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European Observatory on Health Systems and Policies

Greece


Health Systems in Transition (HiT) profile of Greece

5. Provision of services

Chapter summary

  • Public health services have taken a back seat in favour of the development of secondary care services. The services delivered rarely engage in prevention, health promotion, social care and rehabilitation.
  • The primary care system has not been developed fully and patients face problems with access, continuity of care and coordination as well as comprehensiveness of services. Currently there is no gatekeeping mechanism that manages the referral system, but a new Primary Care Plan announced in 2017 aims to establish first-contact, decentralized local primary care units staffed by multidisciplinary teams, which also will take on a gatekeeping role.
  • Specialized ambulatory care is characterized by unequal geographical distribution of contracted EOPYY physicians and by a lack of some specialties across the country.
  • The Greek health care system is strongly centred in hospitals. Substitution policies to replace inpatient care with less expensive outpatient, home care and day care largely do not exist and the degree of integration between primary and secondary care providers is low.
  • The provision of physical rehabilitation, long-term and palliative care by the private (profit-making) sector and voluntary and NGOs has increased because of the gaps in ESY services and staff as well as equipment shortages in public facilities.
  • Dental services are de facto fully privatized and not covered under the EOPYY benefits package due to lack of contractual arrangements with dentists.

5.1 Public health

The public health system in Greece carries out epidemiological monitoring and infectious disease control as well as environmental health control, health promotion and disease prevention at community level. The system consists of a centralized service within the Ministry of Health, a grid of services at the regional and local levels and a number of public health organizations under the auspices of the Ministry of Health that operate as autonomous bodies and provide laboratory, research, educational and statistical support.

Responsibility for public health services nationally lies with the Directorate for Public Health within the Directorate General for Public Health and Health Services in the Ministry of Health. It is responsible for monitoring, prevention and combating communicable and noncommunicable diseases; sourcing and quality control of vaccines; public health risk management; child and mother health; environmental health and sanitation; hygienic control of water and waste, air pollution, radioactivity and radiation; health and safety at work; school health; dealing with illicit drug abuse; and the supervision of various public health organizations (e.g. KEELPNO, the National Centre for Diabetes Mellitus, the Organization Against Drugs and the Hellenic Pasteur Institute) and a network of laboratories and services. In addition, the independent ESYDY is responsible for coordinating public health organizations concerned with monitoring and promoting population health, controlling communicable diseases and overseeing pharmaceuticals, medical devices and transplants.

Furthermore, the Ministry produces health promotion and health education leaflets and relevant radio and television advertisements, particularly against tobacco and alcohol consumption. Smoke-free legislation for most indoor public places and public transport was passed in 2010 (Law 3868/2010) but enforcement is weak, particularly in bars and restaurants.

Operational responsibility for public health services falls on a grid of actors at the regional and local level. At the regional level, public health directorates within the regional authorities include health prevention and promotion departments, with competences such as the implementation of programmes for immunization and preventive medicine, mother and child care, chronic ailments, illnesses not easily susceptible to treatment and health education activities. At the local level, municipalities are responsible for running several prevention and promotion programmes within primary care through municipal health clinics, open care centres for the elderly and public infant and child care centres; they also provide care for vulnerable population groups.

A Central Laboratory for Public Health, a number of regional laboratories for public health (part of PEDYs) and the public health and hygiene laboratories that operate in medical schools and in a number of selected public hospitals are designated as reference centres for various diseases, such as HIV, hepatitis, salmonella, parasitic diseases and tropical diseases. Greece also participates in several European networks for public health, including the Epidemiological Surveillance Network, the European Legionnaires’ disease Surveillance Network, a surveillance network for meningococcal disease, the European Tuberculosis Surveillance Network and Euro-HIV.

Starting in May 2016, the Ministry of Health and KEELPNO developed a system for epidemiological surveillance in first reception centres hosting refugees coming from Asia, with daily collection of epidemiological data for selected conditions. In addition, contracted NGOs offering services to first reception centres now collect migrant health data through individual health information, organization of patient files and registration of the provided medical services (WHO Regional Office for Europe, 2015).

Traditionally, public health services in Greece have taken a back seat in favour of the development of secondary health care services (Box5.1). Public health doctors have a low status within ESY and there have always been problems with their recruitment. Therefore, all levels of public health services are severely understaffed. Underscoring this situation, the first National Action Plan for Public Health (2008–2012), which was developed by ESYDY, was never implemented. The Plan emphasized 15 major health hazards (substance abuse, cancer, sexual health, diet and nutrition, alcohol consumption, cardiovascular diseases, environmental health, smoking, vehicle accidents, oral health, infectious diseases, travel health, rare diseases, HIV/AIDS, and antimicrobial resistance and nosocomial infections) (Ministry of Health and Social Solidarity, 2008). In addition, the lack of an official national prevention and screening programme has had negative effects on the population’s health (Chapter 7) (Panagoulopoulou et al., 2010; Trigoni et al., 2011).

5.2 Patient pathways

Patients access health services through different pathways depending on whether public or private facilities are used (Fig5.1). While high use of private health services has been a feature of the Greek health system, the economic crisis has impacted on patients’ ability to outlay OOP payments and there has been a significant rise in the utilization of public sector services in recent years.

Currently, there is no gatekeeping mechanism or referral system and patients can directly access ambulatory care by visiting a physician in ESY urban facilities, rural health centres or hospital outpatient departments.4 The physician may prescribe necessary medications or tests or refer the patient to a specialist contracted with EOPYY or a specialist at a public or privately contracted hospital for care. Due to this direct method of access, long waiting lists occur for some specialties. Similarly, overly long waiting lists for screening tests may lead some patients to visit specialists and diagnostic centres in the private sector, paying out of pocket for these services. Hospital care may be provided in public and private hospitals; costs largely must be paid by the patient or by their VHI for the latter (section 3.4.1). Patients often prefer to visit hospitals in Athens or the large university hospitals offering expensive and high-technology services because district hospitals often are understaffed and in some cases have poor infrastructure. As a consequence, many hospitals in Athens have to source extra beds to meet excess demand. Many patients also visit the free-of-charge emergency departments of public or private contracted hospitals, bypassing primary care contact points. Many of these visits are not justified and put unnecessary pressure on these departments.


