Informal payments in the Greek health sector amid the financial crisis: old habits die last

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.

Impact of Medical-Pharmaceutical Separation Reform on Hospitalization Expenditure in Tertiary Public Hospitals: Difference-in-Difference Analysis Based on Panel Data from Beijing

Purpose

The medical-pharmaceutical separation (MPS) reform is a healthcare reform that focuses on reducing the proportion of drug expenditure. This study aims to analyze the impact of the MPS reform on hospitalization expenditure and its structure in tertiary public hospitals.

Methods

Using propensity score matching and multi-period difference-in-difference methods to analyze the impact of the MPS reform on hospitalization expenditure and its structure, a difference-in-difference-in-difference model was established to analyze the heterogeneity of whether the tertiary public hospital was a diagnosis-related-group (DRG) payment hospital. Of 22 municipal public hospitals offering tertiary care in Beijing, monthly panel data of 18 hospitals from July 2011 to March 2017, totaling 1242 items, were included in this study.

Results

After the MPS reform, the average drug expenditure, average Western drug expenditure, and average Chinese drug expenditures per hospitalization decreased by 24.5%, 24.6%, and 24.1%, respectively (P < 0.001). The proportions of drug expenditure decreased by 4.5% (P < 0.001), and the proportion of medical consumables expenditure increased significantly by 2.7% (P < 0.001).

Conclusion

The MPS reform may significantly optimize the hospitalization expenditure structure and control irrational increases in expenditure. DRG payment can control the tendency to increase the proportions of medical consumables expenditure after the reform and optimize the effect of the reform. There is a need to strengthen the management of medical consumables in the future, promote the MPS reform and DRG payment linkage, and improve supporting measures to ensure the long-term effect of the reform.

Impact of Diagnosis-Related Groups on Inpatient Quality of Health Care: A Systematic Review and Meta-Analysis

The aim of this meta-analysis was to comprehensively evaluate the effectiveness of Diagnosis-related group (DRG) based payment on inpatient quality of care. A comprehensive literature search was conducted in PubMed, EMBASE, Cochrane Central Register of Controlled Trials and Web of Science from their inception to December 30, 2022. Included studies reported associations between DRGs-based payment and length of stay (LOS), re-admission within 30 days and mortality. Two reviewers screened the studies independently, extracted data of interest and assessed the risk of bias of eligible studies. Stata 13.0 was used in the meta-analysis. A total of 29 studies with 36 214 219 enrolled patients were analyzed. Meta-analysis showed that DRG-based payment was effective in LOS decrease (pooled effect: SMD = -0.25, 95% CI = -0.37 to -0.12, Z = 3.81, P < .001), but showed no significant overall effect in re-admission within 30 days (RR = 0.79, 95% CI = 0.62-1.01, Z = 1.89, P = .058) and mortality (RR = 0.91, 95% CI = 0.72-1.15, Z = 0.82, P = .411). DRG-based payment demonstrated statistically significant superiority over cost-based payment in terms of LOS reduction. However, owing to limitations in the quantity and quality of the included studies, an adequately powered study is necessary to consolidate these findings.

Hospitals during economic crisis: a systematic review based on resilience system capacities framework

Background

Hospitals are the biggest users of the health system budgets. Policymakers are interested in improving hospital efficiency while maintaining their performance during the economic crisis. This study aims at analysing the hospitals’ policy solutions during the economic crisis using the resilience system capacities framework.

Method

This study is a systematic review. The search strategy was implemented on the Web of Science, PubMed, Embase, Scopus databases, and Econbiz search portal. Data were extracted and analysed through the comparative table of resilience system capacities framework and the World Health Organization (WHO) health system’s six building blocks (i.e., leadership and governance, service delivery, health workforce, health systems financing, health information systems, and medicines and equipment).

Findings

After the screening, 78 studies across 36 countries were reviewed. The economic crisis and adopted policies had a destructive effect on hospital contribution in achieving Universal Health Coverage (UHC). The short-term absorptive capacity policies were the most frequent policies against the economic crisis. Moreover, the least frequent and most effective policies were adaptive policies. Transformative policies mainly focused on moving from hospital-based to integrated and community-based services. The strength of primary care and community-based services, types and combination of hospital financing systems, hospital performance before the crisis, hospital managers’ competencies, and regional, specialties, and ownership differences between hospitals can affect the nature and success of adopted policies.

