The mental health care system for children and adolescents in Greece: a review and structure assessment

Background

The mental health system in Greece faces challenges to complete its transition to a community-oriented model, having significant concerns for child and adolescent care due to lower coverage and service gaps. This component of the mental health system has not been comprehensively evaluated.

Methods

We conducted a review of the mental health care system for children and adolescents in Greece. For a field assessment, we directly collected data from mental health services to map availability and distribution. We analyzed the needs of human resources using professional register data and the national census.

Results

The National Health Care Service (ESY, Εθνικό Σύστημα Υγείας) is the public health system in Greece, characterized by public governance but significant private participation. Although ESY aims for universal care, gaps in population coverage and high user fees create barriers to access. Embedded within ESY, the mental health system is shifting towards a community-oriented structure since the psychiatric reform. For children and adolescents, there is a developing framework for regionalization and community services, including day centers, inpatient facilities, outpatient departments, and school-based psychoeducational facilities. However, services lack coordination in a stepped care model. Patient pathways are not established and primary care rarely involves child mental health, leading to direct access to specialists. Services operate in isolation due to the absence of online registers. There is no systematic performance monitoring, yet some assessments indicate that professional practices may lack evidence-based guidelines. Our mapping highlighted a scarcity of public structures, with an unbalanced regional distribution and many underserved areas. Child and adolescent psychiatrists are predominantly affiliated with the private sector, leading to professional gaps in the public system.

Conclusions

Our assessment identifies an established framework for a community-oriented, universally accessible mental health system, yet several barriers impede its full realization. These include an inconsistent primary healthcare system, a shortage of specialists in the public sector, imbalanced service distribution, lack of coordination among providers, underfunding, and absence of quality monitoring. We propose interventions to promote child and adolescent mental health in primary care, coordinate patient pathways, establish standards of care, and monitor performance.

Valuing Outpatients' Perspective on Primary Health Care Services in Greece: A Cross-Sectional Survey on Satisfaction and Personal-Centered Care

INTRODUCTION

The aims of the study were to identify and analyze the determinants associated with outpatient satisfaction in Greek primary care. This is because there is a general consensus that primary care is the linchpin of effective person-centered care delivery.

METHODS

A cross-sectional survey was conducted with 1012 patients' exit interviews; sociodemographic variables were included in the questionnaire to obtain data on the satisfaction of primary care users with 20 public primary healthcare centers in Athens between June 2019 and April 2021. Statistical analysis was applied to 55 items and eight dimensions of patient satisfaction, namely, arrival and admission, waiting before the appointment, cleanliness of toilets, medical examination and behavior of physician, behavior of nursing staff, laboratories, departure, and contribution of the PHCs. Descriptive analyses and multiple linear regression were used to analyze the factors influencing patient satisfaction through coefficients (β) with 95% confidence intervals and associated tests of statistical significance.

RESULTS

Τwo-thirds (74.21%) of this survey's participants ranged from 45 to 74 years of age. More than half of the participants were women (62.15%). The most common reasons for visits were pathological (26.48%), followed by cardiological conditions (9.78%), orthopedics (9.49%), gynecologic conditions (8.70%), and ophthalmologic problems (7.31%). In the center of satisfaction with primary care was the medical care and the behavior of the physician (β = 0.427; p < 0.01), followed by the time during appointment (β = 0.390; p < 0.01). Dimensions like "accessibility and availability, 2.19/5"; "waiting times, 2.89/5"; "infrastructure of facilities (2.04/5) and cleanliness of them, (2/5)"; "laboratories, 2.99/5" and "bureaucracy in the departure, 2.29/5" were crucial for the trust and satisfaction of patients. Overall satisfaction was rated at a moderate level (2.62 ± 0.18) while person-centered care was rated as weak (2.49 ± 0.28).

CONCLUSIONS

Greece is recommended to increase the sensitivity of the use of the primary health care system by patients as a first contact, continuous, comprehensive, and effective patient- and family-focused care.

Patient Satisfaction With Public Pharmacy Services: Structural and Policy Implications From Greece

Objectives This study aimed at investigating patient satisfaction with services offered by a certain type of public pharmacies in Greece (National Organisation for Healthcare Provision (EOPYY) pharmacies), tasked with dispensing mostly high-cost drugs, in an effort to highlight the aspects to be optimized. Methods  The Patient Satisfaction with Pharmacist Services Questionnaire 2.0 (PSPSQ 2.0) questionnaire was the main instrument of our research. We received 201 full responses from patients themselves and patients' companions who had visited EOPYY pharmacies in Athens, the capital city of Greece, from October 2022 to January 2023. Results  Patients seem satisfied with public pharmacies in general. In fact, the professionalism of the pharmacists, the respect that patients have received from them, and the information and explanations that were given by pharmacists, received a very high score. On the other hand, the parameters referred to the information that patients received from pharmacists for the overall improvement of their health had the lowest score, revealing an apparent lag in the field of medicinal advice. Conclusion  Without any doubt, patients expect their pharmacists to be more guiding and to better communicate this role. This requires more time to be spent with patients, focused training, teamwork, layout, and other organizational interventions.