4 Paradoxically, patients covered by private health insurance contracts based on preferred provider networks or integrated insurer and provider schemes are obliged to visit a first-contact service that will subsequently refer them to specialist or hospital care.

5.3 Primary / ambulatory care

Ambulatory care in Greece is delivered by a mix of public and private health service providers. There are three main modes of delivery:

  • provision through the ESY, including the National Centre for Emergency Care (EKAV; section 5.5), rural health centres and their health surgeries and public hospital outpatient departments (section 5.4.1);
  • provision through local authorities and NGOs, including clinics and welfare services offered free of charge by municipalities and civil society organizations, which are limited in scope, covering only a narrow range of care and are used primarily by uninsured people and (particularly) by refugees and migrants; and
  • provision by the private sector, including medical offices, laboratories, diagnostic centres and outpatient medical consultations at private sector hospitals, which is financed by direct payments or private insurance but may be contracted by EOPYY.

The transfer of all ambulatory care networks operated by the sickness funds to EOPYY in 2011 constituted a major restructuring of ambulatory care (e.g. the large network of approximately 350 polyclinics belonging to IKA ATHINON (IKA), the largest fund and covering white and blue collar workers, were transferred to the ESY). In addition to being the sole purchaser of health services, EOPYY became an ambulatory care provider. A subsequent reorganization of primary care in 2014 (Law 4238/2014) placed all EOPYY ambulatory-care facilities, rural health centres and their surgeries under the jurisdiction of YPEs and their PEDYs (Chapter 2). The aim was for these facilities to function 24 hours a day, seven days a week. In addition, the Law provides for the establishment of a referral system based on family GPs, although it has not yet been implemented. A gatekeeping system does not exist as yet and almost all primary care providers are specialists: according to data from the Hellenic Statistics Authority, in 2014, out of a total of 68 807 doctors, only 2626 (3.8%) were GPs.

Ambulatory care in rural and semi-urban areas is mostly delivered by a network of 205 health centres staffed with GPs and specialists (paediatricians, gynaecologists, orthopaedists, ophthalmologists, urologists, dentists, general surgeons, psychologists, radiologists, physiotherapists, microbiologists, nurses, midwives and social workers). In addition, approximately 1700 rural health surgeries that are administratively linked to health centres are staffed with publicly employed doctors and medical graduates. The latter are required to spend at least one year in a rural area upon graduation and prior to enrolling for medical specialization. The number of available doctors in each health centre depends on the characteristics of the catchment area (e.g. size, economic growth, epidemiological profile and access to hospital).

Each health centre covers the health needs of approximately 10 000 to 30 000 people, operating on a 24-hour basis and includes consultation rooms, rooms for one-day medical treatment, basic diagnostic equipment, radiological and microbiological laboratory, septic surgeries, dental clinics and an ambulance. This infrastructure contributes to the provision of a wide range of services, which include prevention (mainly immunization) and health promotion, emergency services, first aid and transportation, diagnosis, cure, dental treatment, pharmacy services and prescribing, rehabilitation and social care; as well as epidemiological research and training of medical personnel. Health centres are also involved in school hygiene services, occupational health services, family planning and prenatal care. In addition, centres provide short-stay hospitalization and follow up care for recovering patients. Visits to health centres are now free of charge (although a €5 user charge was imposed between 2011 and 2015). Table5.1 presents the regional allocation of health centres as well as their staffing and equipment.

In addition to public ambulatory care services, there are more than 22 000 private practices, over 13 000 private dental practices and approximately 3527 private diagnostic centres. Most are equipped with high-quality and expensive medical technology. The majority of private facilities are located in Athens and Thessaloniki. EOPYY contracts private practices, laboratories and diagnostic centres to provide health care services to those insured. It also provides services directly to patients on a fee-for-service basis, paid directly by patients or through private insurance. Rehabilitation services and services for elderly people are predominantly offered by the private sector (Economou, 2015).

With demand increasing in the public health system, there is a growing role for municipalities, NGOs (through community clinics and pharmacies) and other unofficial networks of health professionals and volunteers designed to help poor and uninsured patients. These services contribute significantly to securing access to a basic set of medical services among poor and unemployed people. A network of around 40 community clinics operates across Greece, offering mostly medications and primary health services free of charge to people unable or ineligible to use public services and provided mainly by GPs, cardiologists, paediatricians, gynaecologists, dentists and opticians (section 2.1).

Since 2014, a system of monthly caps has operated on physician activity. Every doctor contracted with EOPYY has a limit of 200 visits per month (Ministerial Decision No. Y9a/oik.37139 of 9 May 2014) and there are also a monthly ceiling on the value of pharmaceutical prescriptions (Ministerial Decision No.Y9/oik.70521 of 18 August 2014). The latter varies according to specialization, number of patients prescribed for, the prefecture and the month of the year (seasonality). This means that those insured with EOPYY who are in need of a doctor’s visit or a prescription must either find a physician who has not reached the ceiling or they will have to pay out of pocket.

The need to establish an integrated primary care system was not on the health reform agenda during the 2000s and of the many proposals submitted by the scientific community, none was ever implemented (Box5.2).

At the time of writing (2017), a new Primary Care Plan had been formulated by the Ministry of Health, with implementation envisaged over three years. The first axis of the new system will be the establishment of a national, decentralized, community-oriented network of local primary care units, staffed with multidisciplinary teams (e.g. doctors, nurses, social workers) that will be the first contact point within the health system. The second axis will consist of health centres functioning as reference points for required specialized and diagnostic ambulatory services, thus integrating care (Box5.3 and Chapter 6). A project aimed at providing integrated health and social services and funded by the joint European Commission and WHO Regional Office for Europe grant is currently being piloted in the city of Ioannina with a population of 120 000 and two general hospitals (WHO Regional Office for Europe, 2017).