Conclusion

The focus of countries on short-term policies and undermining necessary contextual factors, prioritizing efficiency over quality, and ignoring the interrelation of policies compromised hospital contribution in UHC.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08316-4.

State Incentives and Sustainable Motivation System in the Health Sector

Now that the pandemic has entered the second phase, in which countries are adapting to the crisis, governments need to determine incentives that will contribute to the sustainability of the health system and human health. Regarding this, human resources are a significant factor, which affects the sustainability of any system, and it is important to establish a relevant motivation system that will withstand the challenges that society will face in the coming period. The aim of this paper is to analyse three dimensions of state incentives (employment program, COVID-19 bonus, training opportunities) and to examine their influence on healthcare workers’ motivation and the sustainability of the health system in the Republic of Serbia. The empirical research was conducted on a sample of 207 respondents employed in the tertiary level of healthcare. Data analysis included exploratory factor analysis (EFA), confirmatory factor analysis (CFA) and structural equation modelling (SEM). The research results confirmed the existence of all three incentives and indicated that state incentive “training opportunities” has the strongest effect on the motivation of health workers and the sustainability of the healthcare system.

Informal payments in public hospitals in Malawi: the case of Kamuzu Central Hospital

Background

Informal payments in public health facilities act as a barrier to accessing quality health services, especially for poor people. This research aimed to investigate informal payments for health care services at Kamuzu Central Hospital (KCH), a public referral hospital in Malawi. Results of this study provide evidence on the prevalence and influencing factors of informal payments for health care so that relevant policies and strategies may be developed to address this problem.

Methods

This study employed a mixed methods research design. The quantitative study had a sample size of 295 patients and guardians. The qualitative study had 7 key informant interviews (with health workers, health managers and policy makers) and 3 focus group discussions (FGDs) with guardians. Each FGD included 10 participants. Thus, in total, the qualitative sample comprised 52 participants. Quantitative data was analyzed using Excel and STATA. Qualitative data was analyzed using a thematic content analysis approach.

Results

80% of patients and guardians had knowledge of informal payments. Approximately 47% of respondents admitted making informal payments to access health services, and 87% of informal payments were made at the request of a health worker. Lack of knowledge, fear and desperation among patients and guardians, low salaries of health workers, and lack of effective disciplinary measures, were reported as key factors influencing informal payments. Regression analysis results showed that occupation and gender were the main determinants of informal payments.

Conclusions

Informal payments exacerbate inequality in access to free public health services. Particularly, poor people have limited access to health services when informal payments are demanded. This practice is unethical and infringes on people’s rights to universal access to health care. There is a need to strengthen the public health care system by formulating deliberate policies that will deter informal payments in Malawi.

Unpacking the red packets: institution and informal payments in healthcare in China

Informal cash payments from patient to healthcare providers for services provided by the healthcare system have attracted increasing scholarly interest. However, the root and mechanism of informal payments are not well understood. This paper contributes to the literature by positing informal payments as informal institutions. We use a nationally representative longitudinal survey in 28 provinces in China to explore the root of informal payments. Our empirical findings suggest that patients' informal payments for healthcare services may originate from information acquisition and processing, failure of government and market in allocating healthcare resources, and disparities in utilization. Further, this informal institution could be changed by the self-reinforcement of individual patients. These findings suggest that policies to facilitate transparency and to remove institutional barriers, such as the introduction of market competition, may reduce the incidence of informal payments.

Financial protection in health among the middle-aged and elderly: Evidence from the Greek economic recession

Since the late 2000s, the Greek economy has entered a long period of recession, with reforms and retrenchment in health care being among the main public policy priorities. This study investigates the extent to which financial protection in health has changed among older households during the Greek crisis. We focus on the middle-aged and elderly, the heavy users of health services, who have faced a substantial health and financial burden during the crisis. Our analysis shows that the headcount and overshoot of catastrophic health expenditure (CHE) substantially increased from 2007 to 2015, suggesting that financial protection has eroded to a great extent. Prior to the crisis, CHE was mainly due to inpatient care, followed by outpatient care and medicines. However, the contribution of spending for outpatient medicines to CHE substantially increased during the study period. The headcount of CHE rose across all socioeconomic groups we examined, with low-income households and households with chronic patients being disproportionately affected. In 2007, we do not report signs of socioeconomic inequalities in the risk of CHE. On the contrary, our results show that households of low socioeconomic status are more likely to incur CHE in 2015, revealing substantial inequalities in the risk of CHE. This finding raises significant distributional and equity concerns. Strengthening financial protection among older households is an imperative challenge for the Greek health system, and several policy responses need to be adopted towards this direction.

