Context and impetus for the reform
The operation of afternoon surgeries in public hospitals was launched on 5 March 2024 by the Joint Ministerial Decision signed by the Health Minister and the Deputy Minister of Economy and Finance.
According to the Ministry of Health, the new measure aims to reduce the long waiting lists for surgeries in public hospitals, with some patients waiting up to three years for an operation. Based on the Ministry’s estimations, about 102 634 patients are waiting for a surgery across the country, out of which 43% of cases wait less than 4 months, 31% wait from 4 to 12 months and the remaining 26% wait for more than 12 months. The Ministry of Health is also in favour of the measure arguing that with this policy, employees within the National Health System, namely doctors and nurses, are given an opportunity to increase their incomes in a legal way.
Content of the reform
Afternoon surgeries will be paid for by patients, who will be able to choose which doctor will operate on them, thus bypassing the existing waiting list for free operations that are carried out during the regular operating hours of public hospitals.
These surgeries will be carried out after the regular operating hours of the National Health System hospitals and patients, irrespective of their social insurance status, will have to pay a fee ranging from EUR 300 to 2000, based on the complexity of the operation. The price list is as follows:
- very minor operation: EUR 300
- minor operation: EUR 500
- medium operation: EUR 900
- major surgery: EUR 1200
- heavy surgery: EUR 1600
- extremely heavy surgery: EUR 2000
For example, for a cataract operation, the patient will have to pay EUR 300 to EUR 500; for an inguinal hernia operation, which is considered a minor surgery, the cost will reach EUR 500; for cholecystectomy, prices start at EUR 500 and can reach up to EUR 1200; for knee arthroplasty, the price can reach up to EUR 1600.
However, the Minister of Health declared that 50 000 afternoon surgeries are to be free of charge as they will be funded by the EU Recovery and Resilience Fund under Greece’s National Recovery and Resilience Plan 2021–2026. These surgeries concern patients who remain on the surgery list for a long time and their prioritization will be done in chronological order (from oldest to newest), as reflected in the Unified List of Surgeries (See Country Update: The newly launched Unified Digital List of Surgeries aims to reduce hospital waiting times, 6 February 2024).
Policy implications
Four questions have been raised about the new policy.
The first is the feasibility of implementing the measure. Not all hospitals will be able to implement the afternoon surgeries. Currently, three big hospitals in Athens and one in Thessaloniki are assigned the task of implementing afternoon surgery. This is because about 40% of operating rooms in public hospitals are closed due to personnel shortages. The Panhellenic Federation of Public Hospital Employees, the Federation of Greek Hospital Doctors’ Associations and the Panhellenic Medical Association have raised strong objections to the afternoon surgeries due to staff shortages, especially in anesthesiologists, and have pointed to shortages in nursing personnel as well as to bed capacity. Additionally, the gruelling work schedules of doctors and nurses far exceed the maximum weekly limits on working hours, calling into question the feasibility of the additional burden of evening work beyond morning and on-call work. A consequence may be that doctors may concentrate on those patients who use the private option at the expense of patients in the public system, resulting in a reduction in surgeries conducted during the regular operating hours and an increase in surgeries conducted in the afternoon.
The second issue is related to patients’ participation in the cost of the services provided and the economic burden posed on them, possibly resulting in catastrophic health expenditure. This is a basic reason why, according to the results of a recent poll, 59.5% of the respondents were against this practice. From the perspective of patients paying out of pocket for afternoon surgery, the new measure may have more adverse effects than those expected by the Ministry of Health. Under the current policy, instead of hiring additional personnel, the health system imposes an extra charge on patients who already pay social security contributions and yet do not receive the services they need. Moreover, critics point out that the attempt to operate the for-payment afternoon surgeries of public hospitals as market competitors of private hospitals with price lists that burden patients violates the principle of equity in access to health care within the National Health System.
A third criticism is that with this measure the Ministry of Health is trying to avoid the necessary increases in the salaries of public hospital personnel by legitimizing the practice of informal payments and formalizing them into extra payments routed to doctors and other healthcare staff engaged in the afternoon surgeries. However, critics argue that the new arrangements will not eradicate informal payments: rather, existing shortages in health resources in the public hospital system will also put limitations on afternoon surgeries, leading to the risk that patients will have to resort to additional (informal) payments on top of the formal fee to gain a slot and have the procedure done privately in the public system.