5.4 Specialized ambulatory care / inpatient care

5.4.1 Specialized ambulatory/outpatient care

Specialized ambulatory care is provided through private solo or group practices and outpatient departments of public hospitals. Many of the specialists working in their private offices or within diagnostic centres are contracted with EOPYY, providing services on a fee-for-service basis (€10 per visit), with an upper limit of 200 visits per month for each specialist. The uneven geographical distribution of contracted EOPYY physicians is a major problem; most are concentrated in large cities, particularly Athens and Thessaloniki, while other areas of the country lack some specialties (Karakolias & Polyzos, 2014). The highest numbers of specialists are in internal medicine, cardiology, obstetrics/gynaecology and orthopaedics.

The 124 outpatient departments of public hospitals provide specialized outpatient care within the ESY. They cover all specialties and are the major providers of ambulatory care services in urban areas. They provide free services during morning hours and visits are scheduled by appointment. Law 2889/2001 established afternoon services in hospital outpatient departments in which the same publicly employed doctors working in the hospital could provide private consultations on an appointment basis. They are paid directly by patients on a fee-for-service basis with the fee shared between the hospital (40%) and the physician (60%). This used to apply only to hospitals with the necessary infrastructure to support all-day clinics, but in 2010 mandatory all-day functioning was extended to all public hospitals in order to increase access to health services, to cope with extra demand and to increase revenues. The afternoon private consultation fees vary from €16 to €72, depending on physicians’ grades.

5.4.2 Inpatient care

The Greek health care system is strongly centred around hospitals (see Box5.4). In 2014, there were 283 hospitals, of which 124 were public, four were private non-profit-making and 155 were private profit-making. This excludes hospitals with special status (e.g. military or prison hospitals). All have outpatient departments, operating on a rotational basis. Private hospitals are profit-making organizations, usually formed as limited liability companies. According to the type of services they offer, Greek hospitals are categorized as either general or specialized. The former include departments of medicine, surgery, paediatrics and obstetrics/gynaecology, supported by imaging and pathology services. They range from big general hospitals in large urban areas, district hospitals located in the main administrative district to small hospitals in semi-urban areas and towns. Specialized hospitals are referral centres for a single specialty (e.g. obstetrics, paediatric care, cardiology or psychiatry). Hospitals linked to the country’s medical schools offer the most complex and technologically sophisticated services (section 4.1.1). Table5.2 presents the hospital configuration in Greece by legal form of ownership and geographical region.

Approximately 65% of beds are in the public sector and 35% in the private sector. The majority of private beds are in small or medium-sized general, obstetric/gynaecological or psychiatric clinics with fewer than 100 beds, low patient occupancy and low staffing rates for all types of personnel. They are mainly contracted with EOPYY, offering services of moderate quality to insured people. A second category of private beds is found in a small number of prestigious high-cost hospitals with 150–400 beds, located mainly in Athens and Thessaloniki and offering high-quality services to private patients and patients with private insurance (Kondilis et al., 2011). One characteristic of the private sector is its high degree of concentration, with fewer private hospitals holding more and more of the market share (Boutsioli, 2007). It is also remarkable that about 43% of the total number of hospital beds in the country are located in Attica, containing 35% of the Greek population and the capital city Athens. Central Macedonia (which contains Thessaloniki, the second largest city in Greece) has the second highest proportion: 17.8% of total beds.

Operationally, hospitals face a number of problems. The management model is outdated and political interference is widespread, particularly in selecting hospital managers and members of governing boards. Human resources management is also problematic, including delayed recruitment processes, lack of substantive staff evaluation and a culture of no accountability for staff underperformance. Lastly, financing and cash flow is still problematic given that the DRG system has not yet been fully developed because of a number of technical problems (Chapters 6 and 7). The quality of services in Greek hospitals is not rated highly by citizens (Box5.5).

In 2011, a number of proposals for hospital restructuring were submitted by an expert committee appointed by the Minister of Health (Liaropoulos et al., 2012) as well as other sources (National School of Public Health, 2011), aiming to achieve economies of scale, optimal allocation of inputs, efficient operation and lower total costs. After public hearings and consultations in the various regional health administrations, which included health managers and other health professional bodies, the final plan was announced in July 2011 (Ministry of Health and Social Solidarity, 2011a). Public hospital management boards were replaced by a total of 82 councils responsible for the administration of all hospitals. In addition, five hospitals that belonged to IKA were transferred to ESY and became branches of five main public hospitals. The total number of beds in ESY hospitals decreased to 30 157; the number of medical departments and units declined by 600 and 15 000 hospital personnel were cut. Additionally, changes were made to the use of eight small hospitals, which were turned into urban health centres, support and palliative care units and hospitals for short-term hospitalization and rehabilitation (Nikolentzos et al., 2015).

5.4.3 Day care

Day care units have been slow to develop in Greece. Attempts in the past were fragmented and did not engender the organizational culture required for this type of health care practice. Legislation in 2011 (Law 4025/2011) stalled through a failure to issue a presidential edict defining various operational and technical criteria. Three years later, Law 4254/2014 permitted the establishment of public and private day care units providing diagnosis, curative services and surgical procedures as long as these did not require general, spinal or epidural anaesthesia or hospitalization for more than one day. Public hospitals, PEDYs, health centres, private clinics and private ambulatory care enterprises can establish day care units. A subsequent ministerial decision (No A6/G.P.oik.103516) defined the technical and equipment specifications for day care units to obtain authorization as well as their specialties, including internal medicine, surgery and dentistry. At the time of writing, a number of public and private day care units have been established. However, there are no available data on their exact number or the proportion of care they provide.

5.5 Emergency care

Emergency care is provided free of charge at the point of use through the emergency departments of public hospitals and the facilities of EKAV (Papaspyrou et al., 2004). A person with a life-threatening problem can choose either to go directly to an emergency department of a public hospital or to call EKAV.

