Challenges to Healthcare Reform in Crisis-Hit Greece

This paper critically examines the health reform trajectory in Greece in the last decade. The first part provides an overview of the Greek healthcare system shortly before the crisis, with an emphasis on the incomplete development of a national health system beset by inequalities in coverage and funding. At the backdrop of the crippling debt-crisis that engulfed the country in the late 2000s, the second part of the study tracks the major healthcare reforms under the successive bailout packages. These are examined from the point of view of whether they can secure the public system’s long-term viability and promote equity, or if they contribute to its withering away instead. The third part of the article looks at the impact of the austerity-driven reforms on inequalities in healthcare, highlighting some major findings regarding health outcomes.


INTRODUCTION
Greece has suffered the most severe consequences of the crisis that followed the global financial meltdown of 2008. The country went through an eight-year program of external financial assistance by the European Commission (EC), the European Central Bank (ECB) and the International Monetary Fund (IMF), the so-called Troika, in exchange for strict austerity measures and structural adjustment across a large spectrum of policy areas. A moderate economic recovery in 2017 and 2018, accompanied by a limited fall in the unemployment rate (from 25% in 2015 to about 19% in late 2018), is a positive development. Yet the economy is still in dire straits.
Sovereign debt amounts to around 180%of Gross Domestic Product (GDP)the highest in the European Union (EU)and it remains 25% lower than its pre-crisis peak. 1 Moreover, post-bailout commitments for exorbitant fiscal primary surpluses in the years ahead will deprive the economy of serious resources in the road to recovery.
On August 20, 2018 Greece formally exited its bailout program. Yet as the country is highly indebted to the European official sector (close to €260 billion), "enhanced" surveillance by the international lenders will continue (IMF, 2018;EC, 2018a).
Compared to the other Euro area countries that went through a financial bailout, in Greece post-program surveillance will be of higher frequency (on a quarterly basis) and the monitoring of specific policies stricter. 2 For a long time, the Greek healthcare system was stuck halfway between a highly fragmented social health insurance and a national health service model. In the early 1980s a universalist national health system ESY (Ethniko Sistima Ygeias) was introduced. However, until lately, the ESY hardly reached the state of a fully-fledged national health service. Both in terms of funding and service delivery a mixed system continued to operate: an occupation-based health insurance system combined with a national health service, but private provision was expanding too (mostly out-of-pocket payments as private health insurance remained negligible). The economic and financial crisis that engulfed the country as well as strong outside pressure by the international lenders brought reform, along the lines of the "path shift" introduced in 1983, high on the agenda. This precipitated changes, such as the unification of health funds, the standardization of contributions and the equalization of the benefits package across socio-occupational groups. Yet, at the same time, rising user charges, rolling back of public provision, and rationing through increasing waiting times and other blockage mechanisms have a negative impact on access, equity and service quality.
We start our analysis by briefly laying out an explanatory framework for the "incomplete reform" until the eruption of the crisis and the window of opportunity that has emerged since then for pursuing system rationalization and consolidation. Then, we critically discuss the major reforms that took place over the last decade. These are examined along two core dimensions of health systems: a) the funding and allocation of financial resources to providers, and (b) the structure and governance of provision. A major question addressed is whether the ongoing reforms can enhance and sustain universalism, or instead do they contribute to the withering away of a public system, which, anyway, never in the past embraced strong universalistic principles.
Corroborating evidence of a bleak future is manifested by data on increasing inequalities in healthcare regarding accessibility to and affordability of health services.

