Crisis as a serendipity for change in Cyprus' healthcare services

The 2019 introduction of the new National Healthcare System in Cyprus

In 2019, Cyprus launched its new National Healthcare System (NHS) as one of the major structural reforms required by the bail-out agreement with the International Monetary Fund, the European Commission and the European Central Bank (known as the Troika) which averted Cyprus bankruptcy in 2011. This paper presents the key features of the new NHS: A National Health Insurance Fund operated by the Health Insurance Organisation pays for services provided by a mix of public and private providers. A prerequisite for the establishment of this new quasi-market was the transfer of public hospitals from the Ministry of Health to the new State Health Services Organisation, thus establishing a purchaser-provider and regulator split. The first implementation phase started in June 2019 and introduced coverage of outpatient healthcare services for the entire population, providing access - with relatively small user charges - to family physicians, outpatient specialists, pharmaceuticals and laboratories. The second implementation phase began in June 2020 with the inclusion of hospital care, followed by the inclusion of specialty pharmaceuticals in September and was completed in December 2020. The reform is a vital achievement as it is a major step towards the goal of universal health coverage, reducing the excessive reliance on out-of-pocket payment and glaring inequities in access to care.

Will the Economic Recession Inhibit the Out-of-Pocket Payment Willingness for Health Care?

We used an individual regression and panel data regression method to analyze the samples of 60 countries from 2000 to 2016 to study the impact of the economic recession on residents’ out-of-pocket payment willingness for health care. Although we found an increase in the willingness during the economic recession in most countries, we couldn’t find significant evidence of a positive relationship between the economic recession and such willingness. We discovered that the relationship differentiates in different countries, which mainly depends on the differences in the medical systems and degree of economic development. By controlling individual differences in countries, we found that the economic recession inhibited the out-of-pocket payment willingness for health care. Especially after the impact of the financial crisis in 2008, the cumulative effect of the economic recession and the aftershock of financial crisis was discovered, which significantly inhibited residents’ willingness. In addition, we verified that the economic recession inhibited the out-of-pocket payment willingness by reducing employee compensation in specific types of countries.

Single-payer or a multipayer health system: a systematic literature review

OBJECTIVES

Healthcare systems worldwide are actively exploring new approaches for cost containment and efficient use of resources. Currently, in a number of countries, the critical decision to introduce a single-payer over a multipayer healthcare system poses significant challenges. Consequently, we have systematically explored the current scientific evidence about the impact of single-payer and multipayer health systems on the areas of equity, efficiency and quality of health care, fund collection negotiation, contracting and budgeting health expenditure and social solidarity.

STUDY DESIGN

This is a systematic review based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

METHODS

A search for relevant articles published in English was performed in March 2015 through the following databases: Excerpta Medica Databases, Cumulative Index of Nursing and Allied Health Literature, Medical Literature Analysis and Retrieval System Online through PubMed and Ovid, Health Technology Assessment Database, Cochrane database and WHO publications. We also searched for further articles cited by eligible papers.

RESULTS

A total of 49 studies were included in the analysis; 34 studied clinical outcomes of patients enrolled in different health insurances, while 15 provided a qualitative assessment in this field.

CONCLUSION

The single-payer system performs better in terms of healthcare equity, risk pooling and negotiation, whereas multipayer systems yield additional options to patients and are harder to be exploited by the government. A multipayer system also involves a higher administrative cost. The findings pertaining to the impact on efficiency and quality are rather tentative because of methodological limitations of available studies.

The contribution of Cyprus to non-communicable diseases and biomedical research from 2002 to 2013: implications for evidence-based health policy

BACKGROUND

Non-communicable diseases (NCDs) are the leading causes of disease burden and mortality at the European level and in Cyprus. This research was conducted to map the research activities of Cypriot institutions in five NCDs, namely oncology, cardiovascular diseases, diabetes, mental health and respiratory conditions.

METHODS

For the period 2002-2013, research in Cyprus was assessed on its biomedical outputs and compared to the rest of Europe relative to their GDP. The research output in the five NCDs was obtained and contrasted to their respective disease burdens. The results from each of the five NCDs showed the amount of cross-country collaboration with other researchers from other European countries and from the rest of the world, and the research level of the papers on a clinical to basic scale. For each NCD field the research application was assessed, whereas for oncology the research type was also assessed. Information was collected on the development of clinical guidelines, on Cypriot newspapers reporting on medical and policy documents and advisory committees' output as well as research and funding organisations available in Cyprus, for potential evaluation of impact in health policy on the five NCDs.

RESULTS

Cypriot biomedical research output appeared appropriate in volume compared with its wealth and the expected value from a regression line for other European countries. However, it was focused particularly on the molecular mechanisms of transmittable or hereditary diseases, rather than on the five NCDs. Cyprus performs well in palliative care, which receives funding from several local charities and other non-profit organisations. Cyprus has the highest relative burden from diabetes in Europe, but the subject is largely neglected by researchers. Similarly, it suffers more from mental disorders than most of the rest of Europe, but the amount of research is relatively small. Respiratory conditions research is under-funded and under-researched too.

CONCLUSIONS

The biomedical research portfolio in Cyprus is adequate in volume, but not well fitted to its pattern of disease. The means whereby research can be used to improve healthcare in the country are also unsatisfactory, although the Ministry of Health is now developing a comprehensive plan which will include the development of clinical guidelines and proposals for the evaluation of how healthcare is delivered on the island.

