Lancet reply – NHS and financial crisis in Greece: an effort to stabilize and improve services and outcomes

N. Polyzos 2011

As Ministry of Health and Social Solidarity, but more importantly as citizen of Greece who is part of the everyday life of this country, I would like to respond and express my view on the recent article “Health effects of financial crisis: omens of a Greek tragedy”¹, by A. Kentikelenis et al, which was published online in the scientific journal Lancet, on October 10^th, 2011. It should be initially clarified that I fully respect the authors’ perspectives and their research, but my scientific and institutional role oblige me to comment, at least from a political perspective, on the abovementioned article, as well as on related articles^2,3,4.

First and foremost, it should be noted that Kentikelenis et al base their critique on self-reported health data collected from questionnaires during the 2007–2009 period, when Greece was governed by a conservative administration, and not on data from 2010–2011 which coincides time-wise to the recent crisis and the present socialist administration. Indeed, I am the first to admit that there are problems in the Greek Health System, but this is far from advocating that the picture of health in Greece is a “tragedy”.

The authors of the article claim that Greek citizens face severe accessibility problems in the National Health System, mainly resulting from the long waiting lists, the sometimes long travel distance to reach care and other reasons also, and thus choose not to seek any treatment at all. Concerning the NHS, data from Greek studies has shown that waiting times are among the shortest in EU countries⁵, no more than 6 months, when respective figures for other health systems, e.g. the British NHS, may be 9 or more months. A recent statement by the Minister of Health that “….in Greece the patient is operated on before even reaching the hospital⁶”, although obviously an exaggeration, is very characteristic in this respect. It should be noted that all citizens living in Greece have almost free access to NHS hospital emergency departments via transfer by the National Ambulance Centre (EKAB – 166) and a plan is on the way to revise and improve the respective hospital services in Athens, Salonica and other metropolitan and tourist areas, by the end of 2011.

Regarding the alleged cuts in hospital budgets, indeed an effort to increase savings via budget reductions has been made. However, the accurate figures are 12% in 2010 compared to 2009, with an estimated 13% more budget cut in 2011 compared to 2010⁷, as a positive result of improvements in financial management efficiency (e.g. procurement, logistics, accounting systems, etc.), without reducing requirements of sanitary materials, drugs and other services. All relevant data is published monthly on a newly formulated computerized NHS system, known as “Esy.net”, which Kentikelenis et al are obviously aware of as they cite it in their article. Hence, their claim that “there were about 40% cuts in hospital budgets” is far from the truth.

We state that it is unequivocally obvious that our health system is far ahead than that of many other countries in respect to free access to health services, despite certain categories of citizens (unemployed, uninsured, immigrants) who may be abusing this “privilege” as the “Troika” (IMF, EU, ECB) has continuously reported. Greece is regarded to have one of the most advanced, open-access and fastest responding health systems⁸.

What is more, this so-called “tragic” Greek NHS provided inpatient services to more than 2 million citizens in 2010 with more than 20% increase in admissions compared to 2009, as the authors themselves report – based on Esy.net data⁹ (plus 6% in 2011 from September data). Concurrently, a relative decline occurred in the private sector, mainly due to the crisis, but also to small improvements in NHS hospitals’ quality of services. Surveys from 70 hospitals show us a 7/10 satisfaction level in a statistical range between 5 and 9, and has been continuously evaluated by the MoH, in conjunction with efficiency measures that have significantly improved between 2011 and 2009. Also, a recent study employing Data Envelopment Analysis (DEA) carried out by the Secretary General and his affiliates showed an increase in hospital efficiency^10,11 with many hospitals reaching very high relative technical efficiency scores, particularly large (>400 beds) and university hospitals.

Concerning morbidity, we are expecting the publication of relative data from the National School of Public Health, via the “Health Map”, by the end of 2011. As for mortality, Hellastat shows that it has not risen recently, but remains stable (at slightly above 100.000 deaths). Data from the National Centre of Infectious Diseases (KEELPNO) has not suggested a serious increase in new infectious. In addition, Kentikelenis et al anticipate a 52% increase in HIV infections in 2011 compared with 2010 (922 new cases versus 605), with half of the currently observed increases attributable to infections among intravenous drug users^12,13. It is important to be emphasized once again that the surveys on which they base their assertions employ 2009-2010 data and the 52% reported figure cannot be seen as more than a prediction as 2011 is still in progression and at present we can have only preliminary data. Valid conclusions can be drawn only at the end of 2011.

We would like also to inform the international audience that the results of the survey that the authors rely on about drug users and rehabilitation programmes are, fortunately, no longer valid¹⁴. A wide program of treatments offered by NHS Hospitals to drug users started last September with the aim to cover approximately 7.000 drug users by the end of the year, in collaboration with the Organization against Drugs (OKANA). Indeed the health system, as of 8^th September 2011, can satisfy drug addicts’ requests for rehabilitation and treatment.

