5. Provision of services
- 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).
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.
Ministerial Decision No D2a/oik.40101, Determination of the conditions and the prerequisites for the establishment and functioning of Supervised Drug Use Areas.