Interest Groups and Health System Reform in Greece · interest groups, such that the stronger the...

Interest Groups and Health SystemReform in Greece

ELIAS MOSSIALOS AND SARA ALLIN

ABSTRACT Despite the establishment of the National Health System in Greece in theearly 1980s, the institutional framework remained largely unchanged due to oppositionfrom interest groups and large set-up costs, thus allowing the powerful stakeholders topreserve their privileges. Not until almost two decades later was reform attempted inorder to rationalise and modernise purchasing and delivery. The objective of this paperis to analyse the ambitious reform attempt of 2000 through the lens of rational choiceinstitutionalism, identifying the initial goals of the reform, the reactions of the keystakeholders and the legislative outcome.

Introduction

After the establishment of the National Health System (Εθνικό ΣύστημαΥγείας, ESY) in 1984, the next significant attempt to reform the healthsystem in Greece took place almost two decades later. Despite some politicaland health system characteristics that facilitate the implementation ofreform, such as a single-party government and an over-supply of physicians(which may imply a relative decline in the power of the medical profession),there are other features that may impede change, such as clientelisticnetworks and fragmentation in financing. These characteristics allowstakeholders to block the implementation of health reforms in order tomaintain the diverse benefits they derive from the disjointed system. As aresult, the Greek NHS (ESY) continues to possess the qualities of afragmented and regressive funding system, distortions in the allocation ofresources (multiple occupational funds with unequal coverage, historicallybased allocations to hospitals), perverse incentives for providers, and aheavy reliance on expensive inputs.

Several analysts of health reform have employed theories highlighting therole of the medical profession in the reform process. For instance, there isconsiderable literature linking the declining role of the medical professionwith governments’ abilities to enact health care reforms (Salter 2002;

Correspondence Address: LSE Health and Social Care, Cowdray House, London School of

Economics and Political Science, Houghton Street, London WC2A 2AE, UK

West European Politics,Vol. 28, No. 2, 420 – 444, March 2005

ISSN 0140-2382 Print/1743-9655 Online # 2005 Taylor & Francis Group Ltd

DOI: 10.1080/01402380500060460

Hassenteufel 1996; Wilsford 1995). Also focusing on the medical profes-sions, Freddi and Bjorkman (1989: 1–5) identify factors in the political andinstitutional environments of the health system that impact on medicalautonomy. The political environment is characterised by the proximity ofthe health and political systems, the complexity of the environment in whichdecisions are made, and the actors that play a role in the policy domain (e.g.bureaucrats, politicians and trade unions). Additionally, Tuohy (1999)presents a model of decision-making highlighting the importance of thebalance of influence among stakeholders (state actors, private finance andhealth care professionals – mainly medical professionals) and the mix ofsocial control mechanisms (hierarchical, market-based and collegial).

Although elements of these conceptual frameworks are helpful inunderstanding the role of institutions and health professionals in healthreform, the complexity of the Greek case requires a broader framework ofanalysis. The significant rise in the number of medical doctors over the pastdecades has not yet resulted in an expected corresponding decline in theirpower. Medical autonomy has increased because of the fragmented healthsystem in which multiple interest groups perceive change as a zero-sumgame and align their interests against reform. There were two major healthreforms in Greece: the first (1983–84) was only partially implemented whilstthe second (2000–02) was largely blocked by interest groups, with only someelements being legislated and a stalemate occurring after the first two years.This paper examines the motivations of key stakeholders within a splinteredhealth system, a political environment characterised by clientelistic relation-ships between the political party in power and certain groups, and fiscalconstraints that prevent health care from being placed high on the politicalagenda.

New institutionalist perspectives, such as those put forth by Hacker(2002) are useful in understanding the motivations of, and mechanismsthrough which, stakeholders impede reform. Hacker (2002: 303–11)identifies several circumstances where reform is unlikely to be achieved:for example, when policies lead to the creation of institutions withsignificant set-up costs; when institutions reflect the broader features ofthe economy; and when existing institutions benefit important organisedinterest groups, such that the stronger the opposition to change, the moreopportunity the groups will have to impede reform and influence policydecisions. These conditions are applicable to the context of Greek healthcare reform.

Rational choice institutionalism can be used to expound the motives ofmultiple interest groups in preventing reform. According to this approach,actors have fixed preferences and aim to maximise their ‘utility’ byemploying strategic calculations;1 moreover, institutions are createdthrough voluntary agreement between actors, based on an assessment ofhow much can be gained through cooperation (Hall and Taylor 1996).Rational choice theorists also assume that individuals seek to maximise a set

Interest Groups and Health System Reform 421

of goals according to their preferences and that institutions persist becausepeople – or at least those who are most powerful – think that to deviate fromthem would make them worse off. An institution’s survival, therefore,depends on whether it is perceived by powerful stakeholders to generategreater net benefits than alternative institutional forms and, in practice,institutional frameworks, once decided, are likely to be quite rigid(Rothstein 1996; Shepsle 1986).

There are some differences between the reforms of 2000 and 1983–84. The1983–84 reform represented the first attempt to universalise the health caresystem; hence there were significant set-up costs. In 1984 the plan to unifythe insurance funds was abandoned (because of reactions from keystakeholders) and the focus shifted to expansion, primarily of the hospitalsector. The fragmented health insurance system remained and it was notuniversalised. Thus there were several ‘winners’: hospital doctors and staff(civil servants); privileged insurance funds2 which had access to an expandedhospital sector without bearing the full costs (because of governmentalsubsidies); and agricultural workers whose coverage was extended topharmaceuticals. In contrast, the 2000 reform represented an attempt toalter the institutional setting of the health care system and threatened toreduce the privileges of many interest groups. From the perspective ofrational choice theory, in this case, interest groups viewed the reform as azero-sum game; despite their divergent interests, they were motivated topreserve their privileges and oppose the proposed changes.

The next section provides a synopsis of the historical development of theGreek health system followed by a brief description of its current state. Theobjective of this paper is to analyse the ambitious reform attempt of 2000through the lens of rational choice institutionalism, identifying the initialgoals of the reform, the reactions of the key stakeholders and the legislativeoutcome. In closing, we discuss future challenges.

Historical Development of the Health System

Social health insurance in Greece originated from a system of occupationalfunds that covered a small proportion of the population in the early 1930s.The law establishing an insurance fund for all private sector employees(Ίδρυμα Κοινωνικών Ασφαλίσεων – Social Insurance Institute, IKA) in 1932was the first to address inequalities in social security. Since the coverageprovided by IKA was quite limited, several additional funds were createdfor professional groups by 1940. The civil war (1946–49) that followedWorld War II contributed to the depression of the Greek economy andstrong political polarisation, with a significant proportion of the populationinadequately covered for the costs of health services.

