After the 12th Congress of HHSMA (2010) the scientific proposals of our Association regarding the developmental modernization of the health system, were published entitled as "The Future of Health Care in Greece".

Besides some interventions that were imposed by the Troika and vindicated our views, the core of our suggestions has been ignored until today.  Thus, another three years were lost, that could be used creatively with remarkable results.

On the occasion of the 15th Congress (2013), HHSMA considers it necessary to revert, hoping that the current, dramatic situation in the National Health System will impose a serious handling regarding the crucial reengineering of our health system.

As expected, the current debt crisis during the recent years has brought the lack of transparency and the profiteering, which prevailed for decades in the health sector, to the forefront. Inevitably, the reduction of government expenditures had, proportionally, much more consequences in this area compared to others.

Due to a permanently prevailing technocratic inadequacy and lack of meritocracy
in the structures of the National Health System, at all levels, the cost-containment policies have had so far a horizontal dimension,  rushed and unprocessed applications, and implementation efforts, mainly, by executives lacking the necessary knowledge and experience.

In parallel, the fear of the "political cost" contributed to regressions, inconsistencies and "discounts" that led to the loss of critical time and the growth of symptoms of operational and humanitarian crisis.

Besides, it has been revealed that the public health system in Greece is "sick" in all aspects and cannot be cured with "soft" treatments, but only with aggressive, "surgical" type, interventions.

1. A Brief History

After a very long delay, the request for organizing the Greek National Health System developed fully in the mid ‘70s and it was formed in the early ‘80s.

Unfortunately, the development of the NHS through the time, took place in a socio-political environment of unrestrained populism, of political party “meritocracy” and diffusion of self-interest and corruption, in such a way that today the health sector is at the pathetic top in social discontent and very far from its initial mission, despite all demagogic slogans.

Under the spurious slogan of alleged "Free Health for All", a mechanism of permanent
civil servants, doctors and other workers, ostensibly on an "exclusive basis" work was created.  They were selected with no scientific criteria and kept working without any evaluation process for 30 years, whereas many of the most capable members of the medical body chose to contribute to the private sector, which was growing at the same time that the development of the NHS took place!

The founding Law of the NHS established a doctor-centered model, organizationally   incomplete and directly oriented to serve with priority the individual interests of the hospitals’ - health care centers’ staff, instead of a patient-oriented health system that the
country and its population needed.

Allpublic hospitalswere transformed intotypical, ossifiedpublic services(public legal entities) subordinateto bureaucraticentanglementsandcivil service irrational attitudes,totally
incompatiblewiththe nature of thepublichospitals to operate as"business" producing24-hourcrucialservices.

The administration and management of NHS structures has been exerted over time and continues to be exercised by "commissars” of the successive governments, selected without any objective evaluation and usually without any relevance to the administrative science. Despite the existing legislation (that covers the need for scientific background), the positions of Hospital Managers are still distributed among political parties!

Significant responsibility for maladministration lies with the government-funded "trade union" (corporative) movement, the representatives of which have contributed actively to the overall management of the NHS since its establishment.

Over time, all moral inhibitions were abandoned, the legal framework was subverted, the "public" health system was fully commercialized and the cost of the health sector increased significantly and reached the first places among European countries. Citizens were forced to pay for a second time when using health services, although they had prepaid through their insurance contribution and general taxation.

Already in the years 2008-9, Greeks paid privately more than 45% of total health expenditure -according to official data- a rate that is considered worldwide unique for a country with a "public" health system. In fact, the rate was even higher, if we take into account various forms of unrecorded 'black economy' of health.

Today, the measures that are taken due to the inevitable Memorandums of Understanding (MoU)’s, have caused a further raise in the proportion of private health expenditure, even though there’s a decreasing number of citizens that choose private clinics and diagnostic centers due to drastic cuts in their disposable income.

For decades, the corruption, the lack of transparency and the perceived prospect of easy access to money made thousands of young people to desperately search -worldwide- for
a degree in medicine, leading, in overall, to the creation of a medical army, 250% larger than the real needs of the Greek population. In combination with the administrative chaos, the
medical inflation led to a transition of the greatest part of health expenditure representing unnecessary medical fees, subtracting valuable system inputs, with fatal deterioration of the quality of outputs.