THE CRISIS AS CATALYST: AN ANALYTICAL CONTEXT
Two analytical accounts of policy reform are illuminating for understanding: a) why the path shift towards a national health system has for a long-time remained a half way reform in Greece, and b) which dynamic underlies the attempts to complete the reform in the last few years, though amidst severe fiscal retrenchment. These consist in Thelen's conceptualization of "institutional layering" (2004), and Kingdon's analysis of "windows of opportunity" for policy breakthroughs (1995). 3 As extensively shown in the social policy literature, institutional arrangements are characterized by a considerable "stickiness". They consolidate interests and commitments that create "veto" points, which highly increase the political (and often also the economic) cost of change (see Pierson, 1996;also Wilsford, 1994 on "Path dependency"). Critical junctures due to economic and/or political crises provide windows of opportunity for major reforms. However, for this to happen there needs to be an alignment favorable to change between three components: actors, institutions and ideas. Namely, there needs to be problem recognition by actors, willingness/ability to act and availability of policy ideas (Kingdon, 1995). Furthermore, as Thelen (2004: 35) has shown, incremental change, particularly in the form of "institutional layering" (that is, adding a new "layer" on an otherwise stable institutional setting) can be a driver of transformation too, particularly in the long run. Under certain conditions, if this "layering" process takes place in a prolonged period it can "significantly alter the overall trajectory of an institution's development" (ibidem).
In the realm of health politics and policy, in Greece, three reform efforts are of crucial importance: a) the introduction of ESY in the early 1980s; b) a failed attempt to revive reform momentum for completing the shift towards a national health system in the early 2000s; and c) a crisis-driven reform under the bailout program.
A few years after the restoration of democracy in the country, the introduction of a national health system took place at a critical juncture consisting in the rise to power, for the first time, of a socialist party (the Panhellenic Socialist Movement Party -PASOK), in 1981. The way the reform fared reveals the obstacles to wholesale change. As shown elsewhere (Petmesidou, forthcoming): Path-dependent institutional factors hindered the government's willingness/ability to pursue the breakthrough initiated by Law 1397 of 1983 that established ESY.
PASOK consolidated its dominant position in the Greek political system by effectively rebuilding/expanding clientelist relations, a condition that hardly allowed even a minimum consensus among social actors about how to articulate redistributive issues along the lines of universalist citizenship values and criteria.
Hence, a watered-down version of the reform was implemented. This was a politically expedient solution as the government was confronted by strong veto points within the medical profession and the privileged health insurance funds (mostly sickness funds of employees in public banks, telecommunications and other public enterprises).
Major stipulations in the law, such as uniform funding and service provision for all citizens, the gradual absorption of the private by the public sector, and a more balanced regional distribution of health infrastructure and personnel remained largely on paper, and the reform did not significantly change the status quo in health insurance. Universal access was limited to hospital care. Primary care was neglected, largely provided by the private sector, the health centers of IKA (the Social Insurance Organization for the majority of private sector employees), as well as by medical practitioners contracted by various sickness funds. Private spending continued to rise, and many privileged health insurance funds maintained their prerogatives. Thus, quite soon after the proclamation of a radical reform, social policy returned to its old patterns.
Following Thelen (2004), we would argue that the reform added "a new 'layer' (universalist healthcare) onto an existing stable institutional framework (a splintered health insurance system)" (Petmesidou, forthcoming). In the context of a political dynamics heavily relying on statist/clientelist practices, instead of this process triggering a momentum of policy breakthrough over time, it sustained a "disjointed pattern" with low degree of institutional coherence and prevalent path-dependent features, over the following two decades (ibidem). Diversity of coverage, multiplicity of funding and system fragmentation persisted and accounted for lack of coordination of purchasing policies, soaring ESY deficits, alarmingly rising pharmaceutical expenditure and other system predicaments. At the turn of the century, an initiative by the Ministry of Health, under the then PASOK government, to tackle fragmentation, rationalize and de-concenter decision-making and control, and regulate relations between key health actors met strong opposition from various quarters, even within the government. This caused the resignation of the Minister of Health and the downsizing of reform ambitions.
