Open access Original research BMJ Open: first published as 10.1136/bmjopen-2020-038158 on 11 August 2020. Downloaded from Impact of the economic crisis on household health expenditure in Greece: an interrupted time series analysis Catriona Crookes ,1 Raffaele Palladino,1,2 Paraskevi Seferidi ,1 Raeena Hirve,1 Olga Siskou,3 Filippos T Filippidis1 To cite: Crookes C, Palladino R, ABSTRACT Strengths and limitations of this study Seferidi P, et al. Impact Objectives and setting The 2008 financial crisis had a of the economic crisis on particularly severe impact on Greece. To contain spending, ► The use of quarterly aggregate Greek Household household health expenditure the government capped public health expenditure and in Greece: an interrupted time Budget Survey data for the years 2004 and 2008– introduced increased cost- sharing. The Greek case is series analysis. BMJ Open 2017 provides high- temporal resolution. important for studying the impact of recessions on health 2020;10:e038158. doi:10.1136/ ► Household Budget Survey data provide detailed in- systems. This study analysed changes in household bmjopen-2020-038158 formation on household health spending. health expenditure in Greece over the economic crisis ► Interrupted time series analysis is a quasi- ► Prepublication history and and explored whether the impact differed across experimental method. additional material for this socioeconomic groups. paper are available online. To ► The data are repeat cross- sectional and Participants We used data from the Greek Household view these files, please visit self- reported. Budget Survey for the years 2004 and 2008–2017. The the journal online (http:// dx. doi. ► It was not possible to include a control group in this dataset comprised 51 654 households, with a total of 128 org/ 10. 1136/ bmjopen- 2020- analysis. 038158). 111 members. Design We compared pre- crisis and post- crisis trends in Received 29 February 2020 Greek household out- of- pocket payments for healthcare Revised 17 June 2020 from 2004 to 2017 using an interrupted time series involving cost- shifting and budget cuts were Accepted 25 June 2020 analysis. This study explored spending in euros and as a introduced in most European countries, share of total household purchases. resulting in regressive financing schemes http://bmjopen.bmj.com/ Results Our results indicated that the population level and compromising universal health coverage trend in household health spending was reversed after (UHC).2 the crisis began (pre- crisis trend: €0.040 decrease per Greece experienced a uniquely severe quarter (95% CI: −0.785 to −0.022), post- crisis trend: economic downturn.3 Gross domestic product €0.315 increase per quarter (95% CI: −0.004 to 0.635)). (GDP) fell by over 27% in real terms between We also found that spending on inpatient services and 4 pharmaceuticals has been increasing since the start of the 2008 and 2016, unemployment peaked at © Author(s) (or their 5 crisis, whereas outpatient services expenditure has been 27% and the percentage of the population at employer(s)) 2020. Re- use on September 25, 2021 by guest. Protected copyright. permitted under CC BY- NC. No decreasing. Across all households, out- of- pocket payments risk of poverty reached 36% (online supple- 4 commercial re- use. See rights incurred a greater financial burden after the crisis relative mentary table S1). The political context and and permissions. Published by to pre- existing trends, but the poorest households incurred austerity reforms are summarised in table 1. BMJ. a disproportionately higher burden. Between 2009 and 2012 public health expen- 1 Department of Primary Care Conclusions This was the first study to use an interrupted diture on inpatient and outpatient services and Public Health, School of time series analysis to assess the impact of the economic 6 Public Health, Imperial College declined by 9% and 35%, respectively. Public crisis on household health expenditure in Greece. Our sector health workers’ salaries were cut and London, London, UK findings suggest that there was an erosion of financial 2Department of Public Health, a hiring freeze imposed in 2010 contributed protection for Greek households as a consequence of the Federico II University Hospital, 7 economic crisis. This effect was particularly pronounced to a 15% reduction in hospital staff. Many Naples, Italy reforms, including increased cost- sharing 3Nursing Department, Centre for among poorer households, which is indicative of a regressive financing system. and use of generics, targeted pharmaceutical Health Services Management 8 and Evaluation, National and expenditure, which fell by 40% by 2014. Kapodistrian University of Currently, private spending contributes a Athens, Athens, Attica, Greece