Health policy making under information constraints: an evaluation of the policy responses to the economic crisis in Greece

Impact of the economic crisis on household health expenditure in Greece: an interrupted time series analysis

OBJECTIVES AND SETTING

The 2008 financial crisis had a particularly severe impact on Greece. To contain spending, the government capped public health expenditure and introduced increased cost-sharing. The Greek case is important for studying the impact of recessions on health systems. This study analysed changes in household health expenditure in Greece over the economic crisis and explored whether the impact differed across socioeconomic groups.

PARTICIPANTS

We used data from the Greek Household Budget Survey for the years 2004 and 2008-2017. The dataset comprised 51 654 households, with a total of 128 111 members.

DESIGN

We compared pre-crisis and post-crisis trends in Greek household out-of-pocket payments for healthcare from 2004 to 2017 using an interrupted time series analysis. This study explored spending in euros and as a share of total household purchases.

RESULTS

Our results indicated that the population level trend in household health spending was reversed after the crisis began (pre-crisis trend: €0.040 decrease per quarter (95% CI: -0.785 to -0.022), post-crisis trend: €0.315 increase per quarter (95% CI: -0.004 to 0.635)). We also found that spending on inpatient services and pharmaceuticals has been increasing since the start of the crisis, whereas outpatient services expenditure has been decreasing. Across all households, out-of-pocket payments incurred a greater financial burden after the crisis relative to pre-existing trends, but the poorest households incurred a disproportionately higher burden.

CONCLUSIONS

This was the first study to use an interrupted time series analysis to assess the impact of the economic crisis on household health expenditure in Greece. Our findings suggest that there was an erosion of financial protection for Greek households as a consequence of the economic crisis. This effect was particularly pronounced among poorer households, which is indicative of a regressive financing system.

Patient adherence to pharmaceutical care amid the economic crisis in Greece: Underlying priority areas for policy makers

The purpose of the study was to investigate the degree to which chronic patients adhered to medication regimens during the economic crisis in Greece. It is a quantitative cross-sectional study, with a convenience sample of 1,009 residents of Western and Northern Greece, aged ≥ 18 years, with chronic health problems. The survey was conducted between February and June 2016. Data were collected via a structured questionnaire with closed-ended questions, filled out during face to face interviews with all participants. The vast majority of respondents (94.5 %) said that they were able to buy prescribed drugs but had to economise in other ways (for example, by cutting back on clothing and travel) to cope with essential household expenses, including medication. Only 71 % of participants said they remembered to take their prescribed medications every day, following all of their physicians' recommendations. Almost 70 % of participants said that using generic medications made it easier to adhere to their treatment regimens. The results of a correlation analysis showed that patients experiencing financial hardships as a result of health problems were less likely to adhere to pharmaceutical care regiments than those who were not experiencing financial difficulties (p = 0.026). Men had a higher level of adherence than women (p = 0.001).

Physical Activity and Sedentary Behaviors of Young Children: Trends from 2009 to 2018

Over the last decade, the lives of children in several countries, including Greece, have been affected by recession. The aim of the present study was (a) to examine time trends in physical activity (PA) and screen time (ST) of Greek preschool children, together with their family affluence (FA), from 2009 until 2018, and to explore the associations among them; and (b) to investigate the connections of parental educational level and children's BMIs to their achieving ST (<1h/day) and PA (11,500 steps/day) guidelines. A total of 652 children from four cross-sectional cohorts participated. PA was recorded with Omron HJ-720IT-E2 pedometers, whereas ST, family affluence (FA) and parental educational level were reported by participants' parents. The results of the one-way ANOVAs that were computed revealed statistically significant differences among cohorts, albeit of no practical importance, in PA, ST and FA. According to the regressions calculated, neither BMI nor the educational level was related to membership in ST and PA guidelines groups. ST was a significant predictor of children's PA in all week periods (school-time, leisure-time, weekend), whereas FA was not such a strong predictor. Multilevel interventions aiming at both ST and PA seem to be imperative for the benefit of young children's health.