The deep economic and financial crisis significantly reshuffled political relationships. Strong outside pressure by the country's international lenders made it imperative for the government to push through reforms, in tandem with harsh cuts in funding and receding public provision. Under the bailout program a (more or less forced) alignment between the three spheres mentioned aboveinstitutions, actors and ideashas occurred. This created a window of opportunity that made longoverdue reforms possible (Petmesidou, forthcoming). Amidst a severe economic and financial crisis, the resources for clientelist exchanges significantly diminished, the legitimacy of political parties, trade unions and other major political actors waned, and the party system exhibited a deep systemic crisis (Petmesidou, 2017: 157). Moreover, the bailout deal imposed an upward shift in decision-making for major reforms to the international lenders (and mainly to the crisis-management apparatus of the EU). The role of the executive was strengthened, while the ability of trade unions, associations, and other "veto" groups to sway political decisions significantly weakened (Petmesidou and Glatzer, 2015: 170-176). Moreover, the bailout conditions allowed the government to shift the blame of reform and austerity to the Troika, in order to shield itself from political risk. Importantly, a pool of policy measures and regulatory instruments (among others, e-prescribing, diagnosis protocols, closed-budgets of health units, etc.) provided the constitutive elements of the reform. These were advocated by the EC, the IMF and the World Health Organization (WHO), which played a crucial role in guiding policy. The combination of the above factors facilitated a coupling of the three major streams in policy. Namely, under the sovereign debt crisis, the shift in the power and decision-making dynamics forced political actors to recognize the system's functional deficits, made imperative for them to act, and set the policy options.

TRENDS IN HEALTH EXPENDITURE -MAIN DIMENSIONS OF REFORM
Soaring deficits by public hospitals and rapidly increasing pharmaceutical expenditure over the 2000s greatly strained the state budget. In the decade prior to the eruption of the crisis, per capita total health expenditure (measured in constant Purchasing Power Parities, PPPs) grew on average annually by about 6.6% (EU15 average: 3.6%; Petmesidou, forthcoming). Markedly, average yearly per capita private spending rose faster than public spending (by 7.7 and 5.8% respectively). Especially high was the rate of growth of per capita pharmaceutical spending: 11.1% yearly on average (in constant Deep spending cuts took central stage in Greece's Economic Adjustment Program (EAP) under the successive bailout packages. So did also some key issues, which have been debated since the inception of ESY in 1983, but never materialized, such as devolution, integration of primary and secondary care, reduction of fragmentation in health insurance, etc. The changing demographic makeup is also a matter of concern as Greece is set to experience rapid ageing in the coming decades: the share of the population aged over 65 years from about 20% in 2015 is estimated to reach 35% in 2060 (among the highest rates in the EU; EC, 2018b: 191). Together with fast medical technology advancement and rising expectations for quality provisions and choice, population ageing will increase pressure on public spending (particularly on chronic diseases and geriatric and personal care). 5 Strict ceilings were set in the EAP for total public health financing and its constitutive schemesfor instance, total public health spending is capped at (or below) 6% of GDP and pharmaceutical expenditure at about 1% of GDP, which however has shrunk by a quarter since 2010, as mentioned above. From 2009 to 2017 total health spending (in current prices) dropped from €22.5 billion to €14.9 billion and public spending (government and compulsory social health insurance) almost halved (from €15.4 to €9.1 billion). 6 This is a rather steep contraction compared to the other three 4 In 2009, outpatient pharmaceutical expenditure amounted to roughly about 40% of total public health spending. 5  South European countries, which have also implemented austerity programs (for instance in Portugal, in 2017 public health spending in current prices was only about 6% lower than its peak rate in 2009). European countries, and to 24% in EU15 ( Figure II). Taking also into account the persistently low degree of satisfaction with public health services (Petmesidou et al., 2014: 333-335;Eurofound, 2017: 54-56), extensive reliance on private spending highly questions whether a truly universal system has ever been in place in Greece. The crisis intensified financial, organizational and equity problems that characterized healthcare in the country for several decades. Most importantly, great diversity in the range and quality of provisions among the plethora of sickness funds kept inequality high. 7 Since 2011, in the context of the reform dynamics briefly highlighted above, a number of measures have been introduced, apparently in order to tackle major system deficiencies. However, a controversial trend is clearly manifest.
