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13 January 2025 | Policy Analysis
The General Health System of Cyprus – a five-year review
7.4. Health care quality
The scarcity of data does not allow any detailed and comprehensive assessment of the quality and safety of services or the overall effectiveness of the health care system. The performance of specific sectors, such as primary and hospital care, cannot be assessed, as data on quality are not systematically collected either by the HIO or by the SHSO. The limited data available concern only HAIs and antimicrobial resistance, where Cyprus lags in both, compared to other European countries. According to these data, 8.2% of patients were diagnosed with at least one HAI in acute care hospitals in 2018, which is among the highest rates in EU/EEA countries, where the average share of patients with at least one HAI was 5.5% (Suetens et al., 2018). An earlier similar study, carried out by the Medical School of the University of Crete in 2006, found that the number of patients with such infections was 6.1%, with the highest prevalence (21.7%) in ICUs (Medical School of the University of Crete, 2009). From these two studies, it appears that the situation has worsened over time. Antimicrobial resistance is also a major public health threat in Cyprus, despite a national strategy against antimicrobial resistance being in place since 2012 (Ministry of Health, 2012). Meanwhile, in 2020 and 2021, Cyprus had the first and second highest consumption of antimicrobials out of 29 European countries, and was one of only four countries to report Escherichia coli fluoroquinolone resistance over 50% (Mitsoura et al., 2024). Similarly, in a study on HAIs and antimicrobial use in European LTC facilities, the prevalence of antimicrobial use in Cyprus was 9.3% in 2017, a rate almost double the EU/EEA median (4.9%) (Ricchizzi et al., 2018).
The five-year survival rate of cancer patients after diagnosis is also an important indicator for evaluating the quality and effectiveness of cancer screening services and health care. Almost a quarter of all deaths in Cyprus are from cancer, and lung cancer is the most frequent cause of cancer deaths. This is one reason why high levels of tobacco consumption remains a major public health concern. The only data available on five-year survival rates for the most common cancers have been published in 2018, by the CONCORD programme (Allemani et al., 2018). This includes individual records for 37.5 million patients diagnosed with cancer during the 15-year period 2000–2014. The CONCORD programme enables timely comparisons of the overall effectiveness of health systems in providing care for 18 different cancers that collectively represent 75% of all cancers diagnosed worldwide every year. Based on these data, Cyprus compares well with other European countries regarding the five-year survival rates for the most common cancers. Specifically, Fig7.3 shows that more than 70% of adults (15–99 years) who were diagnosed with colon or breast cancer (women) during the period 2010–2014 and children (0–14 years) with acute lymphoblastic leukaemia survived more than five years after diagnosis, which is higher than the EU averages.
Fig7.3
There are no data either on avoidable hospital admissions rates for specific diseases such as asthma, chronic obstructive pulmonary disease, congestive heart failure, hypertension, or diabetes complications, nor on in-hospital mortality rates for admissions following acute myocardial infarction, haemorrhagic stroke and ischaemic stroke, that would allow comparisons with other European countries regarding the quality and effectiveness of primary care and hospital care, respectively. One reason for the lack of data is that there is neither an accreditation system nor a quality monitoring system of the public or the private health sectors. Consequently, improving data collection and sharing is a key focus for the MoH and the HIO.
It is worth adding that in the last year the HIO took some measures, such as the integration of quality and performance indicators in the remuneration of personal doctors, and the development and introduction of medical and therapeutic protocols and guidelines in collaboration with the Medical School of the University of Cyprus, the Cyprus Medical Association and the British National Institute for Health and Care Excellence. Better measurement can be achieved through implementation of quality assurance programmes, which are currently lacking. With the introduction and operation of the GeSY, more data on quality will be recorded by the IT system, which will be used to assess and improve the quality of services. After discussions between the HIO and the contracted hospitals, both public and private, it was agreed to change the compensation method for services provided, with the integration of quality criteria, such as accreditation of the hospitals, patient satisfaction, etc. This new compensation system came into effect in September 2023. The first results showed that the degree of patient satisfaction averaged 90% (HIO, 2023a) and in March 2023 an agreement was signed between the SHSO and a Canadian accreditation body for the accreditation of all public hospitals.
In 2024, Cyprus’s General Health System (GHS), Γενικό Σύστημα Υγείας (ΓεΣΥ), marked its fifth year of operation, providing universal healthcare coverage to all citizens based on residency. The system has achieved significant milestones, including expanding services, improving quality, and maintaining financial sustainability. An actuarial study by the International Labour Organization (ILO) projects that the GHS will remain financially viable until 2031, with reserves totalling approximately EUR 590 million as of 2023.
The GHS has made substantial strides in healthcare service accessibility, with over 90% of the population registered as beneficiaries. The system has expanded its service offerings, improved care quality through performance-based remuneration, and implemented advanced IT solutions for better patient care. However, challenges remain, notably in areas such as waiting times, coverage of certain treatments, and the need for more specialized care. Below, we outline key achievements, ongoing improvements, and strategic recommendations to further enhance the system’s effectiveness.