The political climate remained unfavourable for universalistic ideals in thefollowing decades. The defeat of the left wing in the civil war was one ofmany obstacles. In addition, clientelistic relations developed between the

422 E. Mossialos and S. Allin

state and certain social groups, creating a political environment thatsupported the unequal distribution of privileges (Mouzelis and Pagoulatos2002). Furthermore, there was no definable period of industrialisation, nor adevelopment of a middle class. Rather, through the 1950s and 1960s, manysmall and medium-sized firms employing mainly unskilled labour developed.The climate was further characterised by limited unionisation, and heavystate control of the few existing trade unions. During this time, some white-collar trade unions were able to receive more comprehensive insurancecoverage, thus leading to the development of the so-called privilegedinsurance funds.

At this stage, the health system consisted mostly of private delivery withhealth professionals working in both public and private sectors. In 1961, theright-wing government extended social security by creating an additionalinsurance fund, OGA (Οργανισμός Γεωργικών Ασφαλίσεων – Social SecurityFund for Farmers), mainly providing the rural population with pensionsand basic medical care, probably as a response to the increasing discontentaimed at the government and the unexpected significant gains of a left-wingparty in the 1958 elections. The seven-year military dictatorship and thesubsequent conservative government (Νέα Δημοκρατία – New Democracy,ND) in the 1970s was a period of limited investment in the health sector. In1980 the Minister of Health, Spyros Doxiadis, aimed to reorganise thehealth sector with several changes: developing a National Health Council, ahealth planning body consisting of representatives from the differentstakeholders; decentralising aspects of decision-making to regions; allowingregulated private practice in public hospitals; and reforming medicaleducation. However, in light of strong opposition from all doctors’associations and his own party, in addition to external constraints such asthe oil shocks of 1973 and 1979, the proposed reforms were never discussedin parliament.

The Establishment of the ESY

A new era in health policy began with the Pan Hellenic SocialistMovement’s (Πανελλήνιο Σοσιαλιστικό Κίνημα, PASOK) election to powerin 1981 and the subsequent enactment of the ESY law (in 1983) whichstipulated universal entitlement to health care and fair distribution of healthresources. PASOK won the election with 48% of the vote. With theopposition in disarray, the environment appeared to be ripe for both thepassage and implementation of this reform, with PASOK embracing theideological objectives of major social reform under the motto ‘Allaghi’(Αλλαγή – Change). Furthermore, for the first time, the Athens MedicalAssociation, which in the past had strongly opposed reforms, was influencedby PASOK. Also, support for reform had gained momentum among juniordoctors, who were finding it increasingly difficult to secure their own


practices due to the rising number of physicians in Greece (Davaki andMossialos 2005).

According to the ESY law, the state was to become the main provider ofhealth services and the insurance funds would be united into a single fund.Entitlement to health services would be linked to citizenship, rather than toan occupational group. The law also provided for the absorption andeventual abolition of the private sector; a moratorium was placed on thecreation of new or the expansion of existing private hospitals, while non-profit hospitals were nationalised. Physicians in the ESY (includinguniversity doctors) would be employed full-time, without permission toengage in private practice. In addition, a system of referral based on familydoctors and a network of rural and semi-urban health clinics was meant torepresent a first step towards organising a comprehensive system of primarycare.

The ESY was to be decentralised through the establishment of RegionalHealth Councils, which would have advisory and supervisory authority overhealth matters in ten health regions (Tountas et al. 2002). Decentralisationwas intended to facilitate a fairer distribution of health resources, withpriority given to the development of a rural health infrastructure to reduceinequalities (Kyriopoulos and Tsalikis 1993).

However, opposition from several stakeholders emerged and, as a result,most of the reforms did not materialise. Physicians engaged in privatepractice, autonomous insurance funds, trade unions and social groups thatreceived enhanced health care benefits from privileged funds (e.g. tradeunions from the electricity, banking and telecommunications sectors as wellas civil servants), and bureaucrats who did not want to see powerdecentralised, were threatened by changes that could have diminished thebenefits they derived from the existing fragmented system. Members of theopposition parties, along with high-ranking members of the PASOK,adamantly protested against the unification of insurance funds, and theSpeaker of the Parliament, Ioannis Alevras, even threatened to resign if theprerogatives of the insurance funds were abolished (Davaki and Mossialos2005).

Other contributing factors can be explained by the persistence of longengrained clientelism (Lyrintzis 1984), excessive bureaucratic administra-tion, poor planning and management capabilities, and a lack of technicalcapacity and expertise in managing change. Thus, the ESY was not fullyimplemented.

Between 1983 and 1984, it became increasingly de rigueur to denounce theunification of the insurance funds due to the poor state of the Greekeconomy (between 1981 and 1985 the public deficit increased by almost50%) and by citing the pressures imposed by stakeholders and universitydoctors. Therefore, Georgios Gennimatas, a prominent figure in theSocialist party, was appointed Minister of Health in 1984 and quicklychanged the course of reform. The Minister declared that the funds would


not be unified, and the focus of reform shifted away from primary care anduniversalising the system towards hospital sector expansion. This policyshift was perceived by the government to be a way to ensure a winning handin the next election. Hospital doctors and civil servants also viewed it as ameans of expanding their power base and strengthening their ownclientelistic relationships within the health care system. While about 200rural and semi-urban health centres were established and pharmaceuticalcoverage extended for OGA members, the bulk of the reform shifted itsfocus to developing hospital care, specifically in the two biggest cities(Athens and Thessaloniki), where the leaders of the hospital civil servants’association (Πανελλήνια Οργάνωση Εργαζομένων Δημόσιων Νοσοκομίων –Pan Hellenic Organisation of Public Hospital Employees, POEDYN) anddoctors’ trade unions were based. Personal posts were created in the ESYhospitals for doctors connected to PASOK and, in particular, the attempt in1985 to mandate the exclusive practice of university doctors within the ESYwas never passed by parliament due to heavy lobbying and prime ministerialsanction.

However, unequal coverage persisted, the family doctor and referralsystems were not established, decentralisation was not initiated, and privateexpenditure on health care continued to rise (Tragakes and Polyzos 1998).The increasing private expenditure can be attributed to (a) the restrictionson private hospital development that resulted in private entrepreneursshifting their attention to, and dominating, the diagnostics sector and (b) theculture of informal payments in public hospitals that persisted.