Finally the authors, as part of their critique, claim that “violence has also risen, and homicide and thefts rates nearly doubled between 2007 and 2009”, with reference to three articles, two of which may be seen as out of date (2002¹⁵ and 2006¹⁶) and only one is indeed recent (2011)¹⁷. The latter author, Mrs. Carassava states that: “Final statistics for 2010 are not yet available, but news reports and anecdotal evidence suggest that violent crime is gaining dangerous momentum”.

On our part, it would be unrealistic to deny that there are many difficulties regarding all public services due to the financial crisis, and that the Greek NHS requires even more improvements in quality. However, this cannot justify characterizing the current picture of health sector in Greece as a “tragedy”. Serious efforts to reform the health system in Greece have been made such as unification of financial sources (EOPYY), decentralization and management of the NHS (i.e. hospital mergers without noteworthy closures, primary health care improvements, etc), concrete pharmaceutical policies (i.e. negative or positive lists per ATC, electronic prescriptions, e-auctions, etc.), development of NHS infrastructure and biomedical technology through EU funds, etc.

Greeks have faced serious problems due to the crisis. We insist and feel optimistic that it is manageable to overcome the crisis with hard work, such as that done over the past two years, and to improve public and private sectors of our economy, including the NHS. In any case, no hard evidence has proven that the financial crisis has become a health hazard or even more so a “disaster”. “Unofficial data” should be made “official” by researchers or scientific agencies. We are working close with all special interest groups in order to evaluate, plan and act efficiently, with the public interest at the heart of our efforts. I respectfully regard Kentikelenis et al as such a group and kindly invite them to offer their suggestions on all the above issues.

Nikos Polyzos, Associate Professor at the Democritus University, Secretary General of Minister of Health (email: secretary.gen@yyka.gov.gr)

References

1. Kentikelenis A, Karanikolos M, Papanikolas I, Basu S , McKee M, Stuckler D. Health effects of financial crisis: omens of a Greek tragedy. Lancet, October 10, 2011.
2. Torchia C. Greece: Crisis Takes Toll on Health. Associated Press, October 10, 2011.
3. Gallagher J. Greece health warning after cuts. BBC News, October 10, 2011.
4. Smith H, Boseley S. Greeks pay for economic crisis with their health. The Guardian, October 10, 2011.
5. Sissouras A, Polyzos N, Karokis A. Rationing and Priority Managerial Setting and Organization in the Hellenic Health Care Services System. Leadership and Organizational Management Journal 2007.
6. Papadomarkakis A. Drastic hospital cuts. Naftemporiki, October 12, 2011.
7. Secretary General of Ministry of Health and Social Solidarity. Report Results of MHSS and NHS Units 2010. Athens: Ministry of Health and Social Solidarity, 2011.
8. Press Conference of Political Leaders of Ministry of Health and Social Solidarity. Annual Report September 2010 – September 2011. Athens: MHSS, October 11, 2011. Available at www.yyka.gov.gr.
9. Polyzos N. ESY.net: Presentation of the Secretary General of the Ministry of Health and Social Solidarity. Athens: Ministry of Health and Social Solidarity, 2011.
10. Polyzos N et al. Comparative analysis of the efficiency of Greek NHS Hospitals (2010 versus 2009). Available at Report Results of MHSS and NHS Units 2010 of Secretary General of Ministry of Health and Social Solidarity. Athens: Ministry of Health and Social Solidarity, 2011.
11. National School of Public Health. Here’s what hospitals should merge. Research on the efficiency of public hospitals in the country, prepared for the Ministry of Health and the General Secretary by the National School of Public Health. Published on The World of the Investor, November 27-28, 2010, ss. 18-19.
12. Paraskevis D, Hatzakis A. An ongoing HIV outbreak among intravenous drug users in Greece: preliminary summary of surveillance and molecular epidemiology data. EMCDDA Early Warning System, 2011.
13. Paraskevis D, Nikolopoulos G, Tsiara C, et al. HIV-1 outbreak among injecting drug users in Greece, 2011: a preliminary report. Eurosurveillance 2011; 16: 19962.
14. EKTEPN. Annual report on the state of the drugs and alcohol problem. Athens: Greek Documentation and Monitoring Centre for Drugs, 2010.
15. Krug EG, Mercy JA, Dahlberg LL, Zwi AB. The world report on violence and health. Lancet 2002; 360: 1083-88.
16. Sundquist K, Theobald H, Yang M, Li X, Johansson SE, Sundquist J. Neighborhood violent crime and unemployment increase the risk of coronary heart disease: a multilevel study in an urban setting. Soc Sci Med 2006; 62: 2061-2071.
17. Carassava A. Crime casts long shadow over Athens. Los Angeles Times May 31, 2011.