Informal out-of-pocket payments experience and individuals' willingness-to-pay for healthcare services in Greece

BACKGROUND

Informal out-of-pocket payments to healthcare providers are not uncommon in the Greek health system. We explore individuals' willingness-to-pay (WTP) to secure zero out-of-pocket full coverage for healthcare services and medications and we estimate the impact of past informal payments and individuals' opinion about the legalization of informal payments on WTP.

METHODS

We conducted a survey of 2841 participants from November 2016 to February 2017. We obtained information on WTP using the contingent valuation method. A two-part regression model was used to estimate the association between WTP, informal payments, and respondents' opinion about legalizing such payments.

RESULTS

About 80% of the respondents were willing to pay an average of €95 per month to obtain free access to full healthcare coverage and medications. About 65% of the respondents were involved in an informal payment at least once during the past four months with an average payment of €247. Higher informal payments and supportive opinions towards the legalization of informal payments increased the likelihood of WTP and were also positively associated with increased WTP amounts overall (p < 0.001).

CONCLUSIONS

This survey reveals that individuals' WTP is critically affected by previous experiences and attitudes towards informal payments. Our results imply that the potential introduction of official fees might not suffice to limit informal payments and suggest the need for stricter regulatory policies.

Households Health Expenditure in Interannual Correlation With Public Health Expenditure in Greece

The aim of this article is to investigate the relationship between the public and the private health expenditure (macroeconomic and microeconomic approach) over time and within the recession and austerity period in Greece, in order to find out whether the strict Memorandum health policies pass, influence, or go along with the health expenditure to the final consumer, i.e., the health services user. In this context, by using econometric tools, such as multiple regression and cointegration analysis on the raw microdata of Household Budget Surveys from 1987/88 up to 2018, as well as by using data of public expenditure of Organization for Economic Co-operation and Development-Health Statistics 2019 in the Stata version 13, the study compares the variation of household and public health expenditures before and after the financial crisis in Greece and also examines the correlation between the two variables. The analysis demonstrated that the Greek household health expenditure (HHE) was rapidly increasing during the period 1988-2008, and afterward, it started decreasing. Moreover, the total private and the total public health expenditures seem to have a bidirectional long-run relationship and significant cointegration. The same was observed regarding the public expenditure and household medical services expenditure, as well as pharmaceuticals. Furthermore, the results indicate that over the years of recession, the monthly HHE decreases, due to the confiscation of middle-class income, which led to consumerism restrictions. However, as households are now spending a bigger portion of their shrunken income for health (as health is an inelastic commodity), HHE, as a proportion of total private expenditure, has eventually risen.

Exploring the changes of physicians' behaviour toward informal payment based on Health Transformation Plan in Iran: A qualitative study

By implementation of the Health Transformation Plan (HTP), a revised tariff system for healthcare services was executed in Iran. This study explores the changes in physicians' behaviour in facing informal payment (IP) based on HTP implementation in Iran. We conducted in-depth semi-structured interviews with 15 purposefully selected physicians and policy makers to explore the changes (positive, negative and no) in physicians' behaviours with and without the implementation of HTP. The interviews were conducted individually and face to face. The conventional content analysis for data analysis by MAXQDA ver.10 was used. Based on the results, regardless of the HTP implemented, market competitiveness could control physicians' demand for IP. However, unreal tariffs, irregular payments, inflation, expensive healthcare and comparing income with other occupations increase physicians' demand for IP as negative behaviour. This study explored three patterns of physicians' behavioural change because of HTP implementation: 1-positive behavioural change with four factors; 2-negative behavioural changes with two factors; and 3-no behavioural change with four factors. Various factors influenced physicians' behaviour towards IP with and without the HTP. To combat IP more efficiently, we recommend strengthening the HTP's positive interventions, compensation of physicians' target income, enhancing supervision, reducing the gap among various medical specialities and taking a systematic approach with law offenders.