The burden of disease in Greece, health loss, risk factors, and health financing, 2000-16: an analysis of the Global Burden of Disease Study 2016

Background

Following the economic crisis in Greece in 2010, the country's ongoing austerity measures include a substantial contraction of health-care expenditure, with reports of subsequent negative health consequences. A comprehensive evaluation of mortality and morbidity is required to understand the current challenges of public health in Greece.

Methods

We used the results of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2016 to describe the patterns of death and disability among those living in Greece from 2000 to 2010 (pre-austerity) and 2010 to 2016 (post-austerity), and compared trends in health outcomes and health expenditure to those in Cyprus and western Europe. We estimated all-cause mortality from vital registration data, and we calculated cause-specific deaths and years of life lost. Age-standardised mortality rates were compared using the annualised rate of change (ARC). Mortality risk factors were assessed using a comparative risk assessment framework for 84 risk factors and clusters to calculative summary exposure values and population attributable fraction statistics. We assessed the association between trends in total, government, out-of-pocket, and prepaid public health expenditure and all-cause mortality with a segmented correlation analysis.

Findings

All-age mortality in Greece increased from 944·5 (95% uncertainty interval [UI] 923·1–964·5) deaths per 100 000 in 2000 to 997·8 (975·4–1018) in 2010 and 1174·9 (1107·4–1243·2) in 2016, with a higher ARC after 2010 and the introduction of austerity (2·72% [1·65 to 3·74] for 2010–16) than before (0·55% [0·24 to 0·85] for 2000–10) or in western Europe during the same period (0·86% [0·54 to 1·17]). Age-standardised reduction in ARC approximately halved from 2000–10 (−1·61 [95% UI −1·91 to −1·30]) to 2010–16 (−0·87% [–2·03 to 0·20]), with post-2010 ARC similar to that in Cyprus (−0·86% [–1·4 to −0·36]) and lower than in western Europe (−1·14% [–1·48 to −0·81]). Mortality changes in Greece coincided with a rapid decrease in government health expenditure, but also with aggregate population ageing from 2010 to 2016 that was faster than observed in Cyprus. Causes of death that increased were largely those that are responsive to health care. Comparable temporal and age patterns were noted for non-fatal health outcomes, with a somewhat faster rise in years lived with disability since 2010 in Greece compared with Cyprus and western Europe. Risk factor exposures, especially high body-mass index, smoking, and alcohol use, explained much of the mortality increase in Greek adults aged 15–49 years, but only explained a minority of that in adults older than 70 years.

Interpretation

The findings of increases in total deaths and accelerated population ageing call for specific focus from health policy makers to ensure the health-care system is equipped to meet the needs of the people in Greece.

Funding

Bill & Melinda Gates Foundation.

Improving quality care for diabetes in the community: What do Cypriot patients want?

Objective

To measure patient preferences for their diabetic care in community setting.

Design

Discrete-choice survey.

Setting

Community setting (primary physician and hospital sites) in Cyprus.

Participants

Diabetic patients attending community sites.

Main Outcome Measure(s)

Patient preferences, to estimate which components of quality healthcare service people value, their relative importance but also the potential shift to shared decision-making (SDM).

Results

Older respondents with experience of the private sector already received SDM (managing their care and choosing their treatments; detailed and accurate information, continuity of care; compassion for their personal situation) from their primary care physician with waiting time shorter than 1 h. They valued their 'current' option and they did not want to change it with other services. Younger people from the public sector valued a change in policy and wanted to move from their 'current' to alternative diabetic care services where the waiting times were shorter, they could not only manage their care but also choose their treatments (together with receiving information, continuity of care and compassionate care). Individuals agreed with receiving multidisciplinary care from a team of healthcare providers but they mostly preferred being supported by their primary care physician. The pooled sample valued their 'current' option but they also supported policy changes that would implement SDM service for everybody.

Conclusions

Diabetic patients value SDM and are willing to support a shift of practice to receive it not only in the private but also in the public sector. The forthcoming National Health Insurance Service would aim to address such developments as anticipated both in the European Troika's recommendations and the relevant laws.

Cost-Sharing Rates Increase During Deep Recession: Preliminary Data From Greece

Background: Measures taken over the past four years in Greece to reduce pharmaceutical expenditure have led to significant price reductions for medicines, but have also changed patient cost-sharing rates for prescription drugs. This study attempts to capture the resulting increase in patients’ out-of-pocket (OOP) expenses for prescription drugs during the 2011-2014 period.

Methods: The authors conducted a retrospective review of financial data derived from 39 883 prescriptions, dispensed at three randomly chosen pharmacies located in Lamia, central Greece.

Results: The study recorded an average contribution rate per prescription as follows: 11.28% for 2011 (95% CI: 10.76-11.80), 14.10% for 2012, 19.97% for 2013, and 29.08% for 2014. Correspondingly, the mean patient charge per prescription for 2011 was €6.58 (95% CI: 6.22-6.94), €8.28 for 2012, €8.35 for 2013, and €10.87 for 2014. During the 2011-2014 period, mean percentage rate of patient contribution increased by 157.75%, while average patient charge per prescription in current prices increased by 65.22%. The use of a newly introduced internal reference price (IRP) system increased the level of prescription charge at a rate of 2.41% for 2012 (100% surcharge on patients), 26.24% for 2013 (49.95% on patients and 50.04% on the appropriate health insurance funds), and 47.72% for 2014 (85.06% on patients and 14.94% on funds).

Conclusion: Increased cost-sharing rates for prescription drugs can reduce public pharmaceutical expenditure, but international experience shows that rising OOP expenses can compromise patients’ ability to pay, particularly when it comes to chronic diseases and vulnerable populations. Various suggestions could be effective in refining the cost-sharing approach by giving greater consideration to chronic patients, and to the poor and elderly.