4.2 Human resources
4.2.1 Planning and registration of human resources
The Ministry of Health determines the number of doctors who can practise in publicly funded health facilities but does not regulate their distribution across the country. The Ministry of Education determines the number of places available in medical schools but these are not matched to the needs of population or health system at either central or regional levels. Since the mid-2000s, the Ministry of Education has stabilized the number of new entrants into medical schools (in response to increasing entrant numbers) but this has been the only available measure in terms of planning of human resources. There has also been no planning in terms of the balance between specialties, or between medical and nursing personnel. As a result, Greece now has major imbalances in distribution and availability of human resources.
After completing specialization training for doctors, or professional training for nurses, health professionals must apply for a licence to practise from the health department of the prefecture where they reside. Doctors must also enrol in a medical association according to their specialty. There is a legal requirement for further continuous professional development in order to renew licences to practise, which includes 100 hours of training over a five-year period (section 4.2.4).
4.2.2 Health workforce trends
In 2014, 210 000 people were employed in health and social services in Greece (OECD, 2018a). There was a substantial increase in the health workforce from 1995 until the late 2000s. Subsequently during the economic crisis, there was a 15% decrease between 2009 and 2014 in staff employed in hospitals.
Greece consistently has the highest ratio of physicians among EU countries, a rapid increase only slowing after 2008. In 2014, the number of practising physicians reached 625 per 100 000 population, compared with the EU average of 350 (Fig4.2). In contrast to the ratio of specialist physicians, which also was the highest in the EU, the number of GPs was one of the lowest, at 39 per 100 000, compared with the EU average of 80. The are several reasons for such a striking imbalance between the numbers of GPs and specialists, including historically undeveloped primary care, lack of quality training (Mariolis et al., 2007) and the higher social status attached to being a specialist physician (Kaitelidou et al., 2012). In terms of policy impact, it has been argued that the high number of doctors, combined with providers’ reimbursement methods, can lead to supplier-induced demand, regardless of the real health needs of the population, and also fuel informal payments (Kaitelidou et al., 2012; Souliotis et al., 2016). In addition, Greece faces serious geographical inequities regarding the distribution of doctors. The density of physicians in 2014 varied from about 300 per 100 000 population in Western Macedonia and Central Greece to 874 per 100 000 in Attica (Hellenic Statistical Authority, 2018). Although some incentives (e.g. financial support) have been offered by the Ministry of Health for doctors practising in rural parts of Greece, they have not been enough to recruit and retain staff in these areas.
Greece has the lowest ratio of practising nurses in the EU (344 vs 864 per 100 000 population) and, notably, this number has not changed since the mid-2000s (Fig4.3).
In 2014, Greece had the highest ratio of practising dentists in the EU (125 vs 68 per 100 000 population), although this has reduced slightly in recent years (Fig4.4). The ratio of practising pharmacists was higher than the EU average (105 vs 85 per 100 000 population), with their number steadily increasing since the mid-2000s (Fig4.5).
Despite the oversupply of doctors, Greek public hospitals and certain services are often heavily understaffed (Sakellaropoulos et al., 2012; Ifanti et al., 2014). The problem is even more pressing with regard to nursing personnel. The hiring freeze imposed with the economic constraints resulted in a large number of intensive care units being shut down and many ESY hospital clinics were, at the time of writing, functioning below their operational capacity. As a consequence, long waiting lists have started to emerge for some services (Clarke et al., 2016).
4.2.3 Professional mobility of health workers
Training of doctors and nurses in Greece conforms to EU standards for mutual recognition according to the Community directives regulating the free movement of health professionals. However, no reliable data are available concerning the international mobility of Greek doctors and nurses.
The impact of the economic crisis generally and within the health sector is one of the main factors contributing to the migration abroad of a large number of health professionals, particularly doctors and nurses. According to the Medical Association of Athens, more than 7340 doctors left Greece between the onset of the economic crisis and 2015. The number of doctors leaving Greece has tripled since 2009, which was prior to the start of the economic crisis, and the trend is continually increasing. The most popular destinations in Europe are Germany, the Scandinavian countries and the United Kingdom (Ifanti et al., 2014). The situation for nursing professionals is similar.
