Government Debt Crisis and the Impact on National Health Systems: a Retrospective Study and Policy Recommendations to Greece

Open Access Original Article DOI: 10.7759/cureus.10786 Government Debt Crisis and the Impact on National Health Systems: A Retrospective Study and Policy Recommendations to Greece Evangelos Diamantis 1 , Vasileios Charalampopoulos 2 , Christos Damaskos 3, 4 , Paraskevi Farmaki 5 , Nikolaos Garmpis 2 , Anna Garmpi 6 , Alexandros Patsouras 7 , Georgios Kyriakos 8 , Spyridon Savvanis 9 , Vasiliki E. Georgakopoulou 10, 11 , Nikolaos Trakas 12 , Kostas Kounetas 13 1. Internal Medicine: Diabetes and Endocrinology, Evangelismos Hospital, Athens, GRC 2. Surgery, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, GRC 3. Surgery, Renal Transplantation Unit, Laiko General Hospital, Athens, GRC 4. Surgery, N.S. Christeas Laboratory of Experimental Surgery and Surgical Research, Medical School, National and Kapodistrian University of Athens, Athens, GRC 5. Pediatrics, Agia Sofia Children’s Hospital, Medical School, National and Kapodistrian University of Athens, Athens, GRC 6. Internal Medicine, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, GRC 7. Internal Medicine, Tzaneio General Hospital, Pireas, GRC 8. Internal Medicine: Diabetes and Endocrinology, Hospital General Universitario Santa Lucia, Cartagena, ESP 9. Internal Medicine, General Hospital of Athens “Elpis”, Athens, GRC 10. Internal Medicine: Pulmonology, Laiko General Hospital, Athens, GRC 11. Internal Medicine: Pulmonology, Sismanogleio Hospital, Athens, GRC 12. Laboratory Medicine, Sismanogleio Hospital, Athens, GRC 13. Economics, University of Patras, Patras, GRC Corresponding author: Christos Damaskos, [email protected] Abstract This article aims to explore the impact of the government debt crisis on the national health system (NHS) using a representative sample of respondents in Greek hospitals and provides certain suggestions regarding health policies that could be implemented at the national or local level. This study was conducted at the Evangelismos & Eye Polyclinic of Athens General Hospital in Athens, Greece. The study period was January and February of 2016, and the study included 600 outpatients who frequently submitted to follow-ups and consented to participate. Based on the results of this study, the participants had an average health status, while 94.2% of them had medical insurance. The predominant reason (88%) for choosing public hospitals instead of private practices was insufficient income. Further investigation revealed a significant positive correlation between the participant’s age and the number of hospital visits, the number of medical tests performed, and their satisfaction from the health services provided. Finally, a probit-model was used in order to study factors that could potentially influence their level of satisfaction from the services they used. Categories: Quality Improvement, Environmental Health, Epidemiology/Public Health Keywords: health care system, crisis, health quality Review began 09/11/2020 Introduction Review ended 09/30/2020 The 1976 charter of the World Health Organization (WHO) has defined health as “a state of complete Published 10/04/2020 physical, mental and social well-being” and not simply as the absence of disease or infirmity [1]. Thus, the © Copyright 2020 concept of health is not only defined from a medical perspective, but also as something influenced by other Diamantis et al. This is an open access factors, such as the environment, economy and finances, and employment. For instance, there is no doubt article distributed under the terms of the that a financial crisis along with a direct reduction of public health expenditure leads to unemployment and Creative Commons Attribution License CC-BY 4.0., which permits unrestricted population impoverishment, eventually negatively affecting health indicators such as life expectancy, use, distribution, and reproduction in any morbidity, mortality, access to health services, and weakening of the healthcare system [2-4]. medium, provided the original author and source are credited. In recent years, the global financial crisis, and the economic recession that followed, has imposed a heavy economic burden on citizens and the healthcare systems of the countries that suffer under the vicious circle created by the increase of unemployment, the loss of health insurance, decreases in available income, the inability of the people to bear the healthcare costs, and ultimately poor health outcomes resulting in increased morbidity and mortality through continuous impoverishment [5]. Greece, Spain, and Portugal have adopted strict fiscal austerity measures. As their economies continue to struggle, pressure on their national health systems (NHS) rises. In these countries, suicides and outbreaks of infectious diseases are becoming more common as health expenditure cuts limit the public's access to healthcare services [6]. The direct and indirect effects of the European financial crisis on the healthcare sector has been a debatable subject during the last years [5-8]. For instance, Rodriguez et al. studied