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15 June 2022 | Policy Analysis
Progress on the primary care reform -
30 November 2021 | Policy Analysis
Greece’s Resilience and Recovery Plan emphasizes investment in the health sector
6.2. Future developments
It has been well documented that reforms to the Greek health care system should focus on certain areas of high priority, including restructuring of primary health care, pooling of financial resources, introducing new managerial and administrative methods, adopting cost–effectiveness assessments and monitoring mechanisms and developing policies for better allocation of resources (Mossialos, Allin & Davaki 2005; Economou & Giorno, 2009). Most of these areas are expected to see further strengthening in the near future, given the ongoing changes (section 6.1).
Primary care is currently one of the major areas of focus. A plan for further development of primary care was first approved by the Government Council for Social Policy in 2015 and suggested delivering primary care through two-tiered local primary health care networks operating in small communities in an integrated way (Benos et al., 2015). In August 2017, the Government passed a new law for the reform of primary health care (Law 4486/2017). Under the proposals, primary care should be free of charge, with equitable access, and it should operate on a 12-hours-a-day basis in areas where there is adequate hospital coverage and on a 24-hours-a-day basis where such hospital services are lacking.
Primary health care services will be provided at the first level by local health units and by health professionals who have private practices and contract with EOPYY. At the second level, primary health care services will be provided by health centres. In addition, central diagnostic laboratories will be established in each YPE providing laboratory tests and imaging diagnostic services to the population. Specialized care centres should also be established in each YPE to provide specialized care, special education, physiotherapy and rehabilitation services.
Local health units will operate as family medicine units, providing to their registered patients services including health education and promotion, prevention, assessment and risk management for communicable and noncommunicable diseases, systematic monitoring and screening, addressing acute health problems and referring to health centres or hospitals, monitoring and managing chronic diseases, home care, counselling and support to individuals and families, detection of mental illnesses, and collection and utilization of epidemiological surveillance data. They will be staffed by health teams consisting of GPs, internal medicine specialists, paediatricians, nurses, community nurses, social workers and administrative staff.
As the second tier of the new system, the purpose of health centres is to provide specialized ambulatory care for all patients who are referred by the local health units: emergency services; laboratory tests and imaging diagnostic services; dental care for adults and children; maternal and child care; care for adolescents; specialized prevention; physiotherapy, ergotherapy and logotherapy; occupational medicine; social medicine; and public health. Health centres will be staffed by medical and other personnel:
- medical specialists in general/internal medicine, paediatrics, dentistry, occupational medicine, social medicine and public health, radiodiagnostics, cardiology, gynaecology, general surgery, orthopaedics, ophthalmology, pulmonology, urology, otolaryngology, dermatology, neurology, gastroenterology, endocrinology and rheumatology;
- scientific and other health personnel in nursing and midwifery; public and community health (health visitors/community nurses); physiotherapy, ergotherapy and logotherapy; psychology; social work; radiology and medical device operators; medical laboratory technicians; and nursing assistants; and
- administrative staff.
Patient registration with a local health unit, gatekeeping mechanisms and a referral system will form part of the new delivery framework. An e-health record is also expected to be developed. Systematic monitoring to ensure quality and improve outcomes is expected to be achieved through the introduction of clinical protocols, clinical audit and electronic clinical information systems.
Staffing of units will be determined on the basis of the population: for example, one GP or internal medicine specialist per 2000–2500 adults, one paediatrician per 1000–1500 children, one dentist per 10 000 inhabitants and two specialists in radiodiagnostics, one pathologist and one cardiologist per 25 000–30 000 inhabitants. Under the primary care reform legislation, the aim is to establish 239 local health units throughout the country. To staff these facilities, a recruitment call for 3000 vacancies was published in August 2017. However, to date, only half of the physicians invited (600 out of 1200) have applied. Such shortages risk delaying the strengthening of primary care, particularly in remote areas. The medical associations attribute physicians’ unwillingness to staff local health units to the working regulations in place (as staff are required to work exclusively within their unit and not participate in private practice), while the Ministry of Health links the situation with brain drain and the emigration of doctors.
In May 2022, the enactment of Law 4931/2022 (“Doctor for all, equal and quality access to the services of EOPYY and Primary Health Care and other emergency provisions”) replaced the primary healthcare system introduced in 2017 with a model of public-private partnerships (PPPs).
