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110 Economic crisis, health systems and health in Europe: country experience
capacity and adequate mechanisms to undertake needs assessment (Economou,
2010). Historically, hospitals operated by the national health service (NHS,
known as ESY in Greek) had not enforced transparent and accurate tracking of
their expenditures and the state had to step in regularly to cover accumulated
deficits. In addition, an oversupply of specialist physicians coexisted with an
undersupply of GPs and nurses. The lack of a functioning referral system
between primary and higher level care, and problematic pricing and providerreimbursement
mechanisms, resulted in poor coordination of care, large OOP
payments and a sizable black economy, impeding the system's ability to deliver
equitable financing and access to services (Liaropoulos et al., 2008). At the
same time, the age structure of the country has been changing. The percentage
of the population over 65 rose from 16.6% in 2000 to 18.8% at the end of the
decade (Table 4.1). The implications of this population ageing, together with
the low birth rates, will need to be factored in when considering the country's
economy and health care system.
By the time that the crisis hit, and despite the warning signs, both the Greek
economy and the Greek health care system had amassed a number of structural
problems. Past reform attempts in areas such as primary care, the organization
and provision of health services by hospitals and the enhanced cooperation
of social insurance funds failed to deliver the expected results or were not
fully implemented (Davaki & Mossialos, 2005; Mossialos & Allin, 2005).
Consequently, the need for reforms in the health care system is clear and has
dominated the agenda of policy responses instigated by the crisis, particularly
the attempt at large-scale cost-containment.
3. Health system responses to the crisis
The health policy responses to the crisis and their effects should be seen from
two perspectives. The first perspective relates to implementing much-needed
operational and structural reforms, designed to address the weaknesses in the
health care system as discussed in the previous section. The second perspective,
which is particularly important when considering the effects of changes,
relates to the measures stipulated in the MoUs, which, by and large, are fiscal
consolidation measures.
3.1 Changes to public funding for the health system
Data reveal that public health expenditure, as a share of general government
expenditure, reached its high point of 13.2% in 2006 (Health expenditure
series; OECD, 2013; WHO Regional Office for Europe, 2014). However, after
the introduction of extensive austerity measures, Greece had one of the lowest
ratios in the EU by 2012, not exceeding 11.5% compared with the EU mean
of 15%. Bailout conditions requiring a reduction in overall health expenditure