Corruption and health outcomes within an economic and cultural framework

The purpose of this paper is to investigate the relationship between corruption and population health. Our cross-sectional sample covers 185 countries (54 high-income and 131 low-income countries) and the period of the analysis is 2005-2017. This research provides clear evidence that the level of corruption significantly affects physical health (expressed as life expectancy and Mortality rate) and mental health (expressed by happiness), under the moderating role of economic development and cultural framework. Moreover, we validate a powerful and positive correlation between the income level and both physical and mental health. Culture also has an important role in the corruption-health nexus, because we find evidence supporting four out of the six dimensions of culture (individualism versus collectivism, indulgence versus restraint, uncertainty avoidance and masculinity vs femininity) as having influence upon the physical and mental health of individuals. When we estimate the results on subsamples of countries (high-income and low-income countries), we validate a crisscross effect of corruption. Thus, a high level of corruption more deeply affects the physical health of population in low-income countries than in high-income countries. On the other hand, mental health is more pronouncedly affected by corruption in high-income countries than in low-income countries. This study may have important implications for national or international policy makers who need to acknowledge that anti-corruption policies play an important role in increasing population health, but they also need to adopt them according to the economic and cultural context of each nation.

Inequalities Between Migrants and Non-Migrants in Accessing and Using Health Services in Greece During an Era of Economic Hardship

A cross-sectional study was conducted from April 2013 until March 2014 to explore the existence of inequalities in access to and utilization of health services by migrants compared to non-migrants in Greece and to test the influence of various factors on these disparities. Also, we investigated the influence of several socioeconomic and demographic characteristics. Study population included 1,152 migrants and 702 non-migrants. Migrants, participants suffering from a chronic disease, those without health insurance, and patients who assessed their health status as not at all good/a little good/moderate were statistically more likely to report unmet needs in getting their medication. Uninsured participants, females, those unemployed or without a permanent occupational status, and those who assessed their health status as not at all good/a little good/moderate were statistically more likely to report unmet needs in access to health services during the last year. Regarding the use of health services, those with health coverage, non-migrants, and females were statistically more likely to go for a blood test as a hospital outpatient. Greece, despite administrative delays and barriers, provided full coverage to the uninsured, asylum seekers, and migrants, even many groups of undocumented migrants.

Does health insurance coverage reduce informal payments? Evidence from the "red envelopes" in China

BACKGROUND

Representing a major threat to both equity and efficiency of health systems, the corrupt practice of informal payments is widely found in developing and transition countries. As informal payments are more likely to occur in health systems characterized by a high out-of-pocket payment rate, it is argued that formalized prepaid health insurance programs may help to curb such practice.

METHODS

Using panel data from the China Health and Retirement Longitudinal Survey, this study examined the association between changes in health insurance coverage on patient's behavior proxied with informal payments.

RESULTS

The statistical results reveal that health insurance status in fact increases the probability of patients making informal payments to physicians. However, this association varies among population groups and insurance programs, particularly between social health insurance and private health insurance status.

CONCLUSIONS

In a health system characterized by unequal allocation of medical resources, the dual pursuit of cost saving and quality of care may drive patients to make informal payments for personal gains. This study argues that health policy interventions aimed at curbing informal payments must be based on a thorough understanding of their complex socioeconomic causes and attack the perverse incentives in a coherent and bona fide manner.

New insight into the informal patients' payments on the evidence of literature: a systematic review study

BACKGROUND

Nowadays, a growing literature reveals how patients use informal payments to seek either better treatment or additional services, but little systematic review has been accomplished for synthesizing the main factors. The purpose of this study was to analyze the content of literatures to demonstrate the factors for informal patient payments.

METHODS

In this systematic review study, PubMed, Web of Science, Wiley Online Library, Science Direct, Ovid, Scopus, and Iranian databases were investigated without time limitation for eligible English and Persian studies. Achieved data were analyzed using content analysis approach and MAXQDA 10 software.

