How is Greece conforming to Alma-Ata’s principles in the middle of its biggest financial crisis?

The international Alma-Ata conference are therefore the first point of contact. healthcare services do not provide any held on September 1978 by the World Greece has the largest number of positive incentives for care providers to Health Organisation (WHO) set equity, specialists per population among all improve their services. comprehensiveness, continuity of care, OECD (Organisation for Economic Co- and patient centeredness, as targets for all operation and Development) countries (3.3 ADAPTATION TO ALMA-ATA’S health systems in the world. 1 In order to per 1.000 population according to 2005 PRINCIPLES achieve these targets, it mobilised a data). 5 Greek citizens are unfamiliar with Free provision of public primary healthcare ‘primary healthcare movement’ that GPs. It is notable that less than 3% of the services is hindered, by significant, shifted global thinking about health from doctors in Greece are GPs, a specialty that informal, out-of pocket payments, 10 raising specialist, tertiary care towards is not highly esteemed among the health serious issues of equity. Patients are often ambulatory care. 2 WHO’s report of 2008, professionals. Patients have direct access asked or feel obliged to pay directly Primary Health Care: Now More Than to secondary care as there is no additional fees, as gifts, to physicians, to Ever ,3 reconfirmed WHO’s adherence to gatekeeping system. get access to public healthcare services primary health care as the only way for One of the main characteristics of the that are theoretically free of charge, health systems to respond to the Greek healthcare system is its hospital- despite the fact that the NHS personnel is challenges of a changing world. How has centred 6 orientation, and its substantial supposed to be paid exclusively by state Greece dealt with Alma-Ata’s principals for underfunding of public primary care salaries. Illegal payments are estimated by the last 30 years? And how relevant are services. 7 Rural health centres operate family income surveys to be more than these principles today, in the middle of the without adequate staffing and diagnostic 20% of the total private expenditure. 11 country’s biggest financial crisis? equipment, whereas provincial surgeries Although there is limited evidence on how are staffed with medical graduates informal payments affect access and THE GREEK PRIMARY HEALTH characterised by lack of clinical utilisation of health services, it is clear that CARE experience. In urban areas, hospital patients who cannot afford to pay cannot Inspired by Alma-Ata’s ideals, Greece outpatient clinics and social fund access the same level of services or have instituted a national health system in 1983, polyclinics are incapable of satisfying the to wait longer for care. 12 The increasing so that it could ‘ guarantee that all citizens demand for public primary healthcare use of private health services within the enjoy the benefits of a complete range of services, resulting in long waiting lists and Greek health system is considered another services of high quality, free at the point of causing discomfort to citizens. major cause of pro-rich inequality. 13 Private service ’. 4 Since then, the Greek NHS has However, the most important obstacle in offices visits are estimated to been providing free access and full producing scientific sound, public primary 25–27 million per year, a number that coverage to the entire population, healthcare services of high quality is corresponds to 30% of total health visits. including immigrants. Within NHS or social probably related to their inadequate Another serious drawback in the quality insurance context, primary healthcare organisation frameworks. Management of primary healthcare services offered to services are delivered through health strategies are obsolete, educational and the Greek population is the lack of centres and provincial surgeries in rural training programmes are partial and comprehensiveness. Primary healthcare areas and through outpatient departments incomplete, and mechanisms for services usually provide fragmented, of regional and district hospitals, supervising and evaluating medical impersonal care and do not bear polyclinics of the social insurance practices are completely absent. There are responsibility for the patient as a whole. 14 institutions and contracted physicians and no effective systems of keeping, They are mainly staffed with specialists, diagnostic centres in urban areas. There organising, and coordinating medical trained at various hospital settings, totally are also many private physicians and records, measuring how health resources different to a primary healthcare diagnostic centres that provide services are used, and assessing and monitoring environment, and cannot therefore provide directly to the population. the outcome of care. 8 Practice guidelines, holistic care and cover for the whole range A major shortcoming of the Greek and diagnostic and therapeutic protocols of health needs. This fact, together with healthcare system is that most public and have rarely been used, 9 whereas the absence of a healthcare team private primary care services are staffed prescribing patterns are rather comprising of physicians, community almost exclusively with specialists, who idiosyncratic. Additionally, primary nurses, health visitors, social workers,