Steps are taken towards the completion of the transition to ESY and system rationalization. But large-scale public health spending cutbacks and a range of policy options are shifting the cost away from the State and impose significant barriers of access to and use of care. Strikingly, at the level of rhetoric, the framing of the reform stresses the need for deep cuts as a way to keep the publicly operated system afloat, yet a shift towards a "universalism" of basic provision looms large (Petmesidou et al., 2014: 345 On the funding side, a major structural reform consists in the separation of the health from the pension branches of social insurance funds and the merging of the former into a unitary organization (the National Health Services Organization, Greek acronym EOPYY, legislated in 2011), to act as a single purchaser of health services.
This was accompanied by the equalization of contributions and the standardization of the health benefits basket across occupational groups. Also, mechanisms of monitoring and control of services were put in place, facilitating a tighter spending oversight.
Changes in the allocation arrangements, by which funding is transferred to services providers, were also implemented, particularly regarding hospital payment systems.
On the organizational/governance side, consolidating hospitals into larger units, reconfiguring cost-accounting and management, as well as integrating primary and secondary care have been varyingly implemented so far. Of significant importance is a three-year plan to overhaul primary care, which started being rolled out in 2018. The aim is to create a gate-keeping system with the establishment of first contact, decentralized local health units, which will guide patients, through referral procedures, to the second tier of ambulatory care and to inpatient care. The Greek health system has persistently been highly centralized. Despite the establishment of Regional Health Authorities (YPEs in the Greek acronym) in the early 2000s, plans to devolve responsibility for the operation and management of health units failed to materialize. Recent reforms disclose a two-way trend: The pooling of health insurance contributions through the creation of EOPYY indicates a move towards centralization, while the assignment of control over primary care to YPEs points in the direction of decentralization. However, it remains to be seen whether the latter move will be backed by the devolution of real decision-making power. Regulatory mechanisms introduced include: a) budget ceilings for EOPYY accompanied by a clawback/rebate mechanism for private providers (pharmacies, pharmaceutical companies, diagnostic laboratories and private clinics) so as to keep expenditure within the budget limits; 10 and b) thresholds on physicians' activity (limits in 8 A tiny number of health insurance funds did not join EOPYY (and EFKA). These include the health insurance funds of the Bank of Greece and the National Bank of Greece. 9 Recent legislation (Government Gazette 148/A/9-10-2017, accessed on 30.05.2018, at https://www.enomothesia.gr/kat-ygeia/proedriko-diatagma-121-2017-fek-148a-9-10-2017.html) sets limits to EOPYY's status as an independent organization, through the establishment of a special department in the Ministry of Health, accountable directly to the Minister of Health and responsible for overseeing a wide spectrum of decisions concerning EOPYY's budget, the terms and conditions under which private practitioners, diagnostic laboratories and private clinics are contracted, and other activities. 10 A clawback system requires pharmaceutical companies, private diagnostic centers and clinics, if expenditure exceeds the public health budget, to repay to EOPYY the excess. In 2018, the clawback by pharmaceutical companies reached €560 million, which is about 20% higher than in 2017. the number of referrals for diagnostic tests, compulsory prescribing by active substance, and electronic monitoring).

FUNDING SIDE CHANGES: HOW HEALTHCARE REVENUE IS RAISED
The introduction of e-governance tools and attempts to make the public procurement system more transparent and efficient are also among the main costcontainment measures. However, in the absence of systematic health needs assessment at different levels (e.g. regional, local), caps on referrals and prescriptions per specialty (and prefecture), in place in the last few years, are drawn in a rather ad hoc way. For instance, according to a recent Ministerial Circular 11 average monthly per capita prescription rates for pathologists range from €34 to €45, while for forensic surgeons, who seldom issue prescriptions, the rate is set at about €55. Equally unfounded on any sound evidence of demographic and morbidity trends is the fluctuation of rates per prefecture/per month. The obvious aim is a further cut in the value of physicians' prescriptions in tandem with the doubling of the generics share from about 20 to 40%.