RESULTS

Themes related to informal payments in external context of health system were demographic features of health service consumers, patient's personality features and social & cultural backgrounds of the community. Health system challenges' themes were about stewardship weakness, and sustainable financing and social protection weakness. These were followed by human resources' organizational behavior challenges, drugs, medical products, and services delivery provision process challenges and finally change management weakness for reducing and dealing with IPs.

CONCLUSION

It appears that improving the quality of health care services and accurate monitoring of delivery processes, along with performing some strategies for regulating payroll and medical tariffs, strict rules and regulations and improving health staff motivation, would be effective ways against informal payments. Improving the health insurance contribution, promoting transparency & accountability in health system especially in financing, identify precise control mechanism, using empower patient/public related approach, modifying community perception, reinforcing social resistance to unofficial payments and rebuilt lost social capital in health care are some of the other recommendations in this field. To practice these strategies, a comprehensive and systemic vision and approach is needed, however, the key point is that before applying any strategy the impact of this strategy on access, efficiency, equity, and other health systems' goals and policies should be investigated due to the consideration.

An association of economic hardship with depression and suicidality in times of recession in Greece

The interplay between objective and subjective measures of economic hardship on influencing mental health has not been explored during a period of enduring recession. The present study aims to fill this gap by investigating the relationship between income and economic difficulties in evoking major depression and suicidality in Greece, while taking into consideration gender differences. A random and representative sample of 2188 adults participated in a telephone survey in 2013 (response rate = 81%). Major depression and suicidality were assessed with the pertinent modules of SCID-IV; while financial difficulties were measured by the Index of Personal Economic Distress. Information on confounder variables was also gleaned. Income exerted an independent effect on major depression (OR = 0.37, 95%CI = 0.22-0.63), which was more pronounced among men than women. On the contrary, financial difficulties exerted a strong and independent effect on depression (OR = 1.16, 95%CI = 1.13-1.2). Income was found to bear a strong association with suicidality only among men; whereas financial difficulties were unrelated in both genders. Subjective and objective indices of economic hardship exert a differential impact on mental health outcomes amid recession. Gender-sensitive policies and interventions should be geared towards softening the social effects of the recession in the country.

Emergency inguinal hernioplasties in a tertiary public Hospital in Athens Greece, during the economic crisis

Background

Although the effect of the recent Greek economic crisis and austerity on the population’s health and the health system effectiveness have been discussed a lot recently, data on common surgical conditions affecting large part of the population are missing. Using inguinal hernia as a model we investigated possible changes of citizens’ attitude regarding the time of referral, the perioperative details and the intraoperative findings of the emergency hernioplasties.

Methods

The present retrospective study was conducted by a Department of Surgery in a tertiary public hospital of the Greek capital. We reviewed the records of all hernioplasties performed during two 5-year periods: 2005–2009 and 2012–2016, i.e. before and during the crisis focusing on the emergency ones (either incarcerated or strangulated).

Results

An equal number of hernioplasties was performed in both periods. During the crisis however, an emergency hernioplasty was significantly more probable (HR 1.269, 95% CI 1.108–1.1454, p = 0.001), at a younger age (p = 0.04), mainly in patients younger than 75 years old (p = 0.0013). More patients presented with intestinal ischemia (7 vs 18, p = 0.002), requiring longer hospitalization (5.2 vs 9.6 days, p = 0.04), with higher cost (560 ± 262.4€ vs 2125 ± 1180.8€ p < 0.001). In contrast the percentage of patients with intestinal resection, their hospitalization length and treatment-cost remained unchanged. During the crisis there was a non-significant increase of emergency patients requiring ICU postoperatively (0 vs 4, p = 0.07) and a non-significant 60% increase of emergency operations in migrants/refugees population (3.5% vs 5.8%, p = 0.28). Epidural anesthesia was significantly more frequent during the crisis.

Conclusion

During the crisis: (i) the emergency hernioplasties increased significantly, (ii) more patients (exclusively Greek) presented with intestinal ischemia requiring longer hospitalization and higher treatment cost, (iii) the mean age of the urgently treated patients decreased significantly (iv) regional (epidural) anesthesia was more frequent. Although a direct causal relation could not be proven by the present study most observations can be explained by an increase of the patients who delayed the elective treatment of their hernia, and by a redistribution of the surgical workload towards big central hospitals. This can be prevented by adequately supporting the small district hospitals.