Furthermore, in the current condition of compulsory limitation of “black economy”, the most qualitative part of the Greek medical profession migrates abroad in search of real medical work. In other words, bankrupt Greece offers to the lending countries thousands of top medical physicians, those that have been through pricey basic studies and were paid for the long years of their postgraduate specialization, all financed from the government and their households.

In fact, 6.000 physicians immigrated recently to Germany and -only for undergraduate and postgraduate studies- the burden on our government budget was nearly 2 billion € in vain! Such an unrestrained scientific and financial outflow is a major social irrationality, caused mainly by the irresponsibility of the vast majority of politicians.

2. Basic Principles and Measures of NHS Modernization

Nowadays, the Health Sector is in a state that does not allow reengineering with fragmentary measures. Above all, it requires a radical change in philosophy, relying on the principle "We don't have patients for doctors; we have doctors for patients." Practically, this implies an updated legislation and detailed planning of specific actions, with short, medium and long-term goals.

The Ministry of Health must no longer manage the Health System directly, especially with unscientific criteria, and must restrict itself to purely political decision-making, such as:

a) Determining the goals and priorities of the Health System.

b) The choice and legislation of the general organizational model of the NHS and of the additional relations in the public-private sector cooperation.

c) Defining the resources, the total amount and inner composition of public expenditure on health.

d) Cooperation with the Ministry of Education to adjust the output of skilled human resources, based on the real needs of the population.

e) Determining the requirements and preconditions for practice of the health professions, the initial certification of qualifications of new entrants into the system and the subsequent certification of specialization of health professionals.

f) Establishing specification, accreditation and licensing for public hospitals and private clinics.

g) Compiling specifications and issuing regulations to protect public health, etc.

The organizing, staffing, administration, allocation of funding, operation and quality control of the health system is a purely technocratic project, which should be delegated to specialized bodies.

The basic principles of establishing a modern NHS are:

a)Completeseparation ofthe Demand for services (buyers/users) from the Supply side(producers/suppliers).

b) Independency in theorganizingof the systemsi)Primary andii) Secondary/Tertiarycare

c) Changing theformof the legal entities that public hospitals currently representand introduce a new legal format,that allowsthe implementation of scientific administration principles and operationalflexibility(e.g.private law legal entities, etc),

d) Determination -with internationally acceptable standards- of the necessary ratio of health professionals/population that is needed and considered sufficient for the effective functioning of the public health sector, so that public and social resources are not wasted on unnecessary and non transparent payments,

e) Recruitment of all new entrants in the health profession with a fixed term contract, the renewal of which depends on the outcome of a substantive assessment,

f) Overcome unified salary model and, instead, implement a more fair and personalized system based on incentives, directly related to the quality of work, duration of projects, geographical and other special conditions, educational or research activities and any other individual contribution to improve the public health system

g) Allocation of public funding to the health structures, based on the needs of the covered population, on the quality, quantity and competitive prices of the services provided

h) Direct and broad use of the great potential of e-Health, with reliability, standardization and interoperability, in order to maintain the rapid flow of data and information, while ensuring the necessary protection of personal data.

3. The Financing

In the current circumstances of recession, a pressing issue arose, to redefine and ensure the minimum necessary resources for the Health System financing. The constant shrinking of social security revenues combined with fiscal impasses impose the need of a new financing method, which guarantees that a “minimum” of per capita Public Health Expenditure will be available for the entire population. It is urgent to evaluate some technocratic suggestions that have already been expressed or are currently under preparation.

In any case, it seems, unfortunately, that citizens must undertake an additional cost-sharing when using health services and that is compulsory and no longer under negotiation. The size and the distribution of this burden is a matter of justice, social dialogue and policy decisions. It is obviousthat there must be a differentiationaccording to the principleof selectivity,in favor of disadvantaged social groups.

Furthermore, the implementation of these measures should ensure the elimination of any unnecessary overconsumption or handling of “black” money in the health sector. Instead of converting these resources in unnecessary and unjustifiable incomes, the cost participation of using the health services should contribute to the quality improvement of the provided services and the health level of the population.

4. The Organization of the NHS

A modern, efficient and patient-oriented health system requires, in our judgment, a structure based on four (4) organizational pillars. The first two constitute the demand side and the other two the supply side.