1985–2000: Reform Stagnation

Between 1985 and 2000, health reform was not high on the policy agenda.During the New Democracy government from 1990 to 1993, the objectivewas to reduce the deficits of the social insurance funds and to increaseprivatisation in the health sector. The government allowed new privatehospitals to be established in 1992 but there was little actual change sincethere had already been a shift in private sector focus away from hospitalstowards more profitable investments such as diagnostics and medicaltechnology. Moreover, part-time private practice for doctors in publichospitals was again permitted, but proved unsuccessful, with doctorscontinuing to siphon off patients to their informal private practices. Therewas also a proposal to extend free choice of doctor (available only formembers of the privileged funds) to the entire population, but due to fiscalconstraints this plan never materialised.

With the election of PASOK in 1994, an international committee ofexperts was invited to Greece to examine the reform options for the healthsystem (Abel-Smith et al. 1994). The Committee had several recommenda-tions: develop public health services; introduce a general practitioners’scheme reimbursed by capitation; eliminate the differences in primary care


provision between social insurance funds; improve hospital management;abolish the permanent tenure status of hospital personnel; and introduce areferral system by general practitioners. The Committee emphasised theneed to pool health care resources and to have a unified fund that would actas the sole purchaser of public and private services.

While the Ministry of Health accepted the report’s principles, the tensepolitical climate in Greece, due to Prime Minister (PM) Papandreou’scritical state of health and the ambivalence of the government, did not allowa comprehensive discussion of the Committee’s recommendations (Tountaset al. 1995). Stakeholders with interest in maintaining the status quo werequick to oppose the recommended reforms. For example, hospital doctors’trade unions objected to change in the management of the public hospitalsystem, claiming that it threatened their tenure status and would establishneo-liberal policies (Sanidas 2000).

Between 1996 and 2000, the public policy agenda largely focused onmeeting the criteria for joining the Economic and Monetary Union (EMU).During this time there were three different Ministers of Health, each havinglittle impact on health care reform. In February 1996, the new PM, CostasSimitis, appointed Anastasios Peponis as the new Minister of Health.Although reform plans existed, it is reputed that the PM asked the Ministernot to present them to parliament in light of the forthcoming elections.Following the 1996 elections, a new Minister of Health, Costas Geitonas,was appointed. Some of the reform plans under his stewardship included thecreation of a coordinating body for the insurance funds, albeit withoutgiving it a clear mandate (which entailed regular meetings of the funddirectors, although only two meetings took place in three years), and thecreation of primary care networks for groups of specialists, for which detailswere never produced. Following the 1999 elections, Lampros Papadimastook over as Health Minister but his role was more as a caretaker of thesystem, dealing with daily affairs, rather than one which was geared towardsproposing policy changes.

Health reform initiatives remained relatively static until 2000, whenPASOK was re-elected. The new Minister of Health, Alekos Papadopoulos,who had implemented tax reform measures and reformed local authoritieswith some success, announced a major health reform plan. Prior toanalysing this reform in detail, the current health system will briefly bedescribed.

Overview of the Health System

The Greek health care system is characterised by a fragmentedadministrative framework, high overall expenditure (9.4% of GDP in2000) with a large source of funding from out-of-pocket spending (41%),significant overlapping of private and public medical practice, inadequatehospital services, a low level of primary health care, and unequal benefits


coverage across different occupational groups in the different funds. Thereis insufficient monitoring and oversight within the system and loosecontrol of medical professionals, due to the lack of systems for medicalrecords, health information and quality assessment. Greece is also forcedto rely on more expensive human resources to run its health system: thereis an oversupply of physicians (with the highest number of doctors per1,000 population in the EU), with less than 2% being generalpractitioners.

The system relies on a mix of public and private sources for both fundingand delivery. Health care coverage can be obtained via three main sources:the ESY, health insurance funds, or private health insurance. The ESYprovides hospital and primary care through approximately 200 healthcentres and 1,000 rural doctors’ posts to the semi-urban and ruralpopulation. Insurance funds cover over 95% of the population. Of the 30health insurance funds that currently exist, the three largest funds – IKA(blue- and white-collar workers), OGA (agricultural workers), OAEE(Οργανισμός Ασφάλισης Ελεύθερων Επαγγελματιών – Social Insurance Fundfor the Self-employed) – cover approximately 80% of the population. Anadditional 7% of the population is insured under OPAD (ΟργανισμόςΠερίθαλψης Ασφαλισμένων του Δημοσίου – Social Security Fund for CivilServants), a scheme for civil servants, their dependants and militarypersonnel. Members of IKA have access to their own network of primarycare centres, OGA members have restricted access to primary careproviders, and the remaining funds offer free choice of doctors and betteraccess to private contracted doctors and diagnostic centres. Insurance fundcontributions are derived partly from employers and employees and aresubsidised partly by the government. Approximately 8% of the populationhas private insurance, which mostly consists of individual policies and oftentargets young and healthy segments of the population.

Rational resource allocation methods are not yet employed in Greece toadjust for regional differences in needs and access or differences in riskacross insurance funds. Rather, resources are allocated based on historicalprecedent and, to some extent, on political negotiations. As a result,regional inequalities are significant, with the majority of resourcesconcentrated in urban centres, such as Athens and Thessaloniki. Inaddition, health resources are skewed towards more expensive diagnosticand specialist procedures. For example, the number of computerisedtomography (CT) scanners per million population in 2001 (16.4) is higherthan in the UK (6.1), France (9.7) and the US (13.2) (OECD 2004), whichcan be attributed to the rapid private sector expansion in the area ofdiagnostics and medical technology in the 1980s.

Specialists working in ESY hospitals and primary care centres are paid ona salaried basis. All ESY hospital doctors are full-time employees who, untilrecently, were not allowed to see patients privately. However, many did sodespite this prohibition, and as a result worked less than a full day. Doctors


contracted by health funds are paid on a fee-for-service basis; however, thefees tend to be set quite low and doctors may supplement their income byextra-billing. With no monitoring systems in place, there is little incentive toimprove quality of care and ensure appropriate treatment and rationalprescribing. Moreover, a culture of informal payments thrives in Greece,which is partly attributable to the lack of comprehensive health carecoverage, and is reinforced by the over-supply of rent-seeking physicians.