Achievements and key statistics (June 2023–June 2024)
- Registered beneficiaries: 969 722 (over 90% of the population)
- Utilization of services:
- 807 331 visits to Personal Doctors
- 637 536 visits to Special Doctors
- 319 259 visits to Radiology/Diagnostic Centers
- 501 035 laboratory examinations
- 318 990 dental visits
- 698 650 prescriptions filled
- 83 166 surgeries performed
- New services and providers added: Four new hospitals, two accident and emergency departments, two daycare centres, homecare, and palliative care providers.
- Expansion of coverage: New treatments, speech therapy, clinical dietetics, podiatry, and dialysis centres are being incorporated into the system.
Key actions for quality improvement
The Health Insurance Organisation (HIO), the body responsible for managing the GHS Fund, has undertaken a series of actions to enhance service quality and sustainability, including:
- Performance-based remuneration: Health service providers are now remunerated based on quality criteria and performance indicators.
- Clinical guidelines implementation: Collaboration with the Pancyprian Medical Association and NICE to ensure the adoption of evidence-based practices.
- Chronic patient registries: Specific patient categories, such as those with cancer, diabetes, and thalassemia, have direct access to GHS services.
- Referral categorization: The introduction of routine and emergency referral systems aims to reduce waiting times for specialist consultations.
- IT system upgrades: Beneficiaries now receive notifications about preventive care and follow-up visits via SMS, improving health management and patient engagement.
Research conducted in April 2024 found a high satisfaction rate among beneficiaries, with 92% of participants indicating an improvement in the quality of services since the GHS’s implementation. Key benefits highlighted by beneficiaries included reduced access costs (62%), increased choice of providers (32%), improved service quality (21%), and reduced waiting times (19%).
Challenges and areas for improvement
Despite its successes, GHS faces challenges that need to be addressed to enhance its sustainability and quality further:
- Waiting times: 32% of beneficiaries reported waiting times for doctor visits or surgery as the most significant weakness of the system.
- Coverage gaps: 24% highlighted the lack of coverage for specific tests and treatments, and 23% pointed to the need for referrals from personal doctors to special doctors.
- Specialist shortages: 11% of beneficiaries expressed dissatisfaction with the availability of specialists in certain medical fields.
Recommendations for the future
To build on the GHS’s successes and address its challenges, the following strategic actions are recommended:
- Enhance provider accountability and performance monitoring:
- Extend qualitative criteria and performance indicators (KPIs) linked to provider compensation.
- Reinforce on-the-spot checks to monitor and ensure adherence to quality standards.
- Invest in advanced data analytics and AI:
- Upgrade systems for data analytics and implement artificial intelligence tools to inform decision-making and policy development, ensuring the efficient allocation of resources and service optimization.
- Implement clinical decision support systems:
- Integrate clinical decision support software to improve referral processes, particularly for radiological examinations, following European Radiological Society guidelines.
- Expand rehabilitation and specialized services:
- Expand access to rehabilitation services, particularly for respiratory diseases, and ensure the continued development of specialized care in underserved areas.
- Address gaps in coverage:
- Work toward filling existing gaps in coverage for specific tests, treatments, and pharmaceutical needs, ensuring comprehensive care for all beneficiaries.
- Reduce waiting times:
- Continue the categorization of referrals into routine and emergency categories and implement measures to improve efficiency in specialist consultations and surgeries.
- Public awareness and education:
- Launch large-scale informational campaigns to educate beneficiaries and providers on responsible use of the GHS services, their rights and obligations, and preventive healthcare measures.
References
ILO 2024, CYPRUS Second Report to the Health Insurance Organization Actuarial valuation of the General Healthcare System as of 31 December 2021, covering the period 2022–2031, https://www.gesy.org.cy/el-gr/pressrelease/ilo-tf-cyprus-r.26-web.pdf.
Health Insurance Organisation Press Release 30 May 2024, Δελτίο Τύπου «5 Χρόνια ΓεΣΥ» Με στόχο τον συνεχή εμπλουτισμό των παρεχόμενων υπηρεσιών και την αναβάθμιση της ποιότητας (in Greek), https://www.gesy.org.cy/el-gr/announcementdef/20240601-press-release-5-years-gesy-0.pdf.
Republic of Cyprus Press Information Office, Press Conference on the 5 years of GHS (ΓεΣΥ) (in Greek), https://www.pio.gov.cy/assets/pdf/newsroom/2024/05/30052024_GESYPRESENTATION.pdf.
Health Insurance Organisation, Strategic Plan 2024–2026 (in Greek), https://www.gesy.org.cy/el-gr/annualreport/hio-strategic-planning-2024-2026.pdf.