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The following OECD assessment and recommendations summarise chapter 3 of the Economic Survey of Greece published on 31 July 2009.
Public health care services need improvement, especially in the primary care sector
While Greek health outcomes compare favourably with the OECD average, the state of the public health care system sparks dissatisfaction amongst the population. This reflects inter alia the inability of public care to meet people’s expectations, especially as regards the quality of primary health care services. Households are also burdened by substantial private medical expenses, including high informal payments, raising questions about equitable access to some services and the efficiency of the system. This is due to distortions in pricing of services, and a limited supply of generalists and nurses in contrast to an oversupply of specialists. Enhancing the quality of public primary health care services is rightly a priority for the authorities. Draft legislation is underway to develop a system of referring physicians, individual health care budgets by patient, as well as medical protocols to harmonise and rationalise medical practices. These reforms are welcome. A system of referring physicians would help achieve a better balance between preventive and curative medicine, and better monitoring and co–ordination of health care, especially in respect of chronic illnesses, which will rise as the population ages. More nurses and general practitioners are also needed. Changes in the structure of remuneration of practitioners would help reduce the currently large informal payments. Introduction of a hybrid system combining capitation payments and payments by the act for outpatient doctors working for health insurance funds could stimulate competition and improve the supply of health care. Another option would be to ban dual practice, whereby some doctors work half–time for the funds, which can encourage them to minimise their efforts in the public sector and to use their positions to expand their private practice. Salaries between hospital doctors could be differentiated to attract more physicians to specialities for which demand is high. Moreover, it is vital to strengthen controls and sanctions against informal payments.
Human resources in the health care sector
1. 2006 or latest available year.
2. Per cent of total practising GPs and practising specialists.
Source: OECD Health Data 2008.
Major overhaul of the health care system would improve service quality
The health system is also highly fragmented, which increases administrative costs and reduces quality of care. Resolving these problems now is important in view of the expected rise in demand for care in the coming decades and the need to contain public spending. Governance and efficiency can be improved by reducing the fragmentation of the system between the National Health System and the multiple health insurance funds. These health funds should be separated from pension administration, as planned by the government, and all health–related activities should be concentrated in one ministry. Merging the funds would also bolster the bargaining power of public insurers and trim administrative costs; however, this should proceed in a carefully designed way, to avoid increased red tape and a lower quality of services. The recent reform to centralise and manage public hospital procurement by a specialised committee is a step in the right direction. Centralised management of all public funding earmarked for health care would enhance resource allocation, which currently favours hospital care over primary care and prevention. Separating the function of medical insurance from that of care provision, and encouraging competition among health–care providers could also improve cost efficiency. Resource allocation should be based more on economic assessments and give precedence to cost–effective medical practices. Doing so would require filling the serious gaps in the statistical systems; the move to double–entry bookkeeping in NHS hospitals at the end of 2008 is welcome in this regard.
Hospital management should be modernised and better control exerted over pharmaceutical expenses
The current method of control over public hospital expenses results in excessive and ineffective micromanagement by the Ministry of Health. Moreover, hospitals have taken the habit of accumulating large arrears, which have been paid by the government without introducing effective cost controls. Also since 1990, pharmaceutical spending has been growing faster than in most other OECD countries, which reflects lack of proper incentives to contain costs. Enhancing the effectiveness of hospitals will entail expanding their management autonomy, completing the move to international accounting standards for the few hospitals that have not already done so, appointing qualified managers and revising the funding system. The system should be based on comprehensive, forward–looking and binding budgets with inputs derived from cost assessments by categories of pathologies rather than length of hospital stays. Spending on drugs could be contained by increasing patients’ formal contributions to costs, encouraging the use of generic products and reforming the compensation system for pharmacists. Their compensation should stem in part from services rendered to customers based on flat–rates rather than turnover, as for example, in Switzerland. Restoring the positive list of reimbursed drugs with no exceptions should also be considered. The recently launched system for monitoring prescriptions for drugs will make an important contribution to controlling pharmaceutical expenditures. While the effectiveness of each of these measures is potentially limited, a programme encompassing a number of different actions would certainly prove effective.
How to obtain this publication
The complete edition of the Economic Survey of Greece is available from:
The Policy Brief (pdf format) can be downloaded in English. It contains the OECD assessment and recommendations.
For further information please contact the Greece Desk at the OECD Economics Department at firstname.lastname@example.org.
The OECD Secretariat's report was prepared by Claude Giorno and Vivian Koutsogeorgopoulou under the supervision of Piritta Sorsa. Research assistance was provided by Joseph Chien.