Co-payments for pharmaceuticals more than doubled, from about 10 to 25% (plus an extra charge of €1 per prescription), and a 15% co-payment for diagnostic and laboratory tests in contracted centers was introduced. Exemptions from co-payments (or lower rates) apply to individuals and families with very low income (including the uninsured with low income) and some vulnerable groups (e.g. people with chronic diseases) on the basis of income criteria. 12 At the same time, existing exemptions from user charges for some groups were lifted. For instance, for the chronically ill persons exemptions are strictly related to their chronic illness, even though some of their ailments maybe an indirect consequence of their health conditions (Petmesidou, 2014: 20).
Other major measures for lowering prices and volumes of pharmaceuticals embrace the establishment of a drug-pricing observatory and a reference pricing system that sets the rates on the basis of the average price of the three lowest-priced markets in the EU; the introduction of a positive (and negative) list for reimbursement purposes; the reduction of the profit margin for pharmacies; and ceilings in physicians' prescriptions, as stressed above.
An entrance fee of €3 for outpatient care, introduced in 2010 (and increased to €5 in 2011), as well as a €5 fee charged for every hospital admission since 2014, were abolished in 2015. But private outpatient clinics, run within public hospitals in the afternoon, charge fees per visit, which, however, are not covered by social insurance.
In the last few years, the rising number of visits to afternoon clinics of public hospitals is 11 Accessed on 15.10.2018, at https://www.taxheaven.gr/laws/circular/view/id/29287. 12 The income thresholds for exemption or lower rates of co-payments are set at €2400 and €3600 per year, respectively, for a single person (they increase by €600 for each dependent).  (Souliotis et al., 2016: 159), and an equally high percentage (36%) of undeclared fees paid for visits to private practitioners and dentists (ibidem; see also Liaropoulos et al., 2008).
In a nutshell, considerable improvements in rationalizing funding accrue to the pooling of resources, the establishment of a single payer, the shift from retrospective reimbursement for secondary health service provision (based on the patient cost per specialty) to a case-mix payment, and a raft of strict monitoring policies for doctors.
Yet, policy wise, a systematic allocation of resources across the country on the basis of need, drawing upon demographic, socio-economic and epidemiological data has hardly been in place. YPEs could potentially play a crucial role in developing needs assessment mechanisms, provided their budgetary and planning competences are strengthened. A Health and Welfare Map to monitor health needs, allocation and use of resources that could feed into policy decision-making has been on the agenda of the Ministry of Health since the early 2000s, but with very little progress so far.

INSTITUTIONAL/ORGANIZATIONAL ARRANGEMENTS IN SERVICE PROVISION
Organizational reform embraces: a) a two-way trend of centralization/decentralization of administrative and governance functions and controls, and b) a consolidation of secondary care providers into larger units.

A Two-Directional Trend
The split trend along the first dimension consists, on the one hand, in: the pooling of financial resources through the establishment of EOPYY (and, later on, of EFKA); the centralization of decision-making and control over the range of service provision and resource allocation methods; and the ongoing trend of centralized procurement of medical supplies and devices so as to reduce less-than-optimal outcomes and improve transparency. Also, new information systemssuch as electronic platforms for collecting/monitoring data on performanceaccompany centralization policies of governance. Though, so far, these do not embrace any quality indicators and quality assurance strategies.