The 2000 Reform: A New Opportunity

Initial Goals of the Reform and Legislative Outcome

With the re-election of PASOK in April 2000, there was some degree ofambiguity regarding the direction of the next major government health plan,especially as the previous four-year plan had focused on meeting theconditions for Greece to join the EMU. The new Minister of Health was apowerful member of the party and there were high expectations for thegovernment to embark on significant public sector reforms. Within fourmonths of his appointment, the Minister announced a health reform planwhich consisted of four components: (1) the coordination of insurancefunds’ purchasing and monitoring activities through the Organisation forthe Management of Health Resources (Οργανισμός Διαχείρισης ΠόρωνΥγείας, ODIPY); (2) the establishment of 17 Regional Health Systems(Περιφερειακά Συστήματα Υγείας, PESY); (3) the organisation of a primaryhealth system through a contractual relationship with primary care doctors;and (4) the introduction of an evaluation programme for ESY doctors, inaddition to addressing employment relations to formalise informalpayments.

The aim of coordinating the insurance funds was to create a monopsonypurchaser in order to rationalise the purchasing system. The Minister’sproposal sought to consolidate the four largest funds, which covered 87% ofthe population, giving the remaining funds the option to join voluntarily.While not dissolving each fund, the Minister proposed instead to create asingle entity (ODIPY) to manage the resources of the individual funds.There were no plans to equalise health benefits across the funds.

The Regional Health Systems aimed at improving efficiency and quality inthe delivery of health services. The legal status of each individual hospitalwas to be abolished and made accountable to the regions. This changewould place regional directors in a position to plan the health system for theregion, rather than having to go through the hospitals that were largelycontrolled by party members and trade unions. In this way, regionaldirectors would have the leverage to influence employees; for example, toallow personnel to move across hospital departments and across hospitals,areas where previously there had been considerable rigidity, with personnelbeing tied to particular departments and hospitals.3 Furthermore, the aim


was to shift the power-base of the hospital boards, the majority of whichwere composed of government-appointed members and representatives ofthe hospital unions, to the regions. Overall, this proposal represented achange in the institutional structure of the health system by introducing amediator between hospitals and the Ministry of Health. Thus, there was ashift in the lines of accountability (and hence a power loss) away from boththe Ministry of Health and the hospitals to the regions, a process that wasexpected to attract significant reactions on both fronts.

The Minister proposed the establishment of a primary care system,which aimed at the population registering with a ‘personal’ doctor.Advisors believed the term ‘family doctor’ would not reflect the‘individualistic culture’ in Greece, and would be perceived by thepopulation as a strict primary care system made up of government-appointed doctors with no choice. Primary care doctors would becontracted by the insurance funds and paid on a capitation basis. Whiledirect access would be permitted to ENT specialists, ophthalmologists,dermatologists, gynaecologists and psychiatrists, access to other specialistswould be based on referrals from the personal doctor, hence establishinga gate-keeping system. If patients bypassed their personal doctor, theywould have to bear half the cost of the visit. Therefore, the proposalallowed for some freedom of choice, but also included incentives forpatients to adhere to the referral-based system. Similarly, in order tomaintain a system of medical records and to coordinate patientinformation, specialists would be required to inform patients’ personaldoctors of their visit. If the patient was not referred, the specialist stillwould be required to inform the personal doctor of the visit, and untilthis was done the specialist would not be paid the remaining half of thefees by the patient’s insurance fund.

The fourth component of the 2000 reform addressed employmentrelations. Permanent ESY doctors were given the option of establishingafternoon private practices within hospitals in order to formalise some ofthe informal payments they habitually received. All tests and diagnosticprocedures linked to the consultation would be paid by the central fund toredirect some of the insurance funds’ payments for diagnostics in the privatesector to public hospitals. The Minister also addressed the multipleemployment relationships of university doctors by obliging them to chooseto practise either in the public or private sector. If they remained in theESY, they would receive a salary bonus of e1,000 per month and maintainthe option of afternoon private practice. However, if they chose the privatesector, university doctors would relinquish the privilege of becomingdirectors of ESY clinics. Also, the Minister proposed to integrate primaryhealth care with that offered by IKA; at which point the 5,000 doctors (outof 8,000) on temporary contracts with IKA would be offered theopportunity to compete with other doctors for contracts in the system ofpersonal, primary care doctors.


The reform plan also included the introduction of formal evaluation forall hospital directors and personnel. Hospitals’ organisational structure ishierarchical, with a set order of positions: director, deputy director, followedby three grades of specialists and trainees. The system is very rigid,promotions are rare and directors are replaced only when they retire. Unlessthere is a vacancy in another hospital, a specialist or deputy director cannotadvance to a higher post. Moreover, the system offers no incentive forprofessional development, skill building and further training. Initially,therefore, the plan was in favour of evaluating personnel and increasingopportunities for promotion so as to encourage quality improvement.Furthermore, the reform included a proposal for the creation of a qualitycontrol agency to collect data on the performance of doctors and hospitals,for example on medical errors and appropriateness of care.

Reactions of Key Stakeholders

Unlike earlier attempts to reform the system, the 2000 reform plan wasclearly defined and left no provisions to be outlined in the second stage ofthe legislative process (Presidential Decree). This factor explains theimmediate and strong reactions by stakeholders to the reform. Normally,laws that require a Presidential Decree cannot be implemented without theinitiative of the relevant Ministry, and components of any law that are leftundefined or are ambiguous can be revised at a later date. In such cases, thepassage of legislation does not guarantee its implementation, making it lessof an imperative for interest groups to oppose the passage of a Bill that theyview as unfavourable. Paradoxically, in these circumstances, legislation maybe enacted without significant opposition, which indeed had been the casewith most health reforms in the past, including those of 1983–84, which leftmuch to be articulated in Presidential Decrees. However, in 2000, notleaving any details of the law to be determined by Decree created anincentive for interest groups to intervene prior to the legislation being placedbefore parliament. As summarised in Table 1 and elaborated below, the keystakeholders in the Greek health system stood to lose from the reform, interms of benefits, power, and autonomy.

