Debt crisis strains Greece's ailing health system

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The Lancet, Volume 378, Issue 9788, Pages 303 - 304, 23 July 2011

Eva Karamanoli

The financial turmoil in Greece is putting pressure on the country's creaking health system as more people turn to public rather than private hospitals for care. Eva Karamanoli reports from Athens.

It is a few minutes after midnight. In the emergency room of a major national hospital in Athens, the corridors look like a conflict zone. People suffering in pain lie on camp beds while waiting in the endless queue of patients who need major or minor medical help. “The doctors and the nurses are very kind and helpful but I think I will be waiting here till morning”, says a 46-year-old ago with chest pain.

She is right. Half the patients will wait until dawn to be examined by a doctor. Those who will need to be hospitalised will probably lie in camp beds in the hospital's corridor until noon, and only one or two of them who need urgent medical care will be placed in a bed in one of the hospital's units—not necessarily the appropriate one as it might already be overcrowded.

The doors open and paramedics bring in a 25-year-old man who has just been involved in a car accident. There is blood everywhere. Two doctors rush to his aid. “Give me a pair of gloves”, orders one to the other. “Give me 5 minutes. I'll have to go to the surgery department to get some. We're out of stock”, is the reply.

The situation described above is typical of emergency rooms in Greek hospitals over the past few years. The financial crisis has made things considerably worse. The reasons are simple. Every day, more and more people choose to be treated in national hospitals rather than private ones, so the faults of an old and declining national health system are more easily exposed.

Additionally, most of the 1.5 million immigrants that reside in Greece and visit the national hospitals to be treated have no social or medical insurance but they do get medical help. “We took the oath of Hippocrates”, I hear a doctor say, and I think that is probably one of the key things that keeps the national health system going: the loving honour. But for how long is anybody's guess.

“The financial crisis has influenced the morale of doctors, nurses, and all other medical staff. In my opinion, this is the most serious consequence. In addition, the general financial predicament the country is facing has a negative impact in hospital finances”, says Grigoris Paspatis, head of the gastroenterology department at Venizeleion Hospital on the island of Crete and president of the Heraklion Medical Association. “Every day, we face practical problems such as lack of stitches, gauzes, IVs as well as basic and standard essential medical supplies, including broken equipment that can't be fixed or kept operational, as the hospital owes money to its suppliers.”

The problem seems to be greater in the hospitals of Athens because of the city's overpopulation and crowding. In many cases hospitals trade essentials between them, and due to equipment being out-of-order, doctors often advise patients to visit other hospitals to have their medical tests done.

According to the latest findings of the National Statistic Force, Greece spends €25 billion each year on medical services, coming sixth worldwide in terms of spending on health. National hospitals owe about €6.5 billion to various medical suppliers for their products and services, of which €1.2 billion is owed to drug companies. As far as the national health insurance services are concerned, they owe €4.5 billion, of which about 1 billion is owed to pharmacists. “A pharmaceutical supplier must wait for at least 6 months in order to get paid from a national health insurance for medicine prescribed“, says Theodore Abatzoglou, president of the Hellenic Pharmaceutical Association.

In a time when Greece needs to cut down spending on every public sector, including the health sector, spending continues to rise. It is estimated that 7% of the national expenditure on health is on drugs alone. This estimate does not take into account the fact that drug companies sell their products directly to hospitals to maximise their profits.

“In order to cut down on medical costs, the government needs to re-examine the operational costs of hospitals. One way is to put in full operation the in-hospital electronic drug prescription system in order to reduce expenses”, says Abatzoglou.

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Greek doctors protest in the centre of Athens against proposed cuts to health care

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Overcrowding in Greece's hospitals has meant long waiting times for many patients

The ministries of finance and health owe money to the hospitals, national health insurance services owe money to the pharmacists and the hospitals, and they, in turn, owe money to the suppliers and, thus, an endless cycle is perpetuated—a cycle that has to be broken for the health system to operate effectively and efficiently once again.

According to official data from the Ministry of Health, the total expenses for health (hospitals, national health insurance services, etc) exceeded €7 billion, of which €3 billion was the cost for national hospital supplies, in 2009. In 2010, the cost of hospital supplies was reduced to €2.6 billion. With a series of austerity measures the Ministry of Health intends to earn a further €350 million in cut backs in 2011.

Over the next few months, the Ministry of Health plans to implement a reduction in drug prescriptions. A list of medicines that are approved and covered by the national health system will be given to hospitals and drug suppliers. If a drug which is not included in the list needs to be prescribed, the patient will have to pay for it themselves. This move is being made to cut down on the expensive drugs that doctors tend to prescribe while there are cheaper and equally effective alternatives.

George Papatheodoridis, associate professor of medicine at Athens University who also practises at Hippokration Hospital, Athens, explains that “this is one of the many efforts that is being done in order to cut down on costs, but sometimes the solutions are not in the patients' best interest”. Lots of drugs, not vital but widely used, such as acne creams, cough syrups, and medicine for vascular diseases will be excluded and so will all drugs that exceed the average cost of their category. “This is not safe because most of these drugs are widely used all over Europe effectively. Besides, one must have in mind that each drug has its own side-effects, dosage, time of treatment, etc”, says Papatheodoridis.

In Evangelismos Hospital, the biggest hospital in Greece, located in the centre of Athens, drugs are already electronically prescribed. “Soon Evangelismos will be the first e-hospital in Greece. Everything will be recorded digitally and will thus be easily verified”, says Michael Theodorou, the hospital's manager.

According to Theodorou, the greatest part of the institution's expenses is allocated to medical supplies and equipment maintenance and repairs. “We manage to cover our expenses and pay our suppliers within 90 days maximum, so the lack of supplies is due to delayed orders.” As Theodorou points out “the financial crisis may be a chance for the national health system—and Greece in general—to reboot and operate effectively again. As far as Evangelismos Hospital is concerned, the key is for the staff working there to adapt to a culture of sensible consumption. “If something is needed and asked for, it will be delivered, but we have to stop the uncontrolled and unreasonable waste of money.”

Meanwhile, the Ministry of Health has proposed a plan to reduce the number of clinics and hospital managers in the national health system to make it more flexible and effective.

We need to develop the national health system in a way that serves the Greeks, says Greece's Minister of Health George Loverdos. According to the minister's plan, the 1900 clinics that operate in the country will be reduced to 1600 and will be run by 83 managers (at present, there are 131). The minister is due to present the plan at the end of this month and it will then be discussed between the parties involved.

The plan to merge hospitals though, is highly questioned by many respectable doctors and academics, for example Emmanuel Kalokairinos, president of the Hellenic Doctors Association, who points out that “There's a lot to be discussed. At winter some islands are cut off and often the transportation of a patient, even to the nearest island which has a medical unit, is very difficult while in Athens, if hospitals are merged, the situation will become very difficult when they are on call. The situation will get even worse as the major hospitals reach their full capacity.”

To avoid this problem, the Ministry of Health, beginning in September, will operate a new body for “simple, everyday health problems”, such as coughs, blood pressure disorders, and minor accidents, that until now were dealt with by hospitals. “For the first time all Greeks will have an equal treatment from a body that will be unified with the national health system. Hospitals will be unblocked”, said Health Minister Loverdos.

“In order for the new body to operate, the cost is estimated at €8 million yearly. Also, the working status of the doctors is still unknown”, Kalokairinos concludes.

There is a lot still to be discussed. But in the midst of the financial crisis in Greece, plans are being implemented and actions are being taken to improve the health system. Perhaps, the debt crisis is a chance for health care in Greece to progress after all..