5 years of austerity takes its toll on Greek health care, by Eva Karamanoli

The Lancet – Volume 386, No. 10010, p2239–2240

Public and private hospitals in Greece are struggling to deliver good quality health care after years of austerity measures and the ongoing financial crisis. Eva Karamanoli reports from Athens.

Corridors overflowing with patients; doctors trying to take care of them under intense physical and psychological pressure; shortages of drugs, medical supplies, and equipment; nurses in the intensive care unit struggling to meet the needs of the five or six patients they each have under their care. This is the typical picture in Greek public hospitals in 2015.

The health-care sector is chronically ill, and getting worse by the day. 5 years of austerity, caused by, and in turn, fuelling the country’s financial crisis, have left scars on the national health system. Social insurance funds are in the red, while private insurers restrict their drug coverage, leaving people with serious illnesses, such as cancer, struggling to meet the costs of the medicine they need. “I have been suffering from cancer the past 7 years. The medicine I am on is extremely expensive, it costs €3300 per month. The cost used to be covered, for the most part, by my private insurance policy. But not anymore. Last week, I was informed that one of the medicines I take is no longer on their lists. I was terrified”, one patient, who wished to remain anonymous, told The Lancet.

Shortages are the order of the day. In June, just before the imposition of controls on capital, which limited bank transactions for citizens and companies, the funds left in government coffers were a mere €77·3 million. In March, there was €796·5 million and in December, 2014, before the January election was called, there was €2·5 billion in cash reserves. In June, to pay pensions and the salaries of state employees, the government raided the reserves of social insurance funds and other public organisations, borrowing €9·7 billion.

Public hospitals under pressure

The income squeeze of the past 5 years has led Greeks—who before the crisis flocked in droves to private hospitals—back to the public health-care system. This influx added to the strain caused by the cuts in funding. “I had a car accident and had multiple injuries. The doctors were very good, that’s the reason I am here talking to you now”, said Christos Oikonomou, who was on his fifth day of recovery in a major public hospital in Athens when The Lancet spoke to him. “On the other hand, I could have died due to the shortage of medical supplies and the difficulty of finding a bed. I would certainly have gone to a private hospital if I could afford it. The combination of the living conditions with my multiple injuries was exhausting.”

Outside Christos’s room is Samir, a refugee from Syria, sitting on a chair in the corridor. He said he was waiting for an intravenous drip to deal with his symptoms of dehydration and malnutrition. Public hospitals treat many of the 2·5 million people who are uninsured, including refugees.

However, funding of public hospitals has been cut by more than 50% since 2009. Public health spending is expected to shrink to 4% of GDP by the end of 2015, compared with an European Union average of 6·9%. According to the Panhellenic Medical Association, public hospitals are in need of 6000 more doctors and 4000 additional paramedics. “Personnel in public hospitals get older and older, because young doctors and nurses leave for foreign countries in search of a better salary”, says Michael Vlastarakos, president of the Panhellenic Medical Association. Senior registrars in the public sector are paid €1700 per month, and consultants no more than €2300 a month.

John Apostolidis and Stavros Gigantes are consultant haematologists at Evagelismos Hospital, the biggest secondary-care facility in the country. Shortages are beginning to occur here too. In the haematology clinic, there are insufficient numbers of beds and nurses, especially in the intensive care unit, where patients recover from transplant surgery. According to John Baltadakis, head of the transplantation department of the Hellenic Association of Hematology, there are only nine beds in the clinic, and there is no special wing for immunocompromised patients. “This is unacceptable”, says Baltadakis, who goes onto describe how the crisis has limited people’s access to transplant surgery. “In our clinic, we perform 60 transplants per year. But the requests are more than 100 and the waiting list extends to 6 months. We have the scientific adequacy but there is no help from the state”, says Baltadakis. “The emergencies strain our resources to the limit due to the volume of the incidents and there is great delay in imaging tests. If there is not an emergency incident, CTs and MRIs may be scheduled after 10 days”, says Apostolidis, noting that the transplantation unit was set up thanks to a private donation, without government funds. Gigantes highlights the lack of nurses and beds as the greatest problem of the clinic. “Immunocompromised patients are placed in six-bed rooms and there is one nurse for 15 patients. In many cases, patients need to wait, not to be treated, but to find a recovery bed.”