any possible impact of the economic crisis in the health sector of the EU countries most affected by the crisis: Ireland, Greece, Spain, Italy, Cyprus, Latvia, Portugal, and Slovenia [9]. Among other things, the researchers concluded that the implementation measures resulted in a significant shift of the respective cost to households, either through an increase of co-payments for the use of health services or through higher fees for pharmaceutical products [9]. How to cite this article Diamantis E, Charalampopoulos V, Damaskos C, et al. (October 04, 2020) Government Debt Crisis and the Impact on National Health Systems: A Retrospective Study and Policy Recommendations to Greece. Cureus 12(10): e10786. DOI 10.7759/cureus.10786 There is no doubt that the 2009 global economic crisis has had a significant impact on all sectors of the Greek economy and particularly on the NHS, which was already facing a number of problems and chronic issues [6]. In order to compensate for the budget cuts in healthcare, the Greek government has implemented a contribution system where the patients have to pay out-of-pocket money in addition to the provisions of their health insurance. However, with no signs of economic recovery despite eight years of austerity policies, the present and future status of the Greek NHS looks uncertain. A systematic review of the existing literature published from January to March 2009 on the impact of the economic crisis on public health and healthcare in Greece revealed that recent efforts to reform the Greek NHS focused mainly on short-term effects, such as expenditure reduction, while the necessary measures appear to have dubious long-term consequences for the Greek public healthcare system [8]. The aim of this study is to evaluate the impact of the government debt crisis on the NHS using a representative sample of Greek hospitals and addressing the question of whether the financial crisis has affected the use of NHS and health insurance by the citizens. Additionally, it provides suggestions regarding appropriate policies that should be implemented in order to avoid further deterioration in the sphere of public health. Materials And Methods Firstly, we statistically analyzed the answers of the participants using descriptive statistics. Then, we attempted to provide an initial estimation of the possible reasons that may influence the degree of patients’ satisfaction. We assumed that each patient could achieve a maximum level of satisfaction, by selecting treatment, which can be considered as a linear function, of the formula: si* = β'x+ei (1) Where x is a vector of k x 1 exogenous variables, β is a vector of parameters to estimate and ei is a disturbance term, normally distributed with zero mean and constant variance. The variable si* is unobservable. On the other hand, it is observed that values of the variable si corresponding to values of the variable si* are: s0 = 0 if si* ≤ 0 (not satisfied) s1 = 1 if 1 < si* (satisfied) (2) The relation (2) in fact illustrates a filter mechanism (censoring) while in the specimen is introduced a selectivity bias, which can be corrected by adding a selection mechanism as follows [10]: θ*= a’z+u θ=1 if θ* >0 θ=0 if θ* ≤0 (3a) and Pr(θ=1)=Φ(a’z) Pr(θ=0)=1-Φ(a’z) (3b) where θ* is the non-satisfaction level, z is a set of exogenous variables, Φ(.) is the cumulative distribution function for a standard normal distribution and u ~ N (0,1). If we consider as θ=1 the fact that the patient receives full satisfaction and 0 otherwise, the model as described by equations (3a) and (3b) is a multivariate probit model and sk is observed if and only if θ=1. Equation (1) can be defined as a sample selection problem (Heckman, 1979): E [S│x, θ*>0]=β’χ +E [e│x, θ*>0] (4) If e and u follow a bivariate distribution with the correlation coefficient, then the equation (4) becomes: E [S│x, θ*>0]=E [e│x,u > -a’z]= ρλ (5) where λ is defined as the ratio of the probability density function and the cumulative distribution function for standard normal variable: 2020 Diamantis et al. Cureus 12(10): e10786. DOI 10.7759/cureus.10786 2 of 15 λ=(−a′) / Φ(a'z) (6) The estimation of equations (3a) and (3b) can be done by the maximum likelihood method. Consistent and effective asymptotic estimators of the model parameters are obtained by maximizing the likelihood function [10,11]. We find the marginal effects of the explanatory variables on the probability as θ Prob (s=0) / θx= -φ (β’x+ρλ) β θ Prob (s=1) / θx=[φ(-β'x-ρλ)-(μ-β'x-ρλ) β (7) A large sample of 600 Greek public hospital users was recruited for the study. A survey was conducted from January 11, 2016, to February 11, 2016, at the Evangelismos & Eye Polyclinic of Athens General Hospital. Based on the data provided by the outpatients’ department administration, 75 people visit the hospital on a daily basis for examination by physicians on average. In order to draw firm conclusions from a representative sample, 600 questionnaires were distributed and completed, representing 40% of the calculated number of patients visiting the hospital within this period.

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