4.1. The Demand Side

4.1. a. Management Authority of Health Resources

This organization would act on behalf of the users/patients, aiming to use efficiently the available resources. It would endeavor to ensure reliable medical equipment and supplies at the best possible rates ​​(centralized procurement processes), process and determine the range of actual cost of certain diagnostic and therapeutic operations (DRGs, clinical protocols, etc), evaluate the prescribing attitude of health professionals, negotiate and sign contracts at the most advantageous rates with public and private service providers, perform pre-hospital audits and, in general, collect and manage public funding in the most efficient possible way.

This authority could be even the present National Organization for the Provision of Healthcare Services (EOPYY) -separated from primary care-, which would absorb the currently ineffectual Health Procurement Committee (EPY), under the leadership of a technocratic management and recruited by experts.

4.1. b. Entity of Assessment, Quality Control and Continuing Education

The second organization must operate in the demand side, aiming to ensure the quality of services purchased and provided to the users / patients. Staffed with a relatively small number of highly skilled personnel and develops external collaborations with institutions and specialists to handle projects such as:

a) Establishing criteria per sector/specialty, organizing regular individual assessments and rating of all scientific and technological personnel with activity in the public and private health sector. If needed, necessary measures for retraining will be defined and reassessments will take place, under the jurisdiction of withdrawing licenses to practice under certain conditions.

b) Setting standards/criteria and regular intervals for the quality control of facilities, operational procedures and statistical data related to the outputs of the health services, both of the public, and the private sector. If necessary, the appropriate measures will be imposed and reassessments will be made, since it has the jurisdiction to withdraw operating licenses.

c) Evaluates the proposed research projects and introduction of technological innovations, with the responsibility for approval or not.

d) Based on the expressed needs, develops and implements or approves the implementation of third parties projects, concerning continuing education of personnel of all disciplines.

4.2.The Supply Side

4.2. a. Entity of Outpatient Nursing/Care

On the supply sideof services, this entity is responsible for thehealthcoverageof the populationinprimary andoutpatientlevel. That body supervises all urban and regional healthcare centers and polyclinics, rural community clinics, post-hospital care centers, etc. Based on internationally applicable ratios of population / health professionals and the geographical or other features of the country, the Organization determines a maximum number and the distribution of the necessary physicians, nurses etc and hires staff  with fixed term contracts, which can be renewed or not, after substantial evaluation.

Aiming to cover all special needs, private practitioners may also participate. The operation of the regular outpatient clinics, the first aid provision and short hospitalization in uncomplicated cases, the referral/transfer of patients requiring hospitalization (via a supervised Ambulance), the monitoring of chronic patients, the home care, rehabilitation, telemedicine, prevention, treatment and health promotion are on the exclusive competence of the organization.

4.2. b. Entity of Hospitalization

The entity must be administratively autonomous with central and 7 regional administrations, supervising all hospitals, regardless of specialty. Its scope includes:

a) The confrontation of emergent incidents in urban centers or following a transfer within the same region,

 b) The provision of secondary and tertiary care, following a referral ofprimaryhealth care centers,

c) The practice ofundergraduate education and completepostgraduatespecializationof health professionals and

d) Theofficiallyauthorizedscientific research.

The Hospitals should be divided into:

a) tertiary (higher), educational and on duty (regional/university)

b) secondary, educational and on duty (prefectural)

c) basicallyrecruited,on duty,non-educational, with personnel of the main specialties only (in large islands orcitiesthat are not prefecturalheadquarters”).

Each Regional Healthcare Administration must have at least one tertiary hospital, as well as the required number of other hospitals, and resolve any matter relating to the allocation of financial resources, to the development or abolition of divisions and to the total number, per specialty, of the necessary personnel, in order to meet the population needs.

The management of each hospital must have absolute power in using the available funding and determining the necessary human and material resources, while respecting the official operating standards and reporting on the quality of outcomes and the management of resources.Eachhospitaladministrationannounces the necessary personnel positions, evaluates thecandidates, selects the most appropriateandidentifies their fees,based on localconditionsand their overall work.

Thehospitalpersonnel must be recruitedwith fixed term contracts, that can be renewedornot,after asubstantial evaluation. Hospitalsmay cooperatewithprivatepractitioners to coverspecial oremergency needs. Outpatientclinicsshould not operatein hospitals, with the exceptionof the strictlyspecialty clinics oftertiaryhospitals,which cannotdevelopin primarycare.