EKAV was established in 1985 and is responsible for the provision of first aid and emergency medical care to all citizens, as well as transportation to health care units, free of charge at the time of use. It also provides training to doctors, nurses and other health care personnel in all aspects of emergency medicine and health care. Its central service centre is located in Athens, with 11 regional stations in major cities and substations in smaller cities, serving about 600 000 patients annually. Box5.6 outlines the method by which patients access emergency care.

Although the Athens Olympic Games in 2004 was a major factor contributing to the modernization of EKAV (Zygoura, Syndos & Kekeris, 2007), the economic crisis and austerity measures implemented after 2010 have had a negative impact on the adequacy and quality of its services. Horizontal cuts in health expenditure, nonrenewal of fixed-term contracts for temporary staff and a reduction in the replacement of retiring staff have resulted in approximately one fifth of the nationwide ambulance fleet being off the road through shortages in ambulance crews, as well as repair requirements and delays in the procurement of new ambulances.

In addition to EKAV, all public hospitals with a capacity of more than 300 beds operate 24-hour independent emergency departments staffed with physicians from the following specialties: surgery, anaesthesia, internal medicine, cardiology, pulmonology, orthopaedics and general practice with proven experience and knowledge of emergency medicine or specialization in intensive care medicine. Emergency departments undertake admission, triage and immediate treatment in life-threatening situations.

The proper functioning of emergency departments is impeded by several factors. First, emergency medicine has not yet been institutionalized as a specialty in Greece. Second, the absence of gatekeeping results in a large number of unnecessary visits to these departments, increasing their workload. Third, budget cuts have resulted in a lack of personnel to triage patients. Shortages of paramedic personnel in emergency departments often results in ambulance crews having to take on the role of paramedic personnel by transferring patients from one hospital department to another, delaying them from performing their core duties.

5.6 Pharmaceutical care

The regulation of pharmaceuticals, including planning and implementation of pharmaceutical policy, pricing of medicinal products and profit margins, is covered in section 2.4.4. Demand-side issues, insurance coverage and pharmaceutical expenditure are analysed in Chapter 3. This section examines the supply side: the production, distribution and provision of pharmaceuticals. The pharmaceutical sector has undergone significant reforms since the mid-2000s (Chapter 6).

Table5.3 gives an overview of the pharmaceutical market in Greece. The supply chain for pharmaceutical products comprises pharmaceutical companies (both manufacturers and importers), wholesalers (both storage and distribution) and pharmacies. All medicinal products are distributed through wholesalers to pharmacies, except products that are only for hospital use, which are sold directly to hospitals. The wholesale segment of the market comprises private wholesalers and pharmacist cooperatives. The majority of high-cost drugs are provided exclusively by EOPYY pharmacies or hospital pharmacies.

Approximately 73.5% of total sales in value in 2015 (84.5% in volume) was supplied to wholesalers and private pharmacies, while the remaining 26.5% (15.5% in volume) was sold to hospitals and EOPYY pharmacies.

In 2015, sales of medicinal products (by value) to pharmacies/wholesalers recorded an overall decrease of 39.7% (9% in volume) compared with 2009 (Table5.4). Comparing sales in volume with sales in value makes clear that the decrease of sales during the period 2009–2015 mainly reflected decreases in prices (by 32.5%; see Table5.3) in response to pricing reforms introduced from 2009 onwards; to a lesser extent there was a decrease in volume of sales (11%). This raises concerns about the effectiveness of the e-prescription system and the prevailing prescription behaviour of physicians (see Chapter 7).

As discussed in Chapter 3, high pharmaceutical spending is one of the main targets for cost containment under Greece’s EAP, resulting in significant reductions in expenditure. Apart from the establishment of positive and negative lists for reimbursement purposes and the introduction of reference pricing (which has resulted in price reductions for some medicines), an e-prescription system for doctors became compulsory in 2012, enabling monitoring of their prescribing behaviour as well as the dispensing patterns of pharmacists. At the same time, prescription guidelines following international standards were issued in 2012, and prescribing budgets for individual physicians have been set since 2014. The use of generic drugs has been promoted by a number of measures: physicians are required to prescribe drugs by the international nonproprietary name, allowing the use of brand names only in specific circumstances; there is a policy that 50% of medicines prescribed/used in public hospitals should be generics; and there is a policy of mandatory generic substitution in pharmacies.

A large range of pharmaceuticals is covered as part of the benefits basket, with varying degrees of co-payments. Measures have also been introduced to liberalize the pharmaceutical market to increase access and enhance efficiency, including a reduction in the population density threshold for setting up a pharmacy and allowing more than one pharmacist to work in the same pharmacy. In addition, to lower outpatient pharmaceutical expenses for some groups, such as chronically ill patients requiring expensive medicines, distribution is now possible through EOPYY public pharmacies, where prices are lower than in private pharmacies (Box5.7 and Chapter 6).

5.7 Rehabilitation / intermediate care

As intermediate care in Greece remains largely underdeveloped and few services are provided by ESY or by municipalities, in 2015 the Ministry of Health launched a pilot project for the development of home care/intermediate services nationwide. In the initial phase, a network of 11 hospitals and four health centres provided health care at home to patients who had been hospitalized and needed post-hospital care and to people with chronic and noncommunicable diseases, injuries and disabilities requiring short- or long-term health care. The health teams consisted of a specialist doctor (internist, anaesthesiologist, surgeon or GP), two nurses and a community nurse.

There are also rehabilitation services for people with disabilities that provide a variety of support including diagnostic services, psychosocial support, education and training for disabled people to attain independence and self-determination; in addition, there are services for children with physical disabilities, autism and learning difficulties. Following a restructuring in 2010, these services are provided through centres for physical medicine and rehabilitation within public hospitals and forming part of the ESY.