Civil Servants

Greek bureaucrats are usually trained in law or political science, but rarelyhave additional pre-service or in-service training. As a result, they often lackthe traditional organisational coherence, status, class assets and expertisecommonly associated with Western European civil servants. Althoughrelatively large in size, the Greek bureaucracy remains largely inefficient andweak compared to political parties (Sotiropoulos 1995). Due to the Greektradition of interest intermediation through patronage, the central bureau-cracy has failed to acquire an independent status in the political system. In


TABLE 1

STAKEHOLDER RESPONSES TO 2000 REFORM

Stakeholder Reasons for objecting to reform Actions and demands

DoctorsIKA doctors Were opposed to the primary

health system, because itwould have meant theselection of the mostcompetent doctors

Tenure posts, increasedsalaries. Repeated strikes:2000–2001

Hospital doctors Evaluations of hospitalpersonnel, monitoring ofactivity, afternoon clinics,decreased influence indecision-making

Increased salaries and staff.Strikes (mainly in January andFebruary 2001)

Private, self-contracteddoctors

Afternoon clinics, coordinatedfund (which entails increasedmonitoring)

Increased fees. Some strikes,coincided with other doctors’associations

University doctors Restricted practice Status quo – to remainworking in public and privatesectors. Repeated strikes

Civil servantsMinistry of Health Reduced power (with regional

health authorities)No explicit actions, despitegeneral dissatisfaction with thereform

Hospitals New PESY represents apower shift from to theregional directors and hospitalmanagers, eroding theclientelistic relationships.Evaluations of hospitalpersonnel

Increased staff and salaries.Some strikes with the hospitaldoctors

Insurance funds‘Privileged funds’ Opposition to the coordinated

fundStatus quo

IKA Opposition to the coordinatedfund

Status quo

Political PartiesSocialist (PASOK) Officially there was no

opposition to reform.Unofficially, because manyMPs and ministers had linkswith and supported the civilservants’ associations, theywere dissatisfied with theMoH’s actions, and the powershift with the PESY

-

Opposition (ND) General opposition to reform;supported the universitydoctors

Made public statements ofdisapproval

GovernmentPrime Minister Openly in favour of the

reform, although did not makestrong supportive statements

Allegedly did not want theMinister to confront theuniversity doctors

Minister of Finance No open opposition to thereform and pledged fundingfor health would increase

In fact funding for health caredecreased

(continued)


particular, the Ministry of Health has been strongly influenced by PASOK;over the years many ministry employees have been re-routed from theiroriginal hospital positions as part of the process of political patronage andare not well equipped in their new roles as functionaries within the centraladministration.

Moreover, both PASOK and the conservative New Democracygovernments have successfully inflated the political component of thebureaucracy by creating inter-ministerial committees of political appoin-tees. This was especially true during the 1980s when PASOK appointed anumber of political supporters to clinical and non-clinical posts withinpublic hospitals. Additionally, the president and several board membersof the Civil Servants’ Association (Ανώτατη Διοίκηση Ενώσεων ΔημοσίωνΥπαλλήλων – Supreme Administration of Greek Civil Servants’ TradeUnions, ADEDY) come from the hospital civil servants’ association(POEDYN), therefore creating more entrenched interests within thisumbrella organisation.

Civil servants both in the Ministry of Health and the hospitals opposedthe regional decentralisation of authority to the PESY, which signified apower shift away from the party-affiliated hospital boards to regionaldirectors. The overall discontentment with the reforms was expressed byPOEDYN as it reportedly argued that ‘the reforms are not in the interests ofhospital staff and patients in the ESY’ (Athens News 2001a). The newPESY law stipulated the replacement of the appointed, clientelistic chairs ofhospital boards with a manager and weakened hospital boards. POEDYNwas determined to gain more authority by undermining the role of thehospital managers. The association initially kept quiet in the hope that itwould be able to influence the appointment of hospital managers, but once itbecame clear that its influence was reduced, and that some of the regionaldirectors and hospital managers were not affiliated to the ruling politicalparty, POEDYN orchestrated protests in several hospitals.

Since hospitals were to lose their individual legal status, this furtherrepresented a power shift to the regions. Opposition to this power shift wasrevealed to some extent by a statement made by ADEDY’s president in

TABLE 1 (continued)

Stakeholder Reasons for objecting to reform Actions and demands

Minister of Education As with the PM, was openly infavour of reform, although hedid not take a strong position

Allegedly sided with theuniversity doctors

Private SectorHospitals and diagnosticcentres

There was no open oppositionto the reform

Status quo, because feltthreatened by the prospect ofunified fund and afternoonclinics


December 2003, some time after this particular policy was actuallyimplemented. The association:

considered [the PESY] as playing a role in planning and to a lesserextent being involved in the daily administrative and managerialproblems of hospitals . . . in the regions. The PESY could haveincreased activities, such as acting as a body that could guaranteecomplementarity of activities . . . in the main urban centres. Hospitalsshould have retained their legal entity. (Hellenic Parliament 2003: 456)

Insurance Funds

The coordination of the funds’ activities represented a means of establishinga monopsony purchaser in order to facilitate more rational resourceallocation and put pressure on providers in terms of quality and prices.Although the proposed coordinating body did not entail the equalisation ofbenefits, it was perceived by the funds to be the first step towards thischange. Moreover, the more powerful and privileged social groups did notwant funds to be coordinated because they were afraid of losing theirprivileges. The president of the hospital doctors’ federation (ΟμοσπονδίαΝοσοκομειακών Γιατρών Ελλάδος, ONGE) revealed the commonly heldopinion that coordinating the funds would reduce the privileges of certainfunds, stating that the Greek General Confederation of Labour (ΓενικήΣυνομοσπονδία Εργατών Ελλάδος, GSEE) ‘is afraid that OGA will be mergedwith IKA and ADEDY and that they may lose free choice of doctors’(Hellenic Parliament 2003: 459).

Finally, some opposition from IKA could be attributed to the ‘personaldifferences’ and a longstanding feud between the director of IKA and theMinister of Health. It was widely reported in the media that the Ministerand IKA’s director, who was accountable to the Minister of Labour,disagreed on the pace of the reform. More specifically, IKA officials sawtheir roles as leading the social insurance coordinating activities as well asprimary care reform, and were not satisfied when it became obvious that thiswould not be the case.

Doctors

Although the level of doctors’ unionisation has fallen in the last 20 years,two main public sector unions remain: those of ESY doctors (ONGE)and IKA doctors (Πανελλήνια Ομοσπονδία Συλλόγων ΕπιστημονικούΥγειονομικού Προσωπικού του Ιδρύματος Κοινωνικών Ασφαλίσεων – PanHellenic Federation of Health Scientists of Social Insurance Institute,POSEYPIKA). Official medical societies, created by national law toperform official, public functions, also negotiate as trade unions on behalfof physicians (Colombotos and Fakiolas 1993) whilst contracted self-


employed doctors in different districts have formed their own association.All doctors must also be members of geographically defined medicalassociations, which are meant to represent their interests. Of theseassociations, the Athens Medical Association (Ιατρικός Σύλλογος Αθηνών,ISA) and its umbrella organisation (the Pan Hellenic Medical Association– Παννελήνιος Ιατρικός Σύλλογος, PIS, which, in theory, is supposed toadvise the Ministry of Health on professional issues) are the most active.These doctors’ unions have had longstanding political links and exertpressure from within competing political parties. The PIS, ISA (apartfrom a short period in the early 1980s when the left wing took control)and POSEYPIKA generally have been seen as representing the right wingof the political scene and ONGE the left wing.