Thumbnail image of Figure. Opens large image

Funding of public hospitals has decreased by more than 50% since 2009

Yorgos Karahalis/Reuters/Corbis

“The number of patients in outpatient clinics, but also in the emergency rooms of public hospitals, has doubled [since the beginning of the crisis]. Medical staff [numbers are] insufficient, because new hiring has been suspended. The staff often become exhausted, creating precarious conditions, especially during long night shifts in the big public hospitals”, says Georgios Hillas, consultant in respiratory medicine in the department of critical care and pulmonary services at the University of Athens Medical School. “Patient overload is even greater because public hospitals provide health services for humanitarian reasons to uninsured people and to foreigners”, he adds.

The head of nursing staff at a major public hospital in Athens, who wished to remain anonymous, told The Lancet that there is only one nurse per shift for as many as 60 patients. When the hospital is on call 24-hours (hospitals in Greece are rotated to be on call), there are 16 nurses for 1600 patients, and one nurse for five patients in the intensive care unit. “In the last 2 years, 2000 new hires were scheduled, but none took place. There are also shortages in drugs and medical equipment, which result in low quality health services”, she said.

Private sector woes

The private health-care sector has also suffered in the years since 2010. The profits of private hospitals and clinics have been substantially reduced, not least because of liquidity problems of the social insurance funds and the long delays in payment by private insurance companies. The decline in profits has led to staff cutbacks and to an increase in part-time employees, who are paid low salaries. “The connection to the social insurance funds is critical for private clinics and hospitals”, says Michael Vlastarakos, pointing out the “vicious cycle” that is created by delayed payments to hospitals, who then cannot pay their staff, and so on.

“Unemployment among doctors is very high”, says John Striftis, an internist who works in a private hospital in Athens. “So to make a living in many cases they have to work long hours, covering as many shifts as they can. This gradually results in loss of motivation for their personal scientific improvement, and for the provision of the best medical care to their patients. Long working hours and low salaries mean less time for reading, research, and developing one’s scientific knowledge. There is less participation in international conferences.”

Nor is it only the hospitals that are making cutbacks; so are patients themselves. “In many cases, patients choose to stop their treatment, or replace the prescribed medication by cheaper alternatives. Sometimes they ask for the cheapest treatment instead of the best. In addition, preventive check-ups and vaccination of high-risk groups, such as old people and children has been greatly reduced”, says Striftis.

Drug shortages

The financial squeeze that the crisis imposed on the health-care sector has also affected pharmacies. According to the latest official statistics, the government owes pharmacies €0·5 billion. In Greece, insured people only pay a percentage of their prescription costs; the rest is paid by social security services. But the financial crisis has meant social insurance services no longer have enough money to cover drug expenses.

There is also a major shortage in vaccines and medicine. In June, when capital controls were imposed, several vaccines that are included in the national vaccination programme were in short supply. “Medicine in Greece is very cheap and multinational pharmaceutical companies prefer to ship them off to other countries in order to make higher profits”, says Constantinos Lourantos, president of the Panhellenic Pharmaceutical Association. Lourantos points out that, in official statements, drug companies claim that they don’t have enough stock. “It is not unusual for me to order 20 anticoagulant injections and, even though I pay cash, they send me ten, claiming that there is no stock”, a pharmacist, who owns a store in downtown Athens and wished to remain anonymous, told The Lancet. “This results in pharmacists and patients trying to find the medication prescribed all over Athens”, she added. The pharmacist showed The Lancet a notebook with names of clients and the total amounts each one owes her. In most cases, the debt is small, no more than €10 or €20. “They come in the first days of the month and they pay me. Most of them live with a €400 pension. It is very difficult for them to pay cash”, she says. Since controls on capital were introduced, the use of credit cards has increased. “I try to satisfy my clients, to help them find what they need, at a price they can afford. Sometimes it’s possible. There are people that have been coming to my store for the past 20 years. Now, they are in financial difficulty. I try to comfort them, even if this makes it harder to operate my store and make the payments I have to make to suppliers.”

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