A significant role is also played by the Hellenic Society for the Protection and Rehabilitation of Disabled Persons, a non-profit-making NGO that provides support, diagnosis, health care, therapeutic and educational services to physically disabled infants, children, adolescents and adults with any type or severity of motor disability. The Society offers its services in six rehabilitation centres nationwide: Agrinio, Athens, Chania, Ioannina, Thessaloniki and Volos. Finally, since the early 2000s, private, profit-making provision of physical rehabilitation centres has increased rapidly as a result of both gaps in ESY services and the suboptimal operation of public facilities owing to staff and equipment shortages. These profit-making centres enter into contracts with EOPYY to provide services.

5.8 Long term care

This section focuses on long-term care provision for people with chronic diseases and for older people. For people suffering from chronic and incurable diseases and those who are not self-sufficient, long-term inpatient care services in Greece are provided mainly by a network of 25 public chronic diseases infirmaries nationwide. Anecdotal evidence also suggests that some smaller private clinics provide long-term care to older patients with incapacitating conditions, such as stroke or respiratory disease, and for patients with cancer receiving terminal care. In 2013, these independent public entities became decentralized units of the newly established social welfare centres (section 5.11), financed by the state budget and by per diem fees paid by SHI.

Church organizations also offer a variety of services, including facilities for people with incurable diseases, infirmaries for chronic diseases, institutions for the disabled and physiotherapy centres. There are also private clinics under contract with EOPYY that provide long-term care, mostly to the terminally ill.

In 2013, legislation stipulated that each regional administration should set up a social welfare centre and transform a broad range of previously residential-oriented rehabilitation centres into decentralized units of these social welfare centres. While potentially the centres could play an important role in developing and improving services, an assessment has not been conducted of the restructuring in relation to effectiveness, efficiency, quality and access to services. One issue is that the centres for physical medicine and rehabilitation are under the jurisdiction of the YPEs, given that they are units of public hospitals, while social welfare centres are under the jurisdiction of the regional authorities, raising the question of integration and the interconnection between the two networks.

Long-term care for the elderly includes both community and residential care. More precisely, there are four types of community care services (Mastroyiannakis & Kagialaris, 2010).

Open care centres for the elderly. These are public law entities, financed by the Ministry of Health and run by municipalities. They provide psychosocial support, health education (on diet, accident prevention and personal hygiene), preventive medical services for older people (e.g. blood pressure measurement, blood sugar tests and physiotherapy) and recreational services, thus improving patients’ well-being while they continue to live in their own personal and social settings. There are more than 900 centres around the country that are staffed by teams of social workers, community nurses, occupational and physical therapists and family assistants.

Friendship clubs. The clubs operate at the neighbourhood level and offer services to senior citizens, including creative pursuits, occupational therapy, physiotherapy, cultural venue visits, artistic endeavours, day trips, walking tours and assistance with adapting to age-related conditions in later life. They also provide a supportive environment, particularly for those who have insufficient financial means or family members to take care of them. They are created in areas and neighbourhoods that do not have open care centres for the elderly, where health care is partly provided through municipal health centres.

Home Help for the Retired programme. This replaced the Home Help for the Elderly programme in 2012 and aims to provide home care to retired elderly people, mainly the frail and those who live alone, in order to improve their quality of life, to ensure that they maintain their independence and to keep them active in their family and social environment, thus reducing the need for institutional hospital care. A social worker, a nurse and a home-helper pay regular visits (on a scheduled basis) to service users in their home, providing help and care, counselling and psychological services and assistance with everyday tasks. Eligibility criteria became stricter under the new programme, including age, income, marital status, health status and disability. Sources of finance for the programme are now exclusively national (financing previously was split between the EU (75%) and national (25%) funds). IKA is responsible for the running and management of the Programme. Competition is encouraged for service providers, as apart from the schemes operated by municipal enterprises, other non-profit-making (NGOs, social cooperatives) as well as profit-making units can submit bids for inclusion in the registry of certified schemes, from which beneficiaries can choose a provider.

Day care centres for the elderly. This alternative form of public support and protection is offered to the elderly with the aim of keeping them within their family environment. This service is provided to people aged over 65 years suffering from chronic or acute physical or mental disorders who depend on others for care, have economic problems and face social and family problems. Services include daily care and coverage of basic needs, psychological and emotional support, plus assured delivery of pharmaceutical care.

A number of public residential homes for the elderly operate under the supervision of the Ministry of Health and provide shelter, food, psychological support, counselling and medical care. There are also private profit-making homes for the elderly as well as a number of church organizations offering last-resort residential care for frail elderly people. In total, residential care homes serve an estimated 2% of the population aged over 65 years. The Greek Care Homes Association represents all legal residential care units for older people in Greece, estimated at around 120, with a total capacity of 10 000 beds. However, a considerable number of residential homes are not registered, functioning illegally, and are licensed as hotels, thus avoiding state inspections and the need to supply regular data.

A review of the scientific research published in the 2000s aimed at assessing community services for the elderly raised serious concerns about the adequacy of financing, the effectiveness and quality of services provided and equity of access. Furthermore residential care, particularly in the private sector, suffered from low-quality services, old buildings, lack of staff and lack of affordability (Economou, 2010). Although more recent evaluation efforts have not been undertaken, improvements since 2010 are unlikely given the limited resources available under austerity policies.

Gaps in public services and economic access barriers to private services are compensated for, to a certain degree, by NGOs. For example, the non-profit-making Athens Association of Alzheimer Disease and Related Disorders provides public information campaigns; easy access to neuropsychological assessment for early diagnosis and treatment; education and training programmes for health professionals, professional formal caregivers, volunteers and informal family carers; community-based and residential care centres; informal carer support groups; participation in research programmes; lobbying for improved public services and free drug treatment; and financial support benefits for patients and/or family carers. The budget is to a large extent covered by the state and the rest usually by donations or other volunteer contributions.

In March 2016, the National Dementia Strategy was approved by the Parliamentary Standing Committee of Social Affairs. It includes three basic actions: the creation of a national dementia registry, the development of a rating system to measure the impact of dementia on families and the establishment of day care centres for people with dementia, scheduled to operate in collaboration with municipalities throughout the country, by the end of 2016. However, at the time of writing, the strategy has not been fully implemented.