A Groundbreaking Insight Into Primary Care Physiotherapists' Remuneration

Introduction Physiotherapy in Greece, as part of primary health care (PHC), faces sound imbalances: reduced quality, productivity, and efficiency, along with rather inflexible remuneration schemes. This study is aimed at reporting the attitude and perceptions of Greek PHC physiotherapists toward their current remuneration and also at identifying any other preferable remuneration schemes. Methods A stratified proportional sampling study was undertaken, using an anonymous, electronic survey. The participants were 250 self-employed physiotherapists running their business in Central and Eastern Macedonia and Thrace, being also contracted with the National Organisation for Healthcare Provision (EOPYY). The sample size stands for 34% of the population with a circa 5% margin of error. Results Nearly 9/10 physiotherapists (84%) underline that remuneration falls short of their productivity, leading to reduced job satisfaction. Moreover, their remuneration does not motivate them to provide services of higher quality (46%), while 58% of them stated that they are forced to claim informal fees. There is no clear desire regarding the remuneration scheme, but nearly ¼ of physiotherapists revealed their preference for the cost-per-case philosophy combined with co-payments. Conclusion The majority of physiotherapists believe that their current remuneration does not reflect their productivity nor the quality of their services and, therefore, informal payments arise. The preference of physiotherapists lies between cost-per-case fees and patient co-payments, which, however, favors supplier-induced demand and access inequalities, respectively. Hence, policymakers should revise the current remuneration scheme and overcome its deficiencies without creating new ones.

Sustainability of Healthcare Financing in Greece: A Relation Between Public and Social Insurance Contributions and Delivery Expenditures

The economic crisis in Greece, which began in 2010 and lasted for 10 years, highlighted the serious problems and challenges of the Greek Social Health Insurance system. The reforms that mainly took place during the crisis provided a temporary solution. They focused on establishing a new National Organization for Healthcare Services (named EOPYY) and merging all the old insurance funds. This paper aims to examine whether this social health insurance fund has been sustainable in the long run. An actuarial model was created to project future expenses and revenues. Demographic and economic trends were considered, while it was assumed that medical technology remains unaltered. The assessment of the system solvency was based on the ratio (Revenue/Liabilities) calculated for each year, from 2020 to 2050. The results led to deficits, the amount and the time point in which they appear depends on how optimistic or pessimistic demographic and economic assumptions were. A new financial flow model was proposed to address the deficits. The results show that under the new model, the system remains solvent until 2050. The state subsidy amount on the employees’ health insurance premium was estimated as a percentage of the employees’ wage.

The effectiveness of primary health care reforms in Greece towards achieving universal health coverage: a scoping review

INTRODUCTION

Between 2010 and 2018, Greece implemented an Economic Adjustment Programme and underwent a series of extensive reforms, including in the health sector. We conducted a scoping review to examine whether the Primary Health Care reforms during that period assisted the country in moving towards Universal Health Coverage.

METHODS

We performed a review of the literature on the following databases: Scopus, PubMed, Epistemonikos, Web of Science, and Google Scholar, including published research articles and grey literature. Findings were synthesised thematically, using the World Health Organization Universal Health Coverage dimensions: population coverage, service coverage, and financial protection.

RESULTS

Forty-four documents were included in this review. Out of these, thirty-eight were research-based (thirty-three qualitative, two quantitative, and three mixed design studies), two grey literature, and four legislative bills. The evidence suggests that despite the systemic interventions addressing longstanding distortions, population coverage, service coverage and financial protection have not significantly improved.

CONCLUSIONS

This review suggests that Primary Health Care reforms in Greece have not managed to substantially improve Universal Health Coverage, although some positive steps towards that direction have taken place with the establishment of community-based multidisciplinary health teams. Before further interventions are implemented, an evidence-based monitoring and evaluation mechanism is necessary in order to clearly evaluate their effectiveness and progress.

Drug Policy in Greece

OBJECTIVES

To provide a detailed overview of the recent reforms in pharmaceutical pricing and reimbursement processes as well as in other important areas of the pharmaceutical policy in Greece.

METHODS

Information was collected via a structured questionnaire. The study used publicly available resources, such as publications, relevant legislation, and statistical data, while health experts were also consulted.

RESULTS

Recent pharmaceutical reforms included significant price cuts, increased co-payments and some provisions for vulnerable groups, rebates/clawbacks, mandatory electronic prescribing and prescription by international nonproprietary name, generics substitution, prescription limits and detailed auditing, centralized procurement, as well as changes in the pricing and reimbursement processes, with the introduction of positive and negative lists and an internal price referencing system. Price lists are compiled by the National Organization for Medicines and are issued by the Ministry of Health (MoH). An advisory pricing committee comprising representatives of stakeholder groups was abolished in early 2018. Nevertheless, under the new provisions, a health technology assessment body for the economic evaluation of reimbursed drugs is to be established for the first time in Greece. The committee is to be staffed by experts appointed by a ministerial decision of the MoH. The specific features of the process are yet to be determined.

CONCLUSIONS

The pricing and reimbursement decision-making processes are centralized under the competence of the MoH. Despite the good intentions of the reformers, there are still some aspects of transparency, equity, and long-term sustainability that remain under question in Greece.