Informal payments for health care in Iran

Purpose

Reducing informal payments (IPs) for health services has always been a top priority for health policymakers all over the world. As the newest attempts to reduce IPs, Iran’s Government applied a set of reforms in the health care system in 2014 called “Health Sector Evolution Plan” (HSEP). The purpose of this paper is to investigate the prevalence and nature of IPs one year after implementing this plan.

Design/methodology/approach

This descriptive and cross-sectional study was a nationwide survey on Iran's health sector informal payments carried out in 2016. To do this, a sample of 1,112 Iranain households was selected from all over the country using a multistage cluster-stratified sampling method. The prevalence and nature of IPs were determined through conducting face-to-face interviews using a standard questionnaire.

Findings

One year after implementing the HSEP, about 27.7 percent of sampled Iranians had at least one experience of IPs for health services. The prevalences of compulsory and voluntary IPs were 21.4 and 11.5 percent, respectively. IPs were reported by 26.1 and 12.5 percent in the inpatient and outpatient services, respectively.

Originality/value

According to the results, compulsory IPs are still prevalent in both the outpatient and inpatient services of Iran’s health system and it seems that the HSEP has not been completely successful in achieving the goal of eradicating IPs. It can be said that the HSEP has been the first step toward eradicating IPs in Iran and should not be the last one. The study provides useful results of the prevalence and nature of IPs after implementing the HSEP, which should be considered in designing the next steps.

Do private hospitals outperform public hospitals regarding efficiency, accessibility, and quality of care in the European Union? A literature review

European countries have enhanced the scope of private provision within their health care systems. Privatizing services have been suggested as a means to improve access, quality, and efficiency in health care. This raises questions about the relative performance of private hospitals compared with public hospitals. Most systematic reviews that scrutinize the performance of the private hospitals originate from the United States. A systematic overview for Europe is nonexisting. We fill this gap with a systematic realist review comparing the performance of public hospitals to private hospitals on efficiency, accessibility, and quality of care in the European Union. This review synthesizes evidence from Italy, Germany, the United Kingdom, France, Greece, Austria, Spain, and Portugal. Most evidence suggests that public hospitals are at least as efficient as or are more efficient than private hospitals. Accessibility to broader populations is often a matter of concern in private provision: Patients with higher social-economic backgrounds hold better access to private hospital provision, especially in private parallel systems such as the United Kingdom and Greece. The existing evidence on quality of care is often too diverse to make a conclusive statement. In conclusion, the growth in private hospital provision seems not related to improvements in performance in Europe. Our evidence further suggests that the private (for-profit) hospital sector seems to react more strongly to (financial) incentives than other provider types. In such cases, policymakers either should very carefully develop adequate incentive structures or be hesitant to accommodate the growth of the private hospital sector.

Out-of-pocket and informal payments in Iran's health care system: A systematic review and meta-analysis

Background: Out-of-pocket and informal payments are considered as 2 most important topics for equity in health care financing. Therfore, this study was conducted to systematically review and meta-analyze the status of these payments in Iran's health care system. Methods: Required data were collected through searching the following key terms: "Unofficial", "Informal Payment", "Iran", "Health Financing", "Health expenditure", and "Out-of-pocket" on Scopus, PubMed, IranMedex, SID, and Google Scholar databases. After extracting and screening previous studies, data were collected from the articles using PRISMA pattern. To perform the metaanalysis, Comprehensive Meta-Analysis (CMA: 2) software was used. Results: A total of 15 studies were entered in this review. Overall, the rate of out-of-pocket payments was estimated to be 50% (95% CI: 45-57%). A significant correlation was found between gender and the rate of out-of-pocket payments (p≤0.05). Moreover, the overall rate of informal payments was found to be 35%. Most of the informal payments were in form of cash, and the main reasons for informal payments were appreciating the staff and medical team as well as requests made by the hospital staff. Length of stay, marital status, employment status, income, and insurance coverage were key factors in the field of informal payments. Conclusion: According to the results of the present study, out-of-pocket and informal payments are more prevalent in Iran. Considering the negative effects of these payments on the health care system, it is of prime importance to implement extensive interventions to reduce or even prevent these payments.