Existing services cover only a limited part of needs. The long-term care sector has developed slowly and in a fragmented way. There is no integrated supply of services to vulnerable groups of the population, particularly the elderly. There is no systematic needs assessment, nor assessment based on special needs regarding gender, age, health status, ethnicity and other relevant characteristics. Therefore, informal care within the family, provided by either informal or privately hired caregivers, plays a major role in meeting the needs of the population (Petmesidou et al., 2015).

5.9 Services for informal carers

Support for family carers in Greece still remains a low priority in the social policy agenda and measures to recognize the value of informal care, protect informal carers and provide them with access to support services are almost non-existent. There are no legal benefits for carers; they are viewed primarily as a resource and not considered to have their own needs for support. In addition, there is no extensive research or information on the dimensions of family care or the needs of carers. National data on family carers are not available, including the number, age, gender, income, hours and caring tasks, educational and employment status. However, a good picture of the prevailing situation concerning carers’ profiles and the support services available to them is provided in two national reports submitted under EUROFAMCARE (2003–2005; Triantafillou, Mestheneos & Prouskas, 2006) and INTERLINKS (2009–2011; Kagialaris, Mastroyiannakis & Triantafillou, 2010), two international projects aimed at supporting family carers for elderly people in Europe. The results of the EUROFAMCARE project, based on a sample of 1014 family carers, highlight that:

  • the overwhelming majority of carers were women (80.9%);
  • over three quarters (76.4%) of family carers were married or cohabitants;
  • 17.1% of the carers cared for their spouses, 55.4% cared for an elderly parent and 13.9% were daughters- or sons-in-law;
  • carers’ educational level was relatively low: 37.4% had a low level of education; 40.6% an intermediate level (finished high school) and 22.1% had a high level of education;
  • just over 50% of family carers shared the same household as the dependent person;
  • 47.2% of carers reported that they still worked for a mean of 40 hours in a job outside of caring duties (with a maximum of 140 hours a week); the mean number of care hours provided was 51 hours per week, indicating the high burden of care;
  • income was low, not exceeding €1100 per month for 55.1% of survey respondents, underlining the fact that carers often provide support with inadequate resources; and
  • the majority of family carers (80.9%) cared for just one dependent older person, 16.8% were caring for two older dependent persons and 2.3% were caring for three or more dependent older people.

The report also highlights that there were no pension and insurance rights or allowances for carers. It is common practice for family carers to use the incapacity pensions and disability allowances provided by SHI funds and welfare services to the individuals being cared for in order to help them in their caring activities. Sometimes, family carers use private residential homes for short-term respite care, even though these may be of questionable quality. In addition, few service providers were aware of the needs of family carers and what forms of support could best help them. Psychosocial services were available in community mental health centres, but they were not specifically geared to providing counselling to family carers and there are no data on their use by carers.

The INTERLINKS project confirmed these findings and also raised another important issue concerning the increased use of privately employed, lived-in migrant care workers (Kagialaris, Mastroyiannakis & Triantafillou, 2010). The majority are women, many of them working without work permits and social insurance and in many cases without residence permits or good knowledge of the Greek language. Their exact number is not known as no data are available.

The lack of formal support has resulted in the setting up of self-help groups and volunteer organizations for the support of family carers and the provision of counselling, information, guidance and training on disease and pharmaceutical management, and respite care services (Courtin, Jemiai & Mossialos, 2014). One issue of major concern is that informal carers in Greece have low educational levels and limited access to training programmes. Despite this lack of qualifications, they undertake a range of duties (from shopping to disease management) because of gaps in the official system of home care services. Under these circumstances, the quality of care and safety, of both patients and carers, are questionable.

The findings of the i-CARE EU project (Kaitelidou et al., 2016a) brought to light a variety of educational and support needs that would improve the competences of carers. Specifically, informal carers need information about diseases, training for drug administration and knowledge of hygiene and safety for both the people being cared for and themselves. Additionally, both formal and informal carers would benefit from using information and communication technologies and having access to psychological and emotional support to combat depression and burnout, and to carve out a balance between caring duties and their own personal well-being. Consequently, a specific recommendation for Greece is that the development of an open access, user-friendly e-learning programme for carers should be considered a high priority for both policy-makers and the scientific community.

5.10 Palliative care

Greece is among the group of countries characterized by the sparsity of their hospice/palliative care services, which are often home-based in nature and limited in relation to the size of the population (Lynch, Connor & Clark, 2013). There is limited availability of morphine, promotion of palliative care is patchy in scope and not well supported, and funding sources are often heavily dependent on donors. The underdevelopment of palliative care can be attributed to a number of barriers including the lack of awareness and recognition of palliative care, the limited availability and choice of opioid analgesics, limited palliative care education and training programmes, the lack of recognition of palliative care as a medical or nursing specialty, limited funding, and lack of coordination between state and voluntary services (Lynch et al., 2010).

Palliative services for patients are provided mainly on a voluntary basis by anaesthesiologists, oncologists, psychologists, nurses and other relevant health care personnel in pain centres located within anaesthesia departments and in oncology departments of public hospitals. They offer pain relief and counselling to patients suffering from long-term diseases, including cancer, HIV/AIDS and multiple sclerosis. Data from the Atlas for Palliative Care in Europe (Centeno et al., 2013) revealed that there were no official national palliative care units in 2013 in Greece, but 72% of the unofficial services provided were part of the pain centres of anaesthesia departments and a 24-hour service was offered by pain and palliative care specialists on a voluntary basis. In addition, there were 80 volunteer pain services, 57 hospital pain services, 15 home-based pain services, four mixed pain services, two pain services in a tertiary hospital and eight pain services in day care centres. Palliative care services for children are provided through six volunteer paediatric pain teams, two paediatric hospital pain teams, four paediatric home pain teams, two paediatric mixed pain teams, two paediatric pain units in tertiary hospitals, two paediatric pain services in day care centres and one paediatric inpatient pain service.