The proximity of university physicians to the political environment isparticularly close. University doctors are reputed to have a powerfulinfluence on the government’s personnel appointments in universityhospitals and on health policies. Their influence is usually expressedinformally and personally, on an individual level (Colombotos and Fakiolas1993), or through their strong links with media owners rather than throughany formal organisation (Davaki and Mossialos 2005).

Since there are competing trade unions within the medical profession,with little cooperation across groups, one would have expected thissegregation to weaken the power of physicians. However, the differentphysician associations all had a common interest in blocking healthsystem reform, albeit for different reasons, and therefore remained apowerful interest group. IKA doctors were the first to react to thereform, as they adamantly opposed the proposal that the 5,000 out of8,000 doctors who were on short-term rolling contracts should competeto join the new primary health care system. They went on strike in July2001 and continued with strikes for the rest of 2001, demanding tenurestatus for those on rolling contracts. Papadopoulos insisted that doctorswould not have tenure, which triggered further strikes. There also hadbeen pressure for wage increases way above the national collective labourcontract signed by the GSEE and employer organisations. By 2002 IKAdoctors called off new threats of industrial action because their strainedrelations with the Ministry of Health had eased somewhat due to the factthat it had become apparent that the primary care reforms were notgoing to be enacted.

Following IKA doctors’ vehement objections, the most significantreaction to the proposed reforms came from university doctors. From thebeginning, the climate was not favourable for reform, as an editorial clearlyput it:

The small and large interests that were threatened by the attemptedreform got a foothold inside the government, especially the all-powerful faction of university doctors, which spearheaded the overall


campaign against the reform. At first, Papadopoulos was urged bysenior Socialist officials and the prime minister himself not to abolishthe scandalous privileges of university doctors. His refusal to backdown triggered the countdown to the end of his career as healthminister. (Kathimerini 2002a)

University doctors objected to the forced choice of either private or ESYpractice. Another editorial described their reaction to the Minister’s reformplan:

University doctors have proved to be extremely obstinate in their clashwith the Health Ministry. They may not have hoisted red flags ortaken to the streets to protest, but in essence, they make the mostuncompromising unionists look like amateurs. As is usually the case inissues like these, this is a struggle over money. Until now, universitydoctors have been able to hide behind the apathy of the EducationMinistry. (Kathimerini 2002b)

The university doctors voiced their opposition to the Constitutional Court,claiming that their human rights were being violated on the basis of theEuropean Convention on Human Rights. However, the court ruled againstthe doctors, who then went on strike and refused to teach their students.During this time, the press gave significant prominence to their views andcampaigns.

In light of this opposition, the Minister of Health proposed that the newlybuilt hospital in Athens (Haidari Hospital) be given to university doctors fortheir sole use. It is reputed that the doctors viewed this hospital asunsuitably located, being outside the city centre in a low-income area.However, they formally argued that the new hospital was not well equipped(for example, there were not enough teaching theatres although these couldeasily have been built) and they refused to accept this offer. It was not untilthe Minster of Health was replaced in June 2002 by a former universityprofessor that the university doctors accepted Haidari Hospital as theirown,4 while continuing to maintain their clinical freedom to practise in bothprivate sector and ESY hospitals, the very stake that was at the centre of theoriginal trade-off.

The hospital doctors opposed the reform for several reasons. First,hospital managers and the PESY would be monitoring hospital activities ina different manner from the politically appointed hospital boards, whichhave different interests. Second, a unified fund and the resultantrationalisation of the system would impact on doctors’ clinical autonomy,in particular with regard to quality control and clinical guidelines. Third, theproposed formal evaluation and quality control schemes would entail morework for doctors, yet there was no room allowed for promotion within therigid hospital system. Fourth, afternoon private clinics within ESY facilities


were criticised on the basis that it would create a two-tiered system;however, this criticism must be viewed within the context of the two-tieredsystem, characterised by widespread informal payments, that alreadyexisted.

As a result, hospital doctors went on strike in January and February2001, during the period of reform discussions in parliament, demandinghigher salaries and staff increases. According to the president of theAthens hospital doctors’ association, the reason for the strikes that werestaged during the time the bill was being discussed in parliament was to‘stress the importance of maintaining the ESY’s public character andensure it remains accessible to the public’ (Athens News 2001b),highlighting the argument against the private afternoon clinics. It wasalso stated that ‘the bill creates the impression that hospitals will betransformed into private companies . . . it foresees the formation of state-owned companies that will control hospitals’ funding and operation’(Athens News 2001c). ESY doctors demanded ‘more hospital funding’and that the government ‘give more money to the ESY and leave thehospitals alone’ (Athens News 2001d). Furthermore, ESY doctorsreportedly believed that they would ‘not be able to maintain theirprofessional freedom’ and that, despite no plans for staff reductions, oncethe bill was passed they would ‘face difficulties securing full-timeemployment’ (Athens News 2001c).

Private contracted doctors opposed the coordination of the funds andafternoon clinics. A monopsony purchaser would have created a morecompetitive environment and involved increased monitoring, for exampleof quality of care and prescribing patterns. Private doctors organisedstrikes that coincided with those of the hospital doctors (OENGE andEINAP, Ένωση Ιατρών Αθήνας-Πειραιά – Union of Hospital Doctors ofAthens-Piraeus), civil servants (ADEDY) and GSEE (Athens News2001e). Therefore, despite the differing interests of the various doctorsand civil service groups, there were common, and sometimes coordinated,reactions.

The Private Sector

While there was little formal reaction from the private sector, most privatesector entrepreneurs opposed the reform. Although the owners of privatehospitals and diagnostic centres did not openly take sides during the reformprocess, they did not want the reform to succeed. For example, the powerfuldiagnostics sector was against the coordinated fund, because, like thesituation for doctors, this would involve increased monitoring, competitiveprices, increased scrutiny in terms of measuring appropriateness of care andin the design of contracts, where different terms and conditions existedacross different independent funds. Private diagnostic centres also stood tolose their market share if improvements were made to the public system and


they opposed afternoon private practice clinics, as these would redirectinsurance fund payments from private sector diagnostics to public hospitals.As reported in an Athens newspaper, ‘private clinics, hospitals anddiagnostic centres constitute the health insurance funds’ most important‘‘customers’’, absorbing a large chunk of public expenditure’ (Athens News2001f).

