The evolution of health care reforms in Greece: charting a course of change

Connections built and broken: The ontologies of relapse

'Relapse prevention' has become a familiar concept and practice for those engaged with drug treatment services. The ways that 'relapse prevention' is currently practised and talked about departs primarily from research produced within the discipline of psychology, and especially by researchers and practitioners adopting cognitive behavioural (Marlatt & Donovan, 2005; Witkiewitz & Marlatt, 2009) and neurocognitive approaches (Tapert et al., 2004). The outcome has been the production of 'tools' and 'mechanisms', put in place to 'prevent' people from relapsing. This way of thinking about relapse has generated the assumption that once access to these 'tools' has been granted, relapse becomes a problem of the individual, a personal 'success' or 'failure', depending on how these tools are used, a measurement of how much one 'really' wants to recover. This system of thought reproduces longstanding discourses of blame against AOD users and fuels the discussion on the 'revolving doors' of recovery (White & Kelly, 2010), holding treatment services accountable for 'failing' to produce and maintain 'recovered' bodies. In this paper my aim is to challenge the production of relapse as a 'threat' and to rethink it as a desire to connect, a desire that can be either enhanced, or broken. Drawing on empirical data produced in two recovery services, one in Liverpool (UK) and one in Athens (Greece), analysed through a Deleuzo-Guattarian system of thought, I discuss relapse in two different ways: (a) as part of the temporality of recovery, a way to start building connections with services; as the expression of an emerging desire under exploration, and(b) as the consequence of broken and interrupted connections when policy fails to support the encounters emerging in the recovery space, disrupting thus the recovery process.

Explaining the Persistent Dominance of the Greek Medical Profession Across Successive Health Care System Reforms from 1983 to the Present

-The Greek medical profession played an important role at the start of the Greek National Health System (NHS) in 1983 and became intrinsic to its later development. In particular, junior hospital doctors firmly established their position and rights as a result of the new NHS. Using archival sources and interviews with elite participants, this article investigates the specific patterns of power and influence that Greek NHS doctors have exerted from the establishment of the Greek NHS through the latest major attempt at reform in 2001 to the present. Hospital doctors, in particular, have been able consistently to resist any health care system reforms that might affect their dominant position. Their unchallenged position in the system derives from both the particularities of the Greek state and society (in particular, the former's founding institutional arrangements and the latter's clientelistic social relations) and the key role that junior doctors played in the early stages of the Greek NHS. As a result, the system is highly path dependent in that the initial implementation of the NHS during the 1980s ensured that subsequent reforms consistently favored the self-interest of medical doctors. Though challenges to the unaccountable power of the medical profession have emerged in Greece following the financial crisis of 2009, including the beginnings of a popular critique of the medical profession, it is too soon to tell whether these will succeed in bringing about significant change.

Regional Decentralisation in the Greek Health Care System: Rhetoric and Reality

Decentralisation is a complex, yet basic feature of health care systems in many countries entailing the transfer of authority or dispersal of power in public planning, management and decision making from higher to lower levels of government. This paper describes the attempts made in Greece from 1923 until today to decentralise its highly centralised health care system, drawing on a thorough documentary analysis of legislative acts and official reports regarding regional health policy. The analysis shows that, although decentralisation has been attempted on several occasions, in the end it was abandoned every time. The first ever implementation of a decentralised system of governance in 2001 was also curtailed, resulting in only minor decentralisation of authority and real powers. It is suggested that decentralisation has been impeded by many factors, especially obstruction by opposition from key interest groups, absence of policy continuity between governments, the inability to tackle the bureaucratic and highly centralised system and lack of political will.

Reengineering NHS Hospitals in Greece: Redistribution Leads to Rational Mergers

The purpose of this study was to record and evaluate existing public hospital infrastructure of the National Health System (NHS), in terms of clinics and laboratories, as well as the healthcare workforce in each of these units and in every health region in Greece, in an attempt to optimize the allocation of these resources. An extensive analysis of raw data according to supply and performance indicators was performed to serve as a solid and objective scientific baseline for the proposed reengineering of the Greek public hospitals. Suggestions for “reshuffling” clinics and diagnostic laboratories, and their personnel, were made by using a best versus worst outcome indicator approach at a regional and national level. This study is expected to contribute to the academic debate about the gap between theory and evidence based decision-making in health policy.