On the other hand, legislation for primary care enacted in 2014 transferred responsibility for primary care coordination to regional health authorities. The law provided for the redrawing of the primary care map by creating a with contracted private physicians (general practitioners, pathologists and pediatricians) will establish a local gate-keeping network, targeting family doctor services for all. Once more, an attempt is made to integrate primary care into the public system and counteract overreliance on specialist and inpatient care. However, the implementation of the plan is beset with problems. The time-span of budgetary provision for the operation of TOMYs is limited (up to four years maximum) and funding is tied to EU sources. Besides, adequate infrastructure is hardly available in many localities. Similarly, to other services relying on EU sources (e.g. the Home Help program), there is the risk of service discontinuity when EU funding stops. These uncertainties account for the low response by doctors (even junior ones facing unemployment) to repeated calls by the Ministry of Health for filling positions in TOMYs. 13 Equally difficult has been so far to attract private practitioners to the local primary care network, to be contracted family doctors. Significant changes in EOPYY's contract conditions (lower earnings for higher workload and restrictions on private practice) met with the reluctance of private practitioners to join the planned primary healthcare network. As stressed in a recent report (EC, 2018c: 36), "slow progress may increase the risk of future discontinuation or reversal".

Consolidation of Secondary Care Providers
Re-configuration of secondary healthcare service providers has been on the way during the last few years with the aim to contain cost and rationalize structure and governance. Policy measures embrace the redrawing of the hospitals map, by combining them into fewer units under common administration, the cutting down and/or rearrangement of clinics and functional beds, changes in the function of several ESY healthcare facilities, staff relocation and redistribution of heavy equipment across hospitals. However, so far, these policies have limited implementation, and according to a recent study their positive effect on overall hospital efficiency has not been significant (Kaitelidou et al., 2016). Efficiency improvement is also sought by measures such as the introduction of a double-entry accounting system for costing services, the all-day functioning of hospitals, extension of working hours of outpatient offices, and the revision of emergency and on-call duty.
Notably, staff shortages have intensified, due to hiring freeze for several years, and persistent reliance on term-contract appointments of health personnel. Most importantly, the shortage of nursing staff seriously affects service deliveryin some of the main hospitals in Athens cutbacks have left one nurse to look after 20 or more patients (Petmesidou, 2014: 19). Greece ranks last among the EU28 countries in terms of the ratio of nurses per 1,000 population (3.2 in 2014, EU28 average 8.4). Staff shortages also affect intensive care units, some of them operating below their capacity (Economou et al., 2017: 78). According to WHO standards, 9 to 12% of functional hospital beds must be in intensive care units. In Greece, the rate is close to 2%, while over a fifth of them are not in operation due to qualified staff shortages. 14 Overall, major challenges remain with regard to the deployment and management of resources, coordination with primary care, response to need, and quality of services.

INEQUALITIES OF HEALTHCARE: ACCESSIBILITY AND AFFORDABILITY
Austerity-driven cuts and reforms cast doubts on the "universal" character of the system. Equalization of provision across social insurance funds was accompanied by a significant review of the range of public provision, leading towards a low common denominator. This shifted provision to the private sector and, in tandem with significant inequalities in the geographical distribution of public health facilities, greatly impacted upon accessibility to and affordability of healthcare.
Importantly, the crisis conditions brought to the fore the serious problem of a rapidly increasing number of uninsured people. In 2013, it was estimated by EOPYY (Petmesidou et al., 2014: 345) that there were about 2.5 million people lacking healthcare coverage. These included the long-term unemployed and their dependents, people who filed business bankruptcy, or who might still run a business but were unable to pay contributions due to severe hardship, and legal/illegal immigrants and refugees. In 2013, a program was launched providing (on a means-tested basis) vouchers that allowed uninsured persons and their dependents to have access to primary and ambulatory care. However, eligibility and range of ambulatory provisions were limited, inpatient care was not covered, and the scheme fell short of covering need. In 2016, new legislation lifted most barriers for uninsured citizens in accessing outpatient and inpatient publicly provided care. Nevertheless, as the uninsured are barred from contacting private providers contracted by EOPYY, inequity of access persists, especially in regions/localities with staff shortages and lack of diagnostic equipment in public health facilities.