Unlike private hospitals and diagnostic centres, private insurancecompanies had little to gain or lose, as they constituted such a smallproportion of the insurance market.

Government and Opposition

Ministerial responsibility for the health care sector is divided between theMinistry of Health, responsible for hospitals, the Ministry of Labour,responsible for insurance funds, and the Ministry of Education, responsiblefor university doctors. Therefore, there are potentially different interestswithin the government. Within PASOK, opposition to the reform emerged.Politicians, who were accustomed to being able to influence individualappointments in hospital boards, no longer had political connections withsome of the regional directors and hospital managers who were directlyaccountable to the Minister of Health. Additionally, the PM was reluctantto make any changes. Fiscal constraints preoccupied the government sothere was little support for investing in and expanding the health sector; andin the case of the hospital evaluation plan, to create more room forpromotions.

While the political opposition was against the reform, it did not offer analternative. There were several visits, which attracted significant mediaattention, by the opposition leader to public hospitals in the hope ofidentifying visible problems, such as poor hygiene or obsolete equipment.The opposition openly supported the university doctors and their plea toremain in both the private and public sectors. The main opposition party,ND, is reported to have stated that ‘in some areas, the bill violatedconstitutional rights and [they] would take the matter to court if the bill waspassed’ (Athens News 2001b) but this threat never materialised. The partyalso argued that the afternoon private clinics created a two-tier system,undermining the equity principle.

The two left-wing political parties in parliament (the Communist Partyand the Coalition of the Left and Progress) also opposed the reform,claiming it represented a right-wing, neo-liberal and technocratic approachto increase state control and subordinate the rights of employees.

Media and Public Opinion

Although not stakeholders in the health system, it is important to considerthe role the media played during the reform process. The majority of media


groups in Greece are family companies developed from small companiesinto large conglomerates that are also involved in public works, financialmarkets and some in gambling operations. The market is controlled by asmall group of companies that tries to maintain a balance of power andrelies heavily on state-commissioned projects.

The media have not traditionally played a major role in health sectorreforms. However, the idea that this sector is ‘low impact’ has evaporated inlight of its coverage of the health reform package. There was extensivecoverage of health care issues throughout Papadopoulos’ ministerial term.In the initial stages of the reform, there was considerable positive publicity,but after the law was passed in 2001, coverage was mixed and, in some cases,negative, even among ‘government-friendly’ media. It is unclear whether thisreflected the lack of clear government support for the reform.

Public opinion polls revealed elevated interest in health care issues duringthe reform process between 2000 and 2002. The MRB public opinion trendsreported that 43.7% of respondents in December 2001 considered healthcare as one of the most important issues facing Greece;5 health care becamethe second most important issue after unemployment (56.4%), up from36.8% in December 2000 (MRB 2004). In July 2002 health care was evenmore highly cited (55.6%, again ranked as the second most important issue,compared to 64% for unemployment). In December 2003, just six monthsafter the Minister was replaced, there was a decline in the perceivedimportance of health care to 39.7%. Also during this time, media coverageof health care issues was significantly reduced.

Which Measures were Actually Legislated?

The Minister announced his plans for reform in late July 2000 and invitedall stakeholders and interested citizens to express their views on the planwithin the next three months. Opposition to the new reform initiatives camefrom several directions, as shown above. The critical loss of politicalmomentum occurred within six months after the Minister’s white paper waslaunched in July 2000. By December 2000, the Minister had decided tomodify his proposals and the law that was passed by parliament in early2001 was far weaker than was initially expected.

There are several reasons why the reform plans were moderated. First,although the Minister of Finance gave the impression of a healthy economy,and made the statement in May 2000 that the ‘next budget will be a healthcare budget’ (Cryssolora and Politis 2000),6 it was well known that this wasnot the case. The actual budget for health and welfare services was reducedby e4.52 million between 2000 and 2001 (Hellenic General AccountingOffice 2002).7 This fiscal insecurity was exacerbated by the considerableinvestment made for the upcoming Olympic Games, which was becoming anincreasing political priority and straining the already indebted public purse.Second, it was decided not to fully confront trade union leaders in light of


their vociferous opposition to both the unification of the social insurancefunds and the reduction of power that would result from the introduction ofPESY. Third, there was reluctance to displease IKA doctors, who wereopposed to being forced to enter the primary care system, in which manywould probably be excluded on the basis of their competence, andresponded with lengthy rolling strikes. Finally, the climate in thegovernment was not supportive of the minister and his reforms, as reflectedin an editorial in Kathimerini. ‘In the summer of 2000, a few months aftertaking office as health minister, Alekos Papadopoulos announced anambitious reform plan. The Cabinet approved the plan, but soon theminister was all alone’ (Kathimerini 2002a). Therefore, the Minister decidedto first undertake reform of the hospital sector. In 2001, a law was passed toestablish the PESY. Seventeen Regional Health Systems were created: threein Athens, two in Thessaloniki and one in each remaining political region.The decentralised system was intended to create a ‘parallel’ structure to thatof the Ministry to coordinate hospital services and planning at a regionallevel.

The revised law included provisions to develop the PESY, legaliseafternoon private practice, and to mandate university doctors to choose theprivate sector or ESY exclusively. The Minister argued that coordinatingthe insurance funds, introducing the primary care system, and developing aquality control agency was to follow once the first stages had beenundertaken.

The law was passed in March 2001. The Minister moved quickly toappoint regional directors and, soon after, hospital managers; he also askeduniversity doctors to make their decision about which sector they wouldremain in permanently. However, there were crucial problems with thisrapid implementation process. The reactions from the key stakeholders, asdescribed above, persisted throughout the two years of the reform process,creating a turbulent climate. There were staffing problems in the PESYbecause specialised personnel were required, but the Ministry of Interior,Public Administration and Decentralisation rigidly defined hiring proce-dures.

Having given up the plans to set up a monopsony purchaser, significantproblems were created with the implementation of the PESY. If acoordinating body for the insurance funds was formed, it could havecontracted services through the PESY, which in turn would have endowedthe PESY with significant powers to impact on efficiency and quality ofcare. However, because financial resources were not consolidated andallocated to PESY to purchase services, PESY powers to implementchange were limited.