All adults are required to register with a personal doctor who will guide them through the National Health System (ESY) and serve as a gateway to health services. The new law stipulates that the personal physician is selected by the citizen, with the possibility to transfer once a year. The choice can be made either with doctors who currently serve in public primary health care facilities, or with private doctors contracted with the National Organization for the Provision of Health Services (EOPYY). Starting on 1 October 2022, insured people who have not signed up for the new service will have to pay 10% more for prescribed medicines, diagnostic tests and procedures, for treatment at a private medical clinic contracted with EOPYY and for all other services provided by EOPYY. Those costs will go up another 10% on 1 January 2023 if the insured person still fails to comply with the new rules. However, the number of doctors in public units is not sufficient to cover the needs of the population, and private doctors, so far, appear less interested and unwilling to sign contracts with EOPYY.
Besides the administrative and organizational restructuring, and as part of the country’s National Resilience and Recovery Plan, the reform of the primary healthcare system also aims to:
- upgrade the building infrastructures and facilities of the health centers and other primary health care service points through the establishment of Public Private Partnerships;
- upgrade the medical equipment of health centers;
- extend the number of academic curricula to cover 75% of universities and modules in family medicine along with including the module of family medicine as part of the basic curriculum;
- retrain health professionals in modern practices by designing and delivering a learning and development framework as well as a training curriculum for the skills upgrading of medical staff harmonized with the latest trends in digital dimension;
- develop an integrated healthcare system by establishing an effective framework for chronic diseases management and chronic disease management units within the primary health care units; and
- design a new homogeneous compensation system for health professionals that will allow to bring more family doctors into the primary health system.
Authors
As part of its EUR 30.5 billion National Recovery and Resilience Plan, Greece has included a set of investments to address the long-term challenges of the health care system that were exacerbated by the pandemic. A total of EUR 1.5 billion is earmarked to improve the resilience, accessibility and sustainability of health care.
The spending will include:
- organisational reforms;
- infrastructure investments in primary health care (EUR 189 million), supported by measures to increase the stock of GPs;
- renovation and upgrading of public hospitals (EUR 317 million);
- the digital transformation of health services (EUR 278 million);
- funding for the national public health prevention strategy (EUR 254 million), which also encompasses national screening programmes; and
- improving palliative care for cancer patients; and reform in the fields of mental health and addictions (EUR 54.5 million).
More specifically, organizational reforms aim to rationalize reimbursement of hospital medical procedures, the establishment of quality procedures and performance measurements related to patient care, health needs and care delivery, and the creation of a national health map that records the demand and supply of health services. Reform of the primary health care system includes the upgrade of the infrastructure and medical equipment of health centers and the reorganization of their structure by retraining staff to act effectively as first-line care. It also emphasizes the care of chronic diseases and palliative care. Implementation of the National Public Health Prevention Program aims to upgrade the quality of life of the population, to reduce the risk factors for public health and indirectly to relieve pressure on the hospital system.
Furthermore, the Plan provides for a number of key investments in selected areas of the healthcare system. These are: the digital transformation of health focused on the establishment of a national digital health record, the development of a national digital infrastructure to support oncology patients, the expansion of the National Telemedicine Network (EDIT), the improvement of hospital digital readiness and the digital transformation of the National Organization for the Provision of Health Services (EOPYY); the establishment of home health care and hospital at home services with the implementation of telemedicine applications as monitoring tools for patient support; the design and implementation of a national registry for patients treated through home care; the determination of standardized therapeutic protocols as well as quality and safety standards, and the establishment of eight references sites in hospitals that will be able to support the above initiatives; the public hospital building renovation and infrastructure upgrade; the establishment of a radiotherapy center at the “Sotiria” thoracic diseases hospital of Athens; and the construction of a building dedicated to cellular and gene therapies and hematology clinic laboratories within the general hospital of Thessaloniki “Papanikolaou”.
In
the fields of mental health and addictions, the Plan provides for a
number of activities concerning mental health services for patients with
dementia and Alzheimer’s disease, for patients with autism, for
patients in the age group of children, adolescents and young adults, the
development of online applications and digitization of mental health
services and actions in support of dependent individuals who use
addictive substances.