Beds specifically allocated to inpatients for palliative care do not exist officially. However, dated information from a European Association for Palliative Care study conducted in 2005 estimated that, on average, there were two or three beds available for palliative care within public hospital oncology departments and anaesthesia department pain centres.

Hospices are not well developed since it was only in 2003 (Law 3106/2003 on the reorganization of the national social care system) that the legislative framework for their establishment was set and in 2007 that a ministerial decree (DY8/B/oik.89126) determined the prerequisites for building and organizing hospices. In 2011, the Ministry of Health and Social Solidarity announced the restructuring of the public hospital sector, including a plan to transform certain small inefficient hospitals into hospices (Liaropoulos et al., 2012). However, at the time of writing (2017), the plan to establish such public hospices had not yet been implemented and the process was incomplete.

Gaps in the official government policy are partially filled by the voluntary sector and scientific non-profit-making organizations, including the Greek Society for Paediatric Palliative Care, the Hellenic Association for Pain Control and Palliative Care and the Hellenic Society of Palliative and Symptomatic Care of Cancer and Non Cancer Patients. Their objectives include raising awareness; providing training for health professionals in palliative care and palliative regimens for patients suffering from chronic diseases in advanced stages, such as cancer or HIV/AIDS; developing activities to improve the quality of patients’ lives through pain relief; and providing psychological support to the terminally ill, their relatives and carers. In addition, self-help groups have been established, along with charitable foundations that give donations to create and operate facilities for relatives. For example, the Jenny Karezi Foundation for Cancer Pain Relief and Palliative Care financially supports the operation of the Pain Relief and Palliative Care Unit at the Athens University Medical School. The unit is established in a separate building with a day care unit, an outpatient unit and a research room. It also has a seminar/education area for the organization of palliative care seminars for nurses and social workers within the municipality of Athens. Initiatives by the Church of Greece should also be mentioned, including the development of the Galilee Palliative Care Project in 2010 by the Holy Metropolitan Diocese of Mesogaia and Lavreotiki in Attica, which provides home care services, the creation of a centre for day care and occupational therapy and the establishment of a hospice unit.

5.11 Mental health care

Since the establishment of ESY in 1983, four milestones stand out in mental health care (Chondros & Stylianidis, 2016; Giannakopoulos & Anagnostopoulos, 2016). The first period from 1984 to 1990, in accordance with European Regulations 815/84 and 4130/88, saw the training of mental health professionals; the creation of a decentralized community network of preventive, specialized treatment and rehabilitation services; the deinstitutionalization of patients in psychiatric hospitals and a reduction in admissions to psychiatric hospitals. The second milestone revolved around the reform projects Leros I and II (1990–1994), which introduced interventions to improve conditions in the Leros Mental Hospital and discharge patients to placements in community hostels. The third milestone was the introduction of progressive legislation on the development and modernization of mental health services (Law 2716/1999). The legislation established sectoral mental health committees and created infrastructure in the community, including psychiatric departments in hospitals, mental health centres, child guidance centres, day care centres, home care services, vocational training workshops, mobile units, social cooperatives as a tool for increasing working opportunities for people with mental illness and crisis management units.

The fourth and most significant milestone for the deinstitutionalization of mental health services and the development of community-based services were the Psychargos I (1997–2001) and II (2001–2010) programmes. Priority was given to social inclusion, social cohesion and destigmatization. The main objective was the development of services within the community that would enable patients to be supported within their own family environment, maintaining their social activities through every possible means. Particular policies focused on prevention and rehabilitation, the restructuring and strengthening of primary health care, ambulatory care, deinstitutionalization and closure of psychiatric hospitals, psychosocial rehabilitation and housing services, continuity of care and harnessing voluntary assistance from the community for the promotion of mental health.

An ex-post evaluation of the Psychargos programme using qualitative methods reported a number of positive as well as negative elements of the reform (Loukidou et al., 2013a). The positive aspects were:

  • the reduction of hospital-based long-stay accommodation;
  • the vast increase in the number of new mental health services across the country, including day centres, community mental health centres, psychiatric units in general hospitals and children’s mental health centres;
  • positive changes in public attitudes towards mental illness and patients as well as in the attitudes of mental health staff towards person-centred care;
  • the empowerment of service users to express themselves and to defend their rights by participating in mental health organizations and institutions; and
  • increased opportunities for vocational training of service users through the establishment of social enterprises and paid work.

The negative aspects include:

  • the significant shortages of staff and services in several parts of the country, particularly in rural areas, resulting in inequities in the development of services between different areas and inadequate provision on the ground;
  • incomplete sectoral framework and the lack of coordination between mental health services and central government, local authorities, social services and other relevant public sector organizations;
  • absence of evaluation and monitoring of provided services, quality assurance and clinical governance systems;
  • deinstitutionalized patients resettled in community services representing only a small proportion of people suffering from mental ill health, with a larger number of people still living with their families, homeless, in poverty or ending up in private clinics where the quality standards are questionable;
  • gaps in specialist mental health services, such as those for children, adolescents, autistic spectrum disorders, intellectual disabilities, eating disorders and forensic psychiatric services;
  • lack of information about locally available services and poor information flow between different services;
  • lack of thoughtful planning and implementation;
  • only partially achieving the aim to introduce psychiatric services in general hospitals; and
  • lack of a population-based approach to the mental health system, without clear evidence for assessing the needs of local populations and no clear understanding at the local level of what components are necessary for a comprehensive system of care.

Furthermore, a quantitative evaluation of the achievement rate of the targets set in the Psychargos programme revealed its strengths and weaknesses (Loukidou et al., 2013b). Positive developments were the closure of five mental hospitals and exceeding the target number of sheltered apartments by 211%, Alzheimer’s centres by 180% and day centres by 95%. In contrast, negative developments were the limited capacity of the over 60 NGOs providing mostly residential and day care, and the fact that boarding houses achieved 89% of the target, sociovocational rehabilitation units reached 69% of the target, outreached teams achieved 68% of the target, general hospital psychiatric and child psychiatric units reached 55% of the target, guest houses achieved 52% of the target, community mental health centres reached 43% of the target, and social enterprises reached only 33% of the target. None of the projected drug and alcohol abuse centres was established.