The Minister also began implementing the afternoon private clinics in theESY hospitals. It is thought that the implementation of this plan wasrushed, and adequate infrastructure and support was not well considered.For example, there was no information provided to hospitals detailing how


the afternoon clinics would function, and appropriate space was notallocated for the clinics. Although there has been no formal evaluation ofthe afternoon clinics, it is believed that they have been relativelyunsuccessful. The fee for surgical specialists remained low, thereforeattracting very few surgeons to sign up to the scheme. In addition, manyphysicians have been reluctant to limit their private practice to formalisedafternoon hours, and have preferred to continue to accept informalpayments (i.e. un-taxed income). Physicians have also been reluctant toparticipate out of fear that a poor reputation would prevent them fromattracting patients.

As revealed by their reactions, the feud with university doctors wassignificant. The strikes meant that many medical students were unable totake their exams. Once the court ruled against them, the strikes intensified.

Further complicating the implementation of the reforms was the shift inthe government’s political focus from health to pensions during this time.As a newspaper stated in 2001, ‘the present impasse over pensions . . . mayput a break [sic] on Papadopoulos’ reforming zeal’ (Athens News 2001f).Together with fiscal constraints and the vehement reactions of the tradeunions, the Minister became less popular within the government. Giventhis, many key stakeholders expected that the Minister would be replacedin the October 2001 Cabinet reshuffle following the PASOK conference.Somewhat unexpectedly, however, Papadopoulos was elected, withsignificant support amongst party members, to PASOK’s CentralCommittee at the conference, a factor which probably explains the PM’sreluctance to replace him at that time. By the beginning of 2002, pressureon the Minister, in terms of successfully implementing his reform, wasmounting. In an interview with Kathimerini in June 2002, he expressed hisdissatisfaction with the Greek political system, and publicly announcedthat he would not be a candidate for the next election, although he wantedthe PM to proceed with the implementation of the reform (Kathimerini2002a). Several ministers and leading party members attacked him for notsupporting the government.

The PM promptly replaced Papadopoulos with Costas Stefanis, a retiredmedical school professor who also was an eminent member of the AthensAcademy. Independently of the competence of the new Minister of Health,his appointment was criticised for its symbolic impact. In light of the feudbetween university doctors and the previous Minister, Stefanis’ appoint-ment could be viewed as the PM taking sides in support of the universitydoctors.

Between June 2002 and December 2003 there was a slowing down in thepace of change, and the main concern was not to instigate further negativereactions and opposition from stakeholders. In December 2003, anamendment to the legislation was passed, allowing the president of ADEDYto be included in the ESY hospital managers’ evaluation committee,significantly increasing the power of this influential interest group.


Furthermore, in April 2003 the Minister announced his plan to develop aprimary care system and to coordinate the insurance funds with the Ministryof Labour, with backing from the Minister of Finance. The plan was tobring the four largest funds (IKA, OAEE, OGA and OPAD) under onesupervisory IKA-based agency headed by the Deputy Labour Minister, withthe Minister of Finance stating: ‘The four funds will coordinate theirprimary health care programmes so as to improve their members’ access topublic hospitals, private diagnostic centres and private clinics’ (Athens News2003). However, no concrete proposals were produced until December 2003,three months before the election (which was subsequently lost by PASOK),which casts some doubt on their credibility.

Conclusion

This paper has reviewed the historical development of the Greek healthsystem and its current status, and has analysed the latest attempt to reformthe system almost 20 years after the last significant change that introduced anational health system. A conceptual framework focusing on the role ofmedical professionals cannot fully explain the course of reform in Greece.Although doctors represent an important interest group, there are manyother vested interests that need to be incorporated into a broaderframework. Rational choice institutionalist perspectives offer insights intowhy different politically affiliated interest groups with diverse privileges andvested interests took a common stance against the reform, as each groupviewed it as a zero-sum game. These actions were facilitated by thefragmented health system; fiscal considerations based on strained publicresources that created a reluctance to invest in the significant set-up costsassociated with institutional changes, such as the establishment of a primarycare system; and the institutional framework underwriting the health caresystem, containing clientelistic networks that favour particular interestgroups that the government is reluctant to confront.

The legacy of the 2000 attempt to reform the health system in Greececould be that in the foreseeable future governments may be reluctant toembark on any major health reforms. On the other hand, the system isevolving, such that public expenditure is increasing and public dissatisfac-tion is growing. Therefore, if these trends continue, given the grim state ofpublic finances, there may be pressure from the Ministry of Finance tocontain costs. It is unclear whether future governments will focus onprivatisation (shifting costs to the individual) or on rationalising the system.Rationalisation, in the form of coordinating the fragmented purchasingsystem, creating a monopsony purchaser, for example, as opposed toprivatisation, may eventually improve coverage and delivery of health care,but may be politically contentious.

Until now, the focus of most health reforms has been on improvingmanagement structures (as with the introduction of the PESY), given that


many powerful interest groups blocked the unification or coordination ofthe social insurance funds, but what needs to be addressed is the importantissue of financial flows and purchasing power. Until some type ofcoordinated insurance fund is created, any attempt to address the manyproblems with the Greek health system (such as regressive funding, resourceallocation, poor incentives for providers to improve quality and productiv-ity, the lack of monitoring and information systems and informal payments)will have little success due to the limited financial leverage that can beexercised on the producers of health care in the public and private sectors.

Notes

1. However, there is abundant evidence in the experimental economics and psychology

literature that shows that individuals do not carry fixed preferences, but rather construct

their preferences according to the way in which decision tasks are described or ‘framed’. See,

for example, Kahneman and Tversky (2000).

2. Privileged insurance funds refer to funds that offer extended coverage to their members, and

free choice of doctor.

3. The rigidity and political infiltration in the health sector was noted in a statement of the

former IKA deputy governor, Hadziandreou: ‘I have to say that I met with a great deal of

resistance when I tried to transfer people simply because I was absolutely convinced that they

were not doing their job properly and were obstacles to improvement . . . It is a shame when

you are trying to transfer a person to another position because he or she is proving to be a

major obstacle when that person invokes party affiliation, claiming to be the victim of

political persecution’ (Kathimerini 2003).

4. About 170 university doctors, representing only 20% of the medical school staff, ended up

going to work in Haidari Hospital.

5. It is not clear whether this has been the case because of the high expectations for the reform

plan implementation or because of the increasing coverage of health system issues in the

media or for both reasons.

6. Deputy Finance Minister George Drys also made these claims in October 2000: ‘the 2001

budget is characterised as a health care, education and employment budget . . . (Our aim is)

to achieve, for the first time, a budget surplus of 0.5% of GDP’ (Tsolis 2000).

7. The decrease is greater if expenditure is estimated at 2000 prices (e135.6 million or 3.87%).

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