Understanding the oversupply of physicians in Greece: the role of human resources planning, financing policy, and physician power

Planning of the workforce has emerged as a critical issue in European health policy, as the need for human resources for health is changing in light of demographic, epidemiological, and socio-cultural trends and patterns of supply and demand in service provision. Greece represents a country with an oversupply of physicians, having the highest concentration of physicians among European Union countries. The study aims to analyze the factors influencing the high number of physicians in Greece and make policy recommendations. The analysis was conducted through international literature review and database searches. Neither the demography of the physician population in terms of age, gender composition, and geographic dispersion, nor the epidemiology of the Greek population, can explain the relatively high number of physicians in Greece. Despite the physician surplus, Greece faces serious geographical inequities regarding the distribution of physicians. There are also imbalances within the specialist category, with certain specialists (e.g., cardiologists) being in oversupply compared to other European countries, while others (e.g., general practitioners) remain weakly represented. Inadequate planning of human resources for health, inadequate health financing policy regarding primary care, gatekeeping mechanisms, and medical power constitute the primary themes explaining the trends of physicians' population in Greece.

Public procurement of health technologies in Greece in an era of economic crisis

Public procurement is generally an important sector of the economy and, in most countries, is controlled by the introduction of regulatory and policy mechanisms. In the Greek healthcare sector, recent legislation redefined centralized procurement through the reestablishment of a state Health Procurement Committee (EPY), with an aim to formulate a plan to reduce procurement costs of medical devices and pharmaceuticals, improve payment time, make uniform medical requests, transfer redundant materials from one hospital to another and improve management of expired products. The efforts described in this paper began in early 2010, under the co-ordination of the Ministry of Health (MoH) and with the collaboration of senior staff from the International Monetary Fund (IMF), the European Commission (EC) and the European Central Bank (ECB). The procurement practices and policies set forth by EPY and the first measurable outcomes, in terms of cost savings, resulting from these policies are presented. The importance of these measures is discussed in light of the worst economic crisis faced by Greece since the restoration of democracy in 1974, as a result of both the world financial crisis and uncontrolled government spending.

Assessment of health care needs and utilization in a mixed public-private system: the case of the Athens area

Background

Given the public-private mix of the Greek health system, the purpose of this study was to assess whether variations in the utilisation of health services, both primary and inpatient care, were associated with underlying health care needs and/or various socio-economic factors.

Methods

Data was obtained from a representative sample (N = 1426) residing in the broader Athens area (response rate 70.6%). Perceived health-related quality of life (HRQOL), as measured by the physical and mental summary component scores of the SF-36 Health Survey, was used as a proxy of health care need. Health care utilization was measured by a) last-month visits to public sector physicians, b) last-month visits to private sector physicians, c) last-year visits to hospital emergency departments and d) last-year hospital admissions. Statistical analysis involved the implementation of logistic regression models.

Results

Health care need was the factor most strongly associated with all measures of health care utilization, except for visits to public physicians. Women, elderly, less wealthy and individuals of lower physical health status visited physicians contracted to their insurance fund (public sector). Women, well educated and those once again of lower physical health status were more likely to visit private providers. Visits to hospital emergency departments and hospital admissions were related to need and no socio-economic factor was related to the use of those types of care.

Conclusion

This study has demonstrated a positive relationship between health care need and utilisation of health services within a mixed public-private health care system. Concurrently, interesting differences are evident in the utilization of various types of services. The results have potential implications in health policy-making and particularly in the proper allocation of scarce health resources.

Can privatising selected services benefit the public healthcare system?: the Greek case

The evaluation of empirical data concerning private physician consultations in public hospitals in Greece suggests that privatisation of selected public services can increase patients' freedom of choice and also improve efficiency and quality of services, thus strengthening the supply side in a mixed healthcare system. The 2001 NHS health reform in Greece provides financial incentives to public hospital physicians to consult patients 'privately' at the outpatient clinics, while remaining restrained by certain provisions regarding fees. Competition between public and private hospitals is centrally regulated, and in this case cumulative data show success for the public sector. At the same time, patient satisfaction with the new arrangement measured in this study was very high. It could be argued that, under certain conditions, attracting private funds into a public health system constitutes an opportunity to reinforce the public provision of the system.

Using DEA to evaluate efficiency and formulate policy within a Greek national primary health care network. Data Envelopment Analysis

The purpose of this paper is to critically evaluate the relative efficiency of primary health care centers of the principal Greek public insurance provider, the Social Security Institute (IKA). The source of the efficiency data was the Statistical Unit of IKA. Using Data Envelopment Analysis, we analyzed data from 133 centers nationwide. Input variables included the number of personnel, stratified in different categories, and the number of people covered by each health center. The number of pensioners enlisted to each health care facility was used as an index of aging and vulnerability of the covered population. According to the results of the study, centers with the technological infrastructure to perform laboratory and/or radiographic examinations exhibited higher efficiency scores. In addition, centers with eligible covered populations from 10,000 to 50,000 were found as the most efficient. Health sector reforms should be planned on the basis of such analyses. If the model is supplemented with valid demographic, socioeconomic, and epidemiological data, it may become the basis for the creation of a national health care chart, matching available resources to the population and its health care needs.