health problems,
Eurozone finance ministers approved and in attempted and completed
€6·7 billion worth of loans to the Greek Meanwhile, the Greek population suicides. There were spikes in HIV
Government. The money represents suffered a prolonged and profound and tuberculosis rates among
the fourth tranche of the 2015 bailout economic crisis. Between 2008 and injecting drug users, after street-work
package. Greece is on course to exit the 2014, Greece’s GDP dropped by 29%. programmes were cut by a third.
bailout programme in August, 2018. Unemployment currently exceeds By 2015, the proportion of Greeks
But progress has come at a cost. 20%; youth unemployment is over reporting unmet medical needs had
40%. Nearly a quarter of doctors are risen to 12·3%, almost four times
Austerity measures thought to be unemployed, and more the EU average. Cost was the most
Greece’s creditors imposed tough than 7000 have left the country since commonly cited reason. “People are
austerity measures on the country. 2009. The ratio of nurses to population not prioritising their health”, said
Conditions attached to the bailouts is the lowest in the EU. Apostolos Veizis, director of the Medical
included public sector redundancies According to EU statistics, in 2015, Operational Support Unit, Médecins
and cutbacks; sharp reductions to 41% of Greeks were materially deprived, Sans Frontières, Athens, Greece. “They
minimum wages, pensions, and welfare meaning they could not satisfy basic only try to access health care when their
payments; and the privatisation of needs such as heating, rent or mortgage situation becomes unmanageable.”
state assets. From 2009 to 2014, Greek payments, and food. 22% were severely
public spending fell by 36%. Health- deprived. Almost half of Greek children Reform was needed
care services were severely affected. were living in deprived households. There is a consensus that the Greek
The 2010 rescue package stipulated WHO reports that nearly a third of the health-care system was in dire need
that Greece caps public expenditure poorest Greek households incurred of reform even before the crisis.
on health at 6% of GDP. “We still have catastrophic medical expenses in 2014, Drugs and diagnostic services were
no idea where this figure came from; it a situation exacerbated by the increases widely overprescribed—pharmaceutical
was entirely arbitrary”, points out David in user fees and copayments for medi-
Stuckler, professor in the Department of cal services and drugs. Social insurance
Policy Analysis and Public Management, funds saw declining revenues as unem-
Università Bocconi, Milan, Italy. ployment soared, wages fell, and Greeks
Greece’s health-care staff had their worked fewer hours.
salaries reduced twice in 2010. Funding Austerity has had some positive
of public hospitals fell by more than effects on public health, albeit driven
half from 2009 to 2015. Treatment by restriction in access. As tobacco
services, diagnostics, and disease became increasingly unaffordable,
Louisa Gouliamaki/Getty Images

prevention programmes were cut by smoking prevalence in Greece dropped


20%, and maternal and child health from 37% in 2012 to 27% in 2017. Fewer
services were cut by 73% between 2009 Greeks have died in road accidents,
and 2012. The government abandoned because people have opted for cheaper
plans to establish child psychiatry forms of transport.
services and instead reduced state But in overall terms, health has Public hospital employees demonstrate against cuts in the public health sector,
funding for mental health services worsened. “It is absolutely clear that the Oct 11, 2017, Athens

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World Report

expenditure rose from around €1 billion health insurance funds into one takes months for pharmacies, whole-
in 2000 to €5·6 billion in 2009. There is main body reduced the fragment­ation salers, and pharmaceutical firms to be
no agency to evaluate drugs and health of the system and standardised benefits. paid—some companies are reluctant
technologies and decide whether they to take on that kind of arrangement.”
should be recommended for use in “‘Reforms, sometimes not- Moreover, the stipulated copayment
the public sector. Primary care is weak evidence-based, came with the for medicines often bears no relation to
and corruption is widespread. Out-of- price of deteriorating access to what patients actually end up spending.
pocket payments by patients stand care, a fleeing workforce, and “Say the doctor prescribes a drug that
at 35% of total expenditure, more drug shortages...’” costs 50 cents, but because of the
than double the EU average. Almost shortages, the pharmacy only has the
a third of out-of-pocket payments In 2016, Greece passed universal version that costs €1—you have to buy
are informal payments to expedite health care legislation, which the more expensive drug, but you will
treatment or to obtain purportedly covers not just all Greek citizens but only be reimbursed for the cheaper
better care. migrants and refugees. “That is a one”, outlines Veizis. “So in reality,
“In principle, reforms could have very positive step, although it has copayments can be up to 75%.”
been designed in ways that resulted in come very late given the scale of the Many other kinds of barriers
greater efficiency and improved patient problem; the data from 2017 will tell exist. Greece is home to some
health, but this did not happen”, us whether it has improved access 50 000 refugees, for example, only
Kentikelenis told The Lancet. “Instead, to care”, stated Marina Karanikolos, 45% of whom have been issued
we saw rapid and large-scale austerity research fellow at the European with the social security number they
measures and budget reductions that Observatory on Health Systems and require to obtain public health care.
essentially crippled the health-care Policies, London School of Hygiene & “Overly rigid bureaucratic procedures
system’s capacity to respond to the Tropical Medicine, UK. and outdated eligibility criteria have
increased medical need.” Efforts are underway to develop resulted in inadequate access to health
Stuckler points out that the bailout primary care. “We are quite far away care”, asserts Kentikelenis.
conditions and reforms of the Greek from a system where you have general “Reforms, sometimes not-evidence-
health-care system were not drawn practitioners as gatekeepers”, explains based, came with the price of deteri­
up by doctors or health experts but Karanikolos. “The new proposals orating access to care, a fleeing
by macroeconomists. “The EU has are going to be easier to implement workforce, and drug shortages—
not made any kind of health impact in rural areas, where there is less fairly catastrophic consequences”,
assessment, even though one would access to hospitals, than in the cities, said Karanikolos. Some studies have
consider that to be a routine policy- where patients can to go directly suggested that productivity has
making step.” A study published in to specialists.” improved; others have reported on
The Lancet Public Health noted that Electronic monitoring systems have worsening hospital care.
the years following the onset of the been established, including electronic “We have already seen very
economic crisis saw a marked rise prescriptions. The use of generics has pronounced health effects on
in the number of Greeks who died been promoted, and reference pricing vulnerable populations, but we do
from adverse events during medical introduced for branded drugs. Greek not yet fully appreciate how the
treatment, a phenomenon that might expenditure on pharmaceuticals in policy response to the crisis will affect
be attributable to staff shortages 2013 was less than half its 2009 level. population health over the long
and burnout. run”, said Kentikelenis. Some effects
“There were indiscriminate cuts, Drug shortage and out-of- could take years to become apparent.
without any effort to protect priority pocket spending “If children have been deprived of
public health spending areas”, In the severest part of the recession, adequate nutrition at an early age, they
continues Kentikelenis. For most of there were drug and vaccine short- will go on to be less healthy adults”,
those who became unemployed or ages, as pharmaceutical companies Kentikelenis told The Lancet. “We will
were no longer able to contribute to prioritised more stable markets. These have to wait for the epidemiological
social insurance funds, health coverage seem to have eased, although Veizis data to become available.”
expired after a maximum of 2 years. It points out that problems remain. Hope increased for the Greek econ-
meant that an estimated 2·5 million “People have had to change their omy last year, as it grew for three suc-
Greeks were left without coverage treatment protocols because many cessive quarters, but the public health
during the crisis. drugs are not circulating any longer”, consequences of the crisis could linger.
Several crucial reforms have been he said. “There are capital controls
enacted. The amalgamation of the and other administrative barriers, so it Talha Burki

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