INTRODUCTION considerable share of health expenditure Following the Great Recession of 2008 the in Greece. Out-of- pocket payments (OOPP) Correspondence to Catriona Crookes; global economy shrank by 1.7%, the first comprised 34.8% of health expenditure in 1 catriona. crookes18@ imperial. worldwide contraction in 60 years. Against 2017, more than double the European Union ac. uk the WHO’s recommendations, many policies (EU) average.4 Crookes C, et al. BMJ Open 2020;10:e038158. doi:10.1136/bmjopen-2020-038158 1 2 Open access Table 1 An overview of the political and socioeconomic context in Greece during the study period (2004–2017)7 May–June 2012 Period 2004–2009 2009–2011 2011–2012 Panagiotis 2012–2015 2015–2019 Prime minister Kostas Karamanlis George A. Papandreou Lucas Papademos* Pikramenos† Antonis Samaras Alexis Tsipras Governing party LP LP Socioeconomic and political ► 2004: Summer Olympic ► 2010: First bailout loan agreed with Troika and ► 2012: Second ► Austerity measures aimed at reducing ► June 2015: referendum to decide environment Games held in Athens, introduction of the first Economic Adjustment bailout loan agreed the budget deficit (eg, large- scale whether to accept the bailout which lead to excess Programme (EAP), which involved: with Troika and redundancies in the public sector) conditions set by Troika (61% No) expenses and deficits –T ax increases (eg, VAT) introduction of further ► 2013: Primary government budget ► July 2015: third bailout agreed with ► Large scale strikes leading – Decrease in public spending (civil servants austerity measures surplus of 0.4% lenders, leading to tax increases and to severe economic wages cuts and hiring freezes) under the second ► Second quarter of 2014: return to growth pensions cuts disruption – Reduction of public sector EAP, such as the ► 2017: Establishment of Unified Social ► Leading to nationwide strikes and protests abolition of bonuses Security Fund (EFKA) and minimum wage ► 2016: Provision of comprehensive cuts health coverage to unemployed and vulnerable groups ► 2016: Introduction of exemptions from €1 prescription fee for vulnerable groups ► 2017: Primary care plan launched. Local public clinics (TOMYs) established with the aim of rationalising first primary care contacts ► 2018: Revision of EOPYY common benefits package Significant health changes/ ► Establishment of new ► Public health expenditure capped at 6% of GDP ► Increased cost- ► 2014: Establishment of National Primary ► 2016: Provision of comprehensive reforms structures in MoH (eg, ► Public pharmaceutical spending capped sharing levels on Healthcare Network (PEDYs) and transfer health coverage to unemployed and general secretariat of public (expenditure fell to 1% of GDP by 2014) pharmaceuticals, of responsibility of primary care provision vulnerable groups health in 2005) leads to ► 2010: Public sector health workers’ salaries cut promotion of the to regional health administrations greater focus on public and hiring freeze imposed use of generics, ► 2014: Free pharmaceutical coverage health services ► 2011: Establishment of National Organisation for introduction of to uninsured population ► Regional health Healthcare Provision (EOPYY) as single payer and a rebate and claw back ► 2014: Introduction of €1 fee per administrations reduced common benefits package mechanisms prescription from 17 to 7 in order to ► 2011: Introduction of a €5 user fee for outpatient ► Introduction of a new improve efficiency of care (abolished in 2015) system for hospitals services ► National health service hospitals restructured reimbursement based ► Development of the central (administrative mergers) on diagnosis related committee for health groups supplies with the aim of unifying procurement for public hospitals New Democracy (ND): liberal conservative centre right party. Panhellenic Socialistic Movement (PASOK): social democratic centre left party. Independent. Democratic left party (DIMAR). The coalition of the radical left (SYRIZA). Ecologists Green Party Right wing independent Greeks party (ANEL). *National unity government made up of PASOK, ND and Popular Orthodox Rally (LAOS). †Caretaker Prime Minister led a government of technocrats. GDP, gross domestic product; LP, leading party; VAT, value added tax. Crookes C, et al. BMJ Open 2020;10:e038158. doi:10.1136/bmjopen-2020-038158 BMJ Open: first published as 10.1136/bmjopen-2020-038158 on 11 August 2020. Downloaded from from Downloaded 2020. August 11 on 10.1136/bmjopen-2020-038158 as published first Open: BMJ http://bmjopen.bmj.com/ on September 25, 2021 by guest. Protected by copyright. by Protected guest. by 2021 25, September on Open access BMJ Open: first published as 10.1136/bmjopen-2020-038158 on 11 August 2020. Downloaded from Economic reforms during