A window-DEA based efficiency evaluation of the public hospital sector in Greece during the 5-year economic crisis

The main objective of this study was to apply the non-parametric method of Data Envelopment Analysis (DEA) to measure the efficiency of Greek NHS hospitals between 2009–2013. Hospitals were divided into four separate groups with common characteristics which allowed comparisons to be carried out in the context of increased homogeneity. The window-DEA method was chosen since it leads to increased discrimination on the results especially when applied to small samples and it enables year-by-year comparisons of the results. Three inputs -hospital beds, physicians and other health professionals- and three outputs—hospitalized cases, surgeries and outpatient visits- were chosen as production variables in an input-oriented 2-year window DEA model for the assessment of technical and scale efficiency as well as for the identification of returns to scale. The Malmquist productivity index together with its components (i.e. pure technical efficiency change, scale efficiency change and technological scale) were also calculated in order to analyze the sources of productivity change between the first and last year of the study period. In the context of window analysis, the study identified the individual efficiency trends together with “all-windows” best and worst performers and revealed that a high level of technical and scale efficiency was maintained over the entire 5-year period. Similarly, the relevant findings of Malmquist productivity index analysis showed that both scale and pure technical efficiency were improved in 2013 whilst technological change was found to be in favor of the two groups with the largest hospitals.

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.

Cost-Effective Surgical Management of Liver Disease Amidst a Financial Crisis

BACKGROUND

Intraoperative use of specialized equipment and disposables contributes to the increasing cost of modern liver surgery. As a response to the recent severe financial crisis in our country we have employed a highly standardized protocol of liver resection that minimizes intraoperative and postoperative costs. Our goal is to evaluate cost-effectiveness of this protocol.

STUDY DESIGN

We evaluated retrospectively all patients who underwent open hepatic resections for 4 years. All resections were performed by the same surgical team under selective hepatic vascular exclusion, i.e., occlusion of the hepatoduodenal ligament and the major hepatic veins, occasionally combined with extrahepatic ligation of the ipsilateral portal vein. Sharp parenchymal transection was performed with a scalpel and hemostasis was achieved with sutures without the use of energy devices. In each case we performed a detailed analysis of costs and surgical outcomes.

RESULTS

Our cohort included 146 patients (median age 63 years). 113 patients were operated for primary or metastatic malignancies and 33 for benign lesions. Operating time was 121 ± 21 min (mean ± SD), estimated blood loss was 310 ± 159 ml (mean ± SD), and hospital stay was 7 ± 5 days (mean ± SD). Six patients required admission in the ICU postoperatively. 90-day mortality was 2.74 %, and 8.9 % of patients developed grade III/IV postoperative complications (Clavien-Dindo classification). Total in-hospital cost excluding physician fees was 6987.63 ± 3838.51 USD (mean ± SD).

CONCLUSIONS

Our analysis suggests that, under pressing economic conditions, the proposed surgical protocol can significantly lessen the financial burden of liver surgery without compromising patient outcomes.

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.

"You have to keep fighting": maintaining healthcare services and professionalism on the frontline of austerity in Greece

BACKGROUND

Greece has been severely affected by the 2008 global economic crisis and its health system was, and still is, among the national institutions most shaped by its effects.

METHODS

In 2014, this qualitative study examined these changes through in-depth interviews with 22 frontline healthcare professionals in five different locations in mainland Greece. These interviews with nurses, doctors and pharmacists explored perceptions of austerity and how ideas of professionalism were challenged and revised by these measures.

RESULTS

Participants reported working conditions characterised by dramatic increases in public hospital admissions alongside decreases in personnel, consumables, materials, and also many hospital closures. Many drew on analogies of war and fighting to describe the effects of healthcare reforms on their working lives and professional conduct. Despite accounts of deteriorating conditions and numerous challenges, healthcare professionals presented themselves as making every effort to meet patients' needs, while battling to resist guidelines which they perceived diminished their roles to production-line operatives.

CONCLUSIONS

Participants considered it their duty to defend their professional ethos and serve patients without compromising standards, even if this meant liberal interpretation and implementation of regulations. These professionals regarded themselves on the frontline of healthcare provision but also the frontline defence in a war on their professional standards from austerity.