In view of the findings of the external evaluation of Psychargos I and II, in November 2011 the Greek Government launched the Psychargos III programme to continue strengthening mental health care reforms until 2020 (Ministry of Health and Social Solidarity, 2011b). The new plan is based on three pillars:

  • actions for the further development of mental health structures in the community at the sectoral level (territorial sectors based on geographical and population characteristics) with allocation of available mental facilities to provide mental health services to a defined catchment area;
  • actions for the prevention and promotion of the mental health among the general population; and
  • actions that would organize the psychiatric care system, including sectoral allocation of services, monitoring, evaluation, research activities and training of staff.

A recent law on the administrative reform of mental health services passed in March 2017 provides for the establishment of a number of scientific and administrative committees, councils at both regional and sectoral levels and coordination bodies in order to achieve better coordination of mental health services, greater participation of citizens in mental health policy decision-making, and the protection of the rights of the users of mental health services.

Tabe5.5 gives an overview of the mental health workforce, availability of services and uptake for 2014.

Funding difficulties and staff shortages during the current financial situation and austerity measures raise serious concerns over the continuation of mental health policy reform and the risk that the positive improvement achieved so far may be halted or even reversed (Ploumpidis, 2015). In addition, the persistent recession in Greece has had negative socioeconomic consequences, which, in turn, have impinged on the mental health of the population. The growing mental health needs of the population in tandem with the limited available resources raise the key question of whether existing mental health services are capable of addressing the increasing demand for mental care (Economou et al., 2016c).

5.12 Dental care

Dental health care is provided by two structures. The first consists of publicly funded ESY services provided through the outpatient departments of public hospitals and PEDY units, including rural health centres and urban primary health care units. The second is the private sector, where providers are remunerated by direct OOP payments.

In theory, the EOPYY scheme for publicly provided dental services should have begun in January 2014. This scheme required EOPYY to define what dental services would be covered and their reimbursement rates, as well as entering into contracts with a range of dental services providers. Insured people were to be eligible to receive treatment and compensation for both preventive and clinical treatment, plus prosthetics, with the freedom to choose a dentist from the network of contracted providers. However, because of budgetary constraints and cuts in public health expenditure, this scheme has yet to start (Damaskinos et al., 2016). This represents a deterioration of dental health insured provision as, prior to the establishment of the EOPYY, those insured under individual health funds had access to salaried and/or contracted dentists, albeit for a limited range of services (Damaskinos & Economou, 2012).

In practice, EOPYY members who are unable to pay out of pocket for private dental services can visit ESY units. Dentists working in public hospitals provide mainly secondary dental treatment for patients with medically complex conditions. Dentists working in health centres provide dental treatment for children up to 18 years of age, and emergency treatment for all ages. Data show a decreased number of dentists working in the public sector, because of the economic crisis, the merging of hospitals and the large-scale retirement of dental professionals in hospitals and health centres (Table5.6). Therefore, in addition to the limited range of dental services provided, there is also understaffing of public hospitals and health centres.

In the private sector patients pay out of pocket for services. The large-scale use of such services means that, in effect, this acts as a substitute for the gaps in public insurance coverage for dental treatment and dissatisfaction with the quality of public services. It is indicative that according to latest available data in 2014 only 0.25% of public expenditure for ambulatory care was devoted to dental care (€2.23 million out of €907.28 million). In contrast, household OOP payments for dental care (€802.07 million) absorbed 54% of OOP payments for ambulatory care (€1483.89 million) (Hellenic Statistical Authority, 2016b). Consequently, it is not surprising that the vast majority of the registered dentists in Greece practise privately (Table5.6).

In terms of dental health policy, a five-year Plan of Action for Oral Health 2008–2012 was published in 2008. Its main goal was to establish a policy targeted at oral disease prevention, oral health promotion, effective treatment and the improvement of dental services (both in efficiency and quality) in the private and public sectors. It also aimed to implement effective policies for the promotion of oral health in children, in adults at work and in older people, using special training programmes for disabled people, refugees, the homeless and Roma. However, the Action Plan coincided with the economic crisis and was never implemented due to lack of funding; in fact, dental care was one of the areas to have its budget reduced (Damaskinos & Economou, 2012; Damaskinos et al., 2016). By the end of 2017 no new plan for oral health had been published.

Newly introduced Supervised Drug Use Areas aim to promote and protect the health of active drug users through a range of services. These include, specially designed areas for injecting, suitable equipment for the safe use of narcotics; information on how to prevent the spread of communicable diseases; emergency care in the case of overdose; outreach programmes;  advise on the safe use of drugs; and access to a range of counseling, rehabilitative, medical and social services. This new initiative will be operated by Greece's Organization Against Drugs (OKANA), the Dependent Users Treatment and Rehabilitation Center (KETHEA), and the two psychiatric hospitals in Athens and Thessaloniki.

Legislation
Ministerial Decision No D2a/oik.40101, Determination of the conditions and the prerequisites for the establishment and functioning of Supervised Drug Use Areas.

New legislation in April 2019 establishes assisted living shelters for people with disabilities over the age of 18. The shelters aim to support residents to participate in the daily life of their communities and to manage their personal lives with independence and autonomy. In line with the deinstitutionalization of care, these new residential arrangements recognize the abilities of disabled adults and their right to live with equality and dignity in the community. They also aim to improve quality of life, support participation in educational programmes, and foster social rehabilitation and integration.

Assisted living shelters provide a healthy, comfortable and safe place to live; healthy and balanced meals; entertainment and participation in social events; access to health care services as well as to life-long learning programmes, training and employment; and help with developing the personal skills and capacities needed to achieve autonomy and social integration.

Legislation
Joint Ministerial Decision No D12/GPoik.13107/283, Prerequisites for the establishment and functioning of Assisted Living Shelters for people with disabilities.