5. The Human Resources

The enormousimbalancebetween the needsand the available number ofhealth professionals andthe intentionallack of scientificmanagement,determined thefailureof the NHS, both concerning theutilization of the availableresources as well asthe quality of serviceanduser satisfaction.

The multiplication of the necessary number of doctors triggered the induced demand, the corruption and the conversion of a disproportionate share of health expenditure in unnecessary, legal or illegal, medical fees.

The deficit of the necessary number of nurses of higher education downgraded the quality of nursing and allowed the development of unacceptable institutions of patient support ("sitters").

The entire absence ofhealth economists andhealth informatics professionals, biomedicalengineers and,mostly, of skilled professionals in health servicesmanagement(managers)led to the administrativechaos, to thecomplete lack ofstatistical data records andvaluable information, to the underutilizationof the available technology,to the permanent infraction of the workethics and, also, to the corruption and misappropriationof public funds.

5.1. The Medical Personnel

The currentsaturationof medical professionals (physicians-dentists-pharmacists) requires thedrastic restrictionofentrystudentsin their respectiveuniversitydepartments,butonly in conjunctionwith extensiveinformative communication and early, official, warning concerning the strict determination of thegraduates number, that can ensure a professionalremunerationat the expense of the government budgetand socialsecurity funds.

The society cannot -and must not- provide public funds to cover all those who decide to study medicine, but only to those who are actually needed in the public system, while the state must select the most capable ones and reward them accordingly!

It is also required to redefine the number and the allocation of the interns (salaried trainee doctors), with a minimization or a temporary suspension for saturated specialties and a significant increase in other specialties, such as General Medicine, Emergency Medicine, Social Medicine, Geriatrics, Physical Medicine and Rehabilitation, Occupational Medicine, Public Health etc.

The choice ofremunerated internsfollowing a nationwide contest, instead ofthe current nomination list, is consideredabsolutelynecessary. The rest that insist and are keen to contribute, could, perhaps, be admitted asunsalaried.

5.2. The Nursing Personnel

The unprecedented -with internationalbenchmarks- deficiencyof qualifiednursing personnelenforces the implementation of measures torestore the socialstatus and the attractivenessof this profession.

Faculties of NursingSciencemust operate in all universities that are linked with relatedteaching hospitals. Theuniversity facultiesshould absorb theexisting departments ofTechnological Educational Institutes (TEI). InstitutionalizedNursingSpecialtiesmust begreatly increased and matchedwiththemedical specialties to collaborate effectively. Existing technical schools of nursing assistantsmustbe converted intotraining schoolsfor elderly care, disabledassistantsetc.

5.3. Modern Scientific Specialties

The reengineeringof the health system, the introduction of principles andsystems of scientific management, the use of modern technology, the promotion of developmentalinnovation, the  utilizationof scarce resourcesandeffective monitoring of thequalitativeoperationof health services impose that relevant specializedscientists will join the scheme.

It is considered essential in the undergraduate university education to immediately launch (with creation / conversion / absorption) one (1) at least department of each of the following subjects:

a) Organization and Management of Health Services

b) Health Economics and Policy

c) Health Informatics and Biostatistics

d) Biomedical Engineering and Medical Physics

Graduatesof the abovedepartmentsshould replace,in medium terms and exclusively,the withdrawing administrative andtechnical workforceof the healthcare services and units.

6. The Need for Immediate Intervention

As obvious, the reengineering of the NHSrequiresa short period of consideration, reflection, dialogue and alegislative processwhich, however, doesn’t need to exceed the 3-4months.

This time frameis consideredrealistic,as long as we can seize the potentialities and the views of experts, who are plenty in the country,leaving all partisanand corporatist, personal and otherunacceptable purposes behind.

The fearof "election cost" toward the trade union-lobby, must no longer determine thehealth policy. Political decisions should only be based on the generalsocial interest, especially in an erawith the obvious risk of humanitarian crisis.

A newlaw-framework of the NHS mustredefine the generalcoordinatesof the system;distinguishentirely betweenthepolitical activity of the Ministry ofHealthandthe technocraticadministration and managementof the NHS, legislate the reengineering of the structure and the managementof hospitals,to eliminatehundredsof “cliental” and iconic arrangements that are currently into effect, to introduceobjectiveassessment proceduresof all personnel and incentivesin order to motivate professionals to cover the islands and other remote areas, etc.

Only in this way can -the dominant component of a Welfare State- the Public Health sector be uplifted.

Athens, October 2013