Crise econômica, austeridade e seus efeitos sobre o financiamento e acesso a serviços públicos e privados de saúde bucal

Resumo O presente estudo analisou os efeitos da austeridade e crise econômica sobre o financiamento da saúde bucal, oferta e utilização de serviços públicos e acesso a planos exclusivamente odontológicos no Brasil, no período de 2003 a 2018. Foi realizado um estudo retrospectivo, descritivo, com abordagem quantitativa. Foram coletados dados da base do Fundo Nacional de Saúde, da Agência Nacional de Saúde Suplementar, da Sala de Apoio à Gestão Estratégica, do Sistema e-gestor. Observou-se que o repasse federal fundo a fundo apresentou tendência crescente de 2003 a 2010 e estável de 2011 a 2018. A oferta decresceu ao final do período com redução da cobertura da primeira consulta odontológica programática, média da escovação dental supervisionada e número de tratamentos endodônticos. Na contramão da crise financeira pública, as empresas de planos exclusivamente odontológicos expandiram o mercado de 2,6 milhões de usuários em 2000 para 24,3 milhões em 2018, com lucro de mais de R$240 milhões. A austeridade fiscal tem forte influência sobre a utilização de serviços públicos odontológicos no Brasil, que pode beneficiar o mercado privado e ampliar as desigualdades.

The health decentralization process in Greece: the insiders’ perspective

Purpose

Greece has legislated health decentralization several times since the 1920s, but none had been implemented until 2001. Even so, the decentralized system was subsequently modified several times, curtailing the powers that were initially delegated to the health regions, while the whole process has been criticized as limited in scope. The purpose of this paper is to explore the reasons that the decentralization process did not fulfil its initial aims.

Design/methodology/approach

Elite interviews were conducted with 37 of the 50 directors of health regions who served between 2001 and 2009. Interview transcripts were divided into four themes and analyzed using thematic analysis.

Findings

The participants agreed that health decentralization in Greece was only administrative rather than political and did not include fiscal decentralization. They described problematic and competitive relations with party officials and civil servants. They blamed their short tenure for the inability to fulfil their plans. Findings indicate that decentralization in Greece did not achieve its objectives because of the dominant mentality of centralized control, the lack of political support, the discontinuity in health policies and opposition from vested interests.

Originality/value

The value of the present study lies in the fact that it examines in depth the issue of health decentralization drawing on the experiences of the former directors of the Greek health regions, i.e. the persons who were called on to put into practice the process of regional decentralization.

Psychiatrists role in primary health care in Greece: findings from a quantitative study

BACKGROUND

Although the need for integration of mental health services into primary care is well established little has been done. The outbreak of the recession found the Greek mental health system in transition. As a response to the crisis, governments implemented horizontal budget cuts instead of health reforms. This resulted in an unfavorable situation for mental health which was set once again on the sidelines of the health policy agenda. Previous studies suggest that the most prevalent disorders in the years of financial crisis in Greece are depression and anxiety while a general increase of the psychiatric morbidity is observed does not follow the population' needs.

METHODS

The present descriptive study was carried out between March and June of 2015. A convenience sample of 174 psychiatrists and psychiatry residents who met the inclusion criteria were finally selected to participate. Data were collected by using a 40-items questionnaire consisted of three sections: (a) nine questions about demographics, (b) nine questions pertaining to general aspects of administrative regulations related to primary care, (c) 22 questions about psychiatrists attitudes and perceptions towards their role in primary care. Quantitative variables are expressed as mean values, while qualitative variables as absolute and relative frequencies.

RESULTS

The vast majority of participants perceives the public primary care services and mental health services in their community as inadequate and considers psychiatrists' participation in primary care as important in order to improve the detection and management rates of people demonstrating mental health symptoms. They also believe that: (a) primary care practitioners' usually fail to detect the mental health conditions of patients; (b) their participation in primary care will decrease the social stigmatization for mental health conditions; (c) patients receiving pharmaceutical treatment for mental health problems by GPs and other primary care professionals usually fail to comply.

CONCLUSIONS

Respondents in the present study are receptive to participate in primary care. They believe that their inclusion to primary care will result to decreased social stigmatization for mental health problems, increased patient' access and improved detection and management rates for common mental health conditions.