Informing primary care reform in Greece: patient expectations and experiences (the QUALICOPC study)

Background

Primary health care is the cornerstone of a high quality health care system. Greece has been actively attempting to reform health care services in order to improve heath outcomes and reduce health care spending. Patient-centered approaches to health care delivery have been increasingly acknowledged for their value informing quality improvement activities. This paper reports the quality of primary health care services in Greece as perceived by patients and aspects of health care delivery that are valued by patients.

Methods

This study was conducted as part of the Quality and Costs of Primary Care in Europe (QUALICOPC) study. A cross-sectional sample of patients were recruited from general practitioner’s offices in Greece and surveyed. Patients rated five features of person-focused primary care: accessibility; continuity and coordination; comprehensiveness; patient activation; and doctor–patient communication. One tenth of the patients ranked the importance of each feature on a scale of one to four, and nine tenths of patients scored their experiences of care received. Comparisons were made between patients with and without chronic disease.

Results

The sample included 220 general practitioners from both public and private sector. A total of 1964 patients that completed the experience questionnaire and 219 patients that completed the patient values questionnaire were analyzed. Patients overall report a positive experiences with the general practice they visited. Several gaps were identified in particular in terms of wait times for appointments, general practitioner access to patient medical history, delivery of preventative services, patient involvement in decision-making. Patients with chronic disease report better experience than respondents without a chronic condition, however these patient groups report the same values in terms of qualities of the primary care system that are important to them.

Conclusions

Data gathered may be used to improve the quality of primary health care services in Greece through an increased focus on patient-centered approaches. Our study has identified several gaps as well as factors within the primary care health system that patient’s perceive as most important which can be used to prioritize quality improvement activities, especially within the austerity period. Study findings may also have application to other countries with similar context and infrastructure.

Combined social and private health insurance versus catastrophic out of pocket payments for private hospital care in Greece

The high level of out of pocket (OOP) payments constitutes a major concern for Greece and several other European and OECD countries as a result of the significant down turning of their public health finances due to the 2008 financial crisis. The basic objective of this study is to provide empirical evidence on the effect of combining social health insurance (SHI) and private health insurance (PHI) on OOP payments. Further, this study examines the catastrophic impact of OOP payments on insured's welfare using the incidence and intensity methodological approach of measuring catastrophic health care expenditures. Conducting a cross-sectional survey in Greece in 2013, we find that the combination of SHI-PHI has a strong negative influence on insured OOP payments for inpatient health care in private hospitals. Furthermore, our results indicate that SHI coverage is not sufficient by itself to manage with this issue. Moreover, we find that poor people present a greater tendency to incur catastrophic OOP expenditures for hospital health care in private providers. Drawing evidence from Greece, a country with huge fiscal problems that has suffered the consequences of the economic crisis more than any other, could be a starting point for policymakers to consider the perspective of SHI-PHI co-operation against OOP payments more seriously.

Primary Care Doctors' Assessment of and Preferences on Their Remuneration

Despite numerous studies on primary care doctors' remuneration and their job satisfaction, few of them have quantified their views and preferences on certain types of remuneration. This study aimed at reporting these views and preferences on behalf of Greek doctors employed at public primary care. We applied a 13-item questionnaire to a random sample of 212 doctors at National Health Service health centers and their satellite clinics. The results showed that most doctors deem their salary lower than work produced and lower than that of private sector colleagues. Younger respondents highlighted that salary favors dual employment and claim of informal fees from patients. Older respondents underlined the negative impact of salary on productivity and quality of services. Both incentives to work at border areas and choose general practice were deemed unsatisfactory by the vast majority of doctors. Most participants desire a combination of per capita fee with fee-for-service; however, 3 clusters with distinct preferences were formed: general practitioners (GPs) of higher medical grades, GPs of the lowest medical grade, residents and rural doctors. Across them, a descending tolerance to salary-free schemes was observed. Greek primary care doctors are dissatisfied with the current remuneration scheme, maybe more than in the past, but notably the younger doctors are not intended to leave it. However, Greek policy makers should experiment in capitation for more tolerable to risk GPs and introduce pay-for-performance to achieve enhanced access and quality. These interventions should be combined with others in primary care's new structure in an effort to converge with international standards.

Out of pocket payments and social health insurance for private hospital care: Evidence from Greece

The Greek state has reduced their funding on health as part of broader efforts to limit the large fiscal deficits and rising debt ratios to GDP. Benefits cuts and limitations of Social Health Insurance (SHI) reimbursements result in substantial Out of Pocket (OOP) payments in the Greek population. In this paper, we examine social health insurance's risk pooling mechanisms and the catastrophic impact that OOP payments may have on insured's income and well-being. Using data collected from a cross sectional survey in Greece, we find that the OOP payments for inpatient care in private hospitals have a positive relationship with SHI funding. Moreover, we show that the SHI funding is inadequate to total inpatient financing. We argue that the Greek health policy makers have to give serious consideration to the perspective of a SHI system which should be supplemented by the Private Health Insurance (PHI) sector.