Every health system is the manifestation of the social, political, economic, cultural and historical conditions, which led to its creation and determined it. This is why no health system in one country is exactly the same as another, even if it falls under the same health system typology. After all, the health system is an open system par excellence with continuous communication, interaction, feedback and readjustment, according to its external environment (socio-economic, physical, epidemiological, etc.), to whose health needs it is called upon to respond. Therefore, social processes play an important role in the establishment, evolution and future formation of a health system.
Previous efforts
In Greece, undoubtedly the establishment of the National Health System (NHS) with n. 1397/1983 is the biggest reform in the health sector. It was a state intervention in the health market, which expressed the assumption of responsibility towards the citizen of a welfare state, with the aim of equality in access to equal quality health services.
The need to address health inequalities (level of health, unequal coverage by different insurance funds, but also unequal availability of health services) was evident as early as the 1950s. Historically, during the post-war era in Europe, social processes for the establishment of public systems are recorded health, with the most emblematic and influential reform being the establishment of the National Health Service in Britain. Greece is trying to follow this trend. However, the various individual efforts, such as, for example, the Papagou law “On the organization of medical care” (1953) with the subordination of public sector hospitals to the state organized by region, as amended and supplemented by the law “On Social Insurance of of Farmers’ (1955) to provide medical care to this group of the population, or even the draft law of Minister of Health L. Patras, “Designing Social Policy” during the period of the dictatorship (1969), they either did not reach institutionalization or were not implemented. Among these (failed) attempts is included the approach of Spyros Doxiadis (“Health Protection Measures” – 1980) as a more comprehensive systemic approach to the field of health, amid reactions from both the medical and political worlds (even the civil society of the time).
Mature social conditions
In 1981, the change in the ruling party – but also the public debate about the social character of the state – brought back the issue of health as one of the great stakes of the time and “charged” politically the need for a reform of the health system. It is worth noting that changes of this nature are extremely large-scale: health systems internationally are one of the largest employers in developed economies, spending on health is about 10% of GDP in OECD countries (lower, of course, by the historical reference period – but still rising to a significant percentage), while the health system itself constitutes a determinant of the level of health, collective well-being and social cohesion. Consequently, any reform of this type is by definition opposed to – extremely strong – established professional interests and at the same time constitutes an intense field of ideological and political confrontation.
The political and social conditions of the time in Greece were largely ripe for such an important reform and government intervention in the health market: about 40% of health expenditure was private expenditure, which weighed on family budgets, geographical disparities in the distribution of health services and infrastructure with an overconcentration of health professionals and hospital beds in the large urban centers at the expense of the province were very intense, the number of insurance of funds was very large and each of them provided different health coverage, which exacerbated the unequal access to health services, outpatient care was mainly a matter of the private sector (despite the existence of IKA polyclinics in urban centers) and concerned therapeutic treatment , with prevention being almost non-existent.
Innovative settings
As a response to this reality, the government at the time, after a long process, submits for approval the later Law 1397 (October 7, 1983). The law, in many respects, is innovative for the time: it explicitly assigns responsibility for the provision of health services to the state (no. 1), incorporates the concept of universal coverage (no. 2), creates decentralization and a regional structure in the system health, strengthens the public character of hospitals and makes hospital doctors public officials without the possibility of private work (the truth is that a large part of the law is “hospital-centric”), attempts to organize Primary Health Care (regional and urban) etc. In the consultations on the law, the idea of consolidating the health insurance funds is even discussed (i.e. a similar proposal to the reform of the EOPYY, which was founded almost 30 years later…), but it is met with strong reactions, even from members of the co-republic of the time .
In order to achieve the goals of the NHS, the legislator adopted some basic principles and provisions, such as the state’s responsibility for providing services to all citizens and therefore the establishment of new private hospitals and clinics, decentralization through the division of the country into health regions (in to which the regional hospital, prefectural hospitals and health centers with regional – rural clinics belong), the development of Primary Health Care (PHY) with a provision for 400 health centers and regional – rural clinics in rural and urban areas staffed with general practitioners, and the development of hospital care by building new hospitals and modernizing existing ones.
Successful changes and unchanging problems
As expected, the opponents of the reform at the time are many – but the government of the day has enough political capital given that a (unseen to many) social need is being heard to build the necessary alliances to pass the law. A law that constitutes a historic turning point in the course of Health in our country.
Of course, as historical experience teaches, in our country the passing of a law does not necessarily imply its (full or partial) implementation. Already in the first years of its passage, several elements of the reform (probably the most innovative ones) began to fall into the background or not be implemented entirely.
However, there were, obviously, several provisions of the law which were finally implemented: the most emblematic of all is the transformation of the character of the NHS hospitals and the working relationships of the staff, while at the same time, as a result of the philosophy of the law, a wide network of structures was created in the region . Although the staffing of these structures has always fallen short of the original plan, there is no doubt that the time since the passing of the law has led to a significant increase in the bed capacity of the public hospital sector.
But beyond the above, the big question, of course, regarding the historical character of the law remains. And this is what n finally achieved. 1397/1983 regarding the progress of the level of health in our country. This valuation is not an easy task. Many issues, despite 40 years of reforms to strengthen the public nature of the health system, remain unchanged: a typical example is the percentage of private health expenditure (remaining at around 40% of the total for four decades). Corresponding problems are the unequal geographical distribution, the movements of the population in search of care, the centripetal administration of the system, the strong inequalities and the ambiguous results at the level of health: Greece is slipping in positions in life expectancy and has a healthy life expectancy in 65 years, which is lower than the OECD average. On the other hand, we have to ask ourselves where these indicators would be today without this reform – one can hardly argue that things would not be worse off. In any case, however, from this reform – but also from all subsequent ones, even the current ones – something that could improve the cycle of creation, feedback and adjustment of the policy was absent: a mechanism for monitoring and controlling the results for the production policy evidence.
*Mrs. Elpida Pavis is a professor of Health Economics and Health Inequalities at the Department of Public Health Policy, dean of the School of Public Health at the University of Western Attica.
*Editor: Evanthis Chatzivasiliou