Unemployment and austerity measures imposed on education and the labour market are considered as some of the main factors generating this exodus in Greece. In addition, the limited public funding for research and reduced salaries have discouraged scientists working abroad from returning (Ifanti et al., 2013). Indeed, according to available data, health professionals from other European countries do not seem to come to Greece to practise. According to the Greek Medical Association, under 1% of practising doctors in Greece are citizens of other EU Member States. This can be attributed to cultural and language factors as well as the less attractive conditions prevailing in the Greek labour market (e.g. low salaries).
4.2.4 Training of health personnel
There are currently seven public university medical schools in Greece offering a basic six-year medical course leading to a medical degree. After university, all medical graduates are required to complete a specialization course in a public or university-affiliated hospital, the duration of which ranges from four years for general practice to seven years for vascular and neurosurgery. Before acquiring full medical specialization status, doctors are also obliged to carry out a mandatory one-year placement in a rural area, after which doctors are free to practise medicine anywhere.
Currently, there are two universities and seven higher technical education institutes that offer a four-year nursing course. Three higher technical education institutes currently provide midwifery courses, which last four years.
There are three types of nursing personnel working in both the public and the private sectors, depending on their education.
- Registered nurses are graduates of either a university or a higher technical education institute and are granted their professional licences by the health department of the region in which they reside.
- Assistant nurses are typically required to have one or two years of hospital-based training prior to their employment and do not hold a graduate nursing degree.
- Midwives are graduates of higher technical education institutes.
Law 1397/83 Article 41 requires 100 hours of continuous education every five years for medical and dental professionals to renew their licence. Additionally, according to Law 2257/94 Article 2, further training is mandatory for ESY doctors, dentists, pharmacists and other health professionals. Under the Code of Medical Ethics, doctors have an obligation to pursue lifelong education and knowledge regarding the developments of medical science and of their specialty. However, in practice, there is no further obligation for health professionals to train beyond the requirements for obtaining their licence to practise, as there is no specific framework that lays down rules for implementing continuing medical education. Consequently, continuous medical education essentially remains an ethical imperative and includes voluntary participation in seminars, symposia, scientific meetings and postgraduate courses, which are usually organized by the medical schools and medical associations. Although doctors are legally required to submit documentation of participation in continuing education activities, there is no substantive monitoring or further action for noncompliance. It should be noted, however, that continuing education activities are taken into account as part of promotion procedures within ESY.
The Panhellenic Medical Association is the authorized coordinating body of continuous medical education in Greece and is also the contact point with the European Union of Medical Specialists.
4.2.5 Physicians’ career paths
Law 2889/2001 imposed restrictions on tenure for ESY hospital doctors through the introduction of performance-based contracts. A permanent contract is granted to new recruits after 10 years of service on condition that they have successfully passed three consecutive evaluations.
There are three grades of specialists: junior registrar, senior registrar and consultant. Evaluations of junior and senior registrars are performed by councils composed of three members of the hospital where they work (hospital director, head of the medical service and the head of department), a consultant of the same or similar specialty appointed by KESY and a senior registrar of the same or a similar specialty appointed by the Greek Medical Association. As a result, representatives of the hospital, the Ministry of Health and the Medical Association participate in the process, with larger weight placed on the hospital where the candidate works.
The council for evaluating consultants consists of a director of the YPE, three consultants of the same or similar specialty appointed by KESY and a professor or associate professor of a medical university with the same or similar specialty. In these cases the promotion decision is made at the national level.
4.2.6 Other health workers’ career paths
Nursing staff working in hospitals, like all employees of public services, have a two-year trial period and after satisfactory completion of this a permanent contract is granted. The grade category of registered nurses varies from D (the most junior) to A (the most senior), depending on their qualifications. In terms of career development, established criteria include professional qualifications, work and management experience, skills and abilities as well as an overall assessment based on an interview.
The departmental board in each public organization is responsible for the decisions regarding promotions. For the higher-ranked positions (e.g. head of a directorate), a committee consisting of two senior representatives from the Ministry of Health, a state legal councillor and two members of the Supreme Council for Civil Personnel Selection is assembled. Indicatively, heads of the directorates are expected to have at least 20 years of work experience.