Medium-term impact of the economic crisis on mortality, health-related behaviours and access to healthcare in Greece

Previous studies on the health consequences of the crisis in Greece investigated short-term impacts on selected outcomes. This study examined the impact of the crisis on a key set of health indicators with longer follow up than previous studies. We conducted interrupted time series (ITS) analysis to compare trends in standardised mortality by cause before and during the crisis. We examined changes in fruit and vegetable consumption, smoking, physical activity, obesity, out-of-pocket payments and unmet needs for healthcare using national household data from the “Hellas Health” surveys. Standardised mortality rates for suicides (p < 0.001) and infant mortality (p = 0.003) increased during the crisis compared to pre-existing trends, while mortality from respiratory diseases (p = 0.053) and transport accidents (p = 0.067) decreased. The prevalence of smoking (42.6% to 36.5%; RR = 0.86) and sedentary lifestyle (43.4% to 29.0%; RR = 0.69) declined. The prevalence of unmet need for healthcare significantly increased from 10.0% to 21.9% (RR = 2.10) and the proportion of people paying out-of-pocket for healthcare from 34.4% to 58.7% (RR = 1.69) between 2010 and 2015. The impact of the economic crisis in Greece on health was more nuanced than previous reports suggest. Effective strategies to mitigate the adverse health impacts of economic crises need to be better understood and implemented.

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.

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.

Bridging knowledge to develop an action plan for integrated care for chronic diseases in Greece

The health, social and economic impact of chronic diseases is well documented in Europe. However, chronic diseases threaten relatively more the 'memorandum and peripheral' Eurozone countries (i.e., Greece, Spain, Portugal and Ireland), which were under heavy recession after the economic crisis in 2009. Especially in Greece, where the crisis was the most severe across Europe, the austerity measures affected mainly people with chronic diseases. As a result, the urgency to tackle the threat of chronic diseases in Greece by promoting public health and providing effective chronic care while flattening the rising health care expenditure is eminent. In many European countries, integrated care is seen as a means to achieve this. The aim of this paper was to support Greek health policy makers to develop an action plan from 2015 onwards, to integrate care by bridging local policy context and needs with knowledge and experience from other European countries. To achieve this aim, we adopted a conceptual framework developed by the World Health Organization on one hand to analyse the status of integrated care in Greece, and on the other to develop an action plan for reform. The action plan was based on an analysis of the Greek health care system regarding prerequisite conditions to integrate care, a clear understanding of its context and successful examples of integrated care from other European countries. This study showed that chronic diseases are poorly addressed in Greece and integrated care is in embryonic stage. Greek policy makers have to realise that this is the opportunity to make substantial reforms in chronic care. Failing to reform towards integrated care would lead to the significant risk of collapse of the Greek health care system with all associated negative consequences. The action plan provided in this paper could support policy makers to make the first serious step to face this challenge. The details and specifications of the action plan can only be decided by Greek policy makers in close cooperation with other health and social care partners. This is the appropriate time for doing so.

Health care financing and the sustainability of health systems

The economic crisis brought an unprecedented attention to the issue of health system sustainability in the developed world. The discussion, however, has been mainly limited to “traditional” issues of cost-effectiveness, quality of care, and, lately, patient involvement. Not enough attention has yet been paid to the issue of who pays and, more importantly, to the sustainability of financing. This fundamental concept in the economics of health policy needs to be reconsidered carefully. In a globalized economy, as the share of labor decreases relative to that of capital, wage income is increasingly insufficient to cover the rising cost of care. At the same time, as the cost of Social Health Insurance through employment contributions rises with medical costs, it imperils the competitiveness of the economy. These reasons explain why spreading health care cost to all factors of production through comprehensive National Health Insurance financed by progressive taxation of income from all sources, instead of employer-employee contributions, protects health system objectives, especially during economic recessions, and ensures health system sustainability.

Estimating the Fiscal Effects of Public Pharmaceutical Expenditure Reduction in Greece

The purpose of the present study is to estimate the impact of pharmaceutical spending reduction on public revenue, based on data from the national health accounts as well as on reports of Greece’s organizations. The methodology of the analysis is structured in two basic parts. The first part presents the urgency for rapid cutbacks on public pharmaceutical costs due to the financial crisis and provides a conceptual framework for the contribution of the Greek pharmaceutical branch to the country’s economy. In the second part, we perform a quantitative analysis for the estimation of multiplier effects of public pharmaceutical expenditure reduction on main revenue sources, such as taxes and social contributions. We also fit projection models with multipliers as regressands for the evaluation of the efficiency of the particular fiscal measure in the short run. According to the results, nearly half of the gains from the measure’s application is offset by financially equivalent decreases in the government’s revenue, i.e., losses in tax revenues and social security contributions alone, not considering any other direct or indirect costs. The findings of multipliers’ high value and increasing short-term trend imply the measure’s inefficiency henceforward and signal the risk of vicious circles that will provoke the economy’s deprivation of useful resources.