456 British Journal of General Practice, June 2010 Essay

psychologists and other health OECD countries, the quality of care is Health Econ 2005; 14(Suppl 1): S151 –S168. professionals explains why Greek primary considered inadequate. The largest 9. Lionis C, Symvoulakis EK, Markaki A, et al . Integrated primary health care in Greece, a missing healthcare services rarely engage in any insufficiencies in the public sector are issue in the current health policy agenda: a systematic promotive, preventive, palliative or located in primary health care; 17 Greece review. Int J Integr Care 2009; 9: e88. rehabilitative activities. has not yet fully established an integrated, 10. Siskou O, Kaitelidou D, Papakonstantinou V, Liaropoulos L. Private health expenditure in the The Alma-Ata’s targets of patient- consistent, equitable, comprehensive, and Greek health care system: where truth ends and the centeredness and continuity of care have patient-centred primary health care, free at myth begins. Health Policy 2008; 88(2 –3): 282 –293. 11. Liaropoulos L, Siskou O, Kaitelidou D, et al . Informal also failed to be met. The lack of some the point of use. payments in public hospitals in Greece. Health Policy kind of personal or family doctor hinders There are fears that the fiscal crisis will 2008; 87(1): 72 –81. the development of a stable, humane, lead to a cost containment policy that will 12. Murthy A, Mossialos E. Informal payments in EU Accession Countries. Euro Observer 2003; 5(2): 1–3. long-term patient –provider relationship. further deteriorate the quality of health 13. Tountas Y, Dimitraki C, Oikonomou N, et al . Health The Greek population are not registered services and put social justice at stake. services in Greece 1996 –2006. Athens: Centre for with a single-provider, and they are self- However, there is another solution: as a Health Services Research, 2008. referred to different specialists and growing body of empirical work suggests, 14. Oikonomou N, Mariolis A. Three trends that undermine the Greek health system: is there a way services, according to perceived need. health systems that embrace the values of out? Eur J Gen Pract 2009; 15(2): 67 –68. This often results in inconsistent Alma-Ata Declaration regarding primary 15. Economou C, Giorno C. Improving the performance of the public health care system In Greece. management of the same episode of care care are generally associated with better Organisation for Economic Co-operation and and poor coordination of different health indicators and lower costs for all Development, Economics Department, Working Paper No. 722, 21 –Sep –2009. episodes of care. The problem is medical services. 18 So, the only way to 16. Tountas Y, Karnaki P, Pavi E. Reforming the reform: exacerbated by poor information transfer provide an effective and efficient health the Greek national health system in transition. Health systems both between primary care system closer to meeting people’s needs Policy 2002; 62: 15–29. providers and between primary and and expectations is by relocating its entry 17. Kyriopoulos JE, Tsalikis G. Public and private imperatives of Greek health policies. Health Policy secondary care, leading to possible point from hospitals and specialists to 1993; 26(2): 105 –117. medical errors, delays in diagnoses and close-to-client generalist primary care 18. Starfield B, Shi L. Policy–relevant determinants of health: an international perspective. Health Policy unnecessary duplication of acts, units, with the personal physician having a 2002; 60(3): 201 –218. examinations and prescriptions. 15 central role. The development of new managerial practices and the rapid ECONOMIC CRISIS AND modification of organisational policies, DOI: 10.3399/bjgp10X509711 ALMA-ATA work procedures and hierarchical Greece is undoubtedly confronted by its structures is urgently needed. biggest economic crisis in modern history. According to many politicians, journalists Nikolaos Oikonomou and political and economical analysts, one and Anargiros Mariolis of the basic causes of the country’s vast public debt and deficits is the notably REFERENCES ineffective and unproductive public 1. Primary health care: report of the International Conference on Primary Health Care, Alma-Ata, administration. The structure and USSR, 6–12 September, 1978, jointly sponsored by organisation of most Greek public the World Health Organization and the United Nations Children’s Fund. Geneva, World Health institutions is considered immensely Organization, 1978 (Health for All Series No. 1). bureaucratic and corrupted, marked by a 2. Lawn JE, Rohde J, Rifkin S, et al . Alma-Ata 30 years on: revolutionary, relevant, and time to revitalise. lack of adequate systems of Lancet 2008; 372(9642): 917 –927. documentation, assessment, control, and 3. The World Health Report 2008. Primary health care, regulation. Policies are shaped more by now more than ever. Geneva: WHO, 2008. http://www.who.int/whr/2008/en/index.html leaders own perceptions, public opinion (accessed 12 May 2010). pressure and professional and financial 4. Ministy of Health and Welfare. Bill for act of Greek interests and less by a rational system of Parliament number 1397/83, National Health System. Athens: Registry of Greek House of Parliament, 1983. priority setting and strategic decision 5. OECD. OECD Health Data 2009: Statistics and making. Indicators for 30 Countries . http://www.oecd.org/document/30/0,3343,en_2649_3 The Greek health sector is no exception. 4631_12968734_1_1_1_37407,00.html (accessed 12 The satisfactory health indicators are May 2010). mostly attributed to the good climate, the 6. Adamakidou T, Kalokerinou A. New health policies on primary health care in Greece. Health Science relatively high quality of life and the rather Journal 2010; 4(1): 15 –23. healthy nutrition. 16 Despite the fact that the 7. Souliotis K, Lionis C. Creating an integrated health total health spending accounted for 10% care system in Greece: a primary care perspective. J Med Syst 2005; 29: 187 –196. of GDP in Greece in 2004, one percentage 8. Mossialos E, Allin S, Davaki K. Analysing the Greek point higher than the average of 8.9% in health system: a tale of fragmentation and inertia.

British Journal of General Practice, June 2010 457