Increased co-payments and fees as well as long waiting lists also function as rationing measures creating barriers to access. In certain prefectures, the quicker appointment one can get for seeing a pathologist or a cardiologist in EOPYY could be in two or more weeks, while in the national hospitals network it might take even longer (Petmesidou, 2014: 23 average, two to four months across the country, but in certain cases waiting may reach or surpass six months (Boulountza, 2016). A ministerial decision issued in late 2016 made obligatory a more transparent use of priority medical criteria for waiting lists.
Public hospitals have started complying with this measure, but it is too early to assess its effectiveness. Discontinuity in the procurement of vital medical supplies in ESY hospitals and PEDY health centers is another blockage mechanism.
Household expenditure data of the lowest income quintile show that, in the beginning of the crisis, average equivalized monthly health spending was a little over 10% of total consumption expenditure. 15 It sharply dropped to about 7% in 2012, but increased afterwards reaching again a ratio close to 10% in 2016 (with a slight decrease in 2017), even though total household expenditure persistently followed a downward trend from 2009 onwards. With regard to the constitution of average monthly spending on healthcare by households in the lowest income bracket (up to €750 monthly), a striking 60% concerns pharmaceuticals (and medical devices), about 25% payments to physicians, and the rest mostly inpatient care in private hospitals and clinics.
As healthcare demands are inelastic, significant cuts in public provision made necessary even among poorer households to spend a growing part of their monthly income in order to cover healthcare needs. In the available literature, a threshold of 10 to 15% (or over) of household monthly income (or consumption) spent on out-of-pocket healthcare payments is considered to be a "catastrophic" and "impoverishing" cost for households (see Xu et al., 2007). A case study conducted by Grigorakis et al. (2017) on the basis of a sample of people covered by mandatory social insurance, who "were hospitalized at least once in private providers contracted by EOPYY", highlights the high risk of "catastrophic health costs". About a third of their respondents declared having incurred a cost amounting to over 30% of their monthly income for health treatment (for the poverty impact of out-of-pocket payments see also Petmesidou et al., 2015: 253-268;Chantzaras and Yfantopoulos, 2018). Other case studies (see Tsiligiani et al., 2013 and2014;Petmesidou et al., 2015: 295-342) also show that a substantial number of people discontinue medication or lower their doses, as they cannot afford the cost, with perilous effects on their health though.
The geographical distribution of health facilities and personnel is a major dimension of unequal access. Among EU countries, Greece exhibits a high ratio of shortage of nursing staff is a persistently serious problem, as indicated earlier. Figure   III shows the high concentration of health personnel in the two regions with the largest urban centers (Attica and Central Macedonia), as well as in two regions with wellestablished medical schools (Epirus and Kriti). It also depicts the prevalence of disability (and chronic diseases) by region (latest available data from an ad hoc study of disability carried out by ELSTAT in the early 2000s). Strikingly, the regions with the highest rates in the prevalence of disability score lowest in terms of health personnel per hundred thousand inhabitants. Inequalities in the spatial distribution of health facilities are compounded by the problem of physicians' brain-drain since the eruption of the crisis (see Ifanti et al., 2014). According to the most recent available data, until mid-2018 about 12,700 physicians (mostly specialists) left the country. 16  Petmesidou et al., 2015: 269-293;Adam and Teloni, 2015).

FIGURE III -Regional Distribution of Health Personnel (2016) and Prevalence of Disability
In the lowest income quintile unmet needs for medical examination have steadily increased from 2008 onwards ( Figure IV). In 2017 close to a fifth of this income group declared unmet needs. A significant increase characterized also middle-income groups (3 rd income quintile). The respective rate for this income group equaled 12% in 2014, and slightly declined to 10% in 2017. 17 Compared to the other three South European countries (and to the EU28 average) unmet needs have been most prevalent in Greece until recently. It is noteworthy also that, in the last few years, the intensification of refugee (and immigrant) flows in the country (mainly from the Middle East and Africa) further ratcheted up the pressure on public and voluntary health services. with a five-times greater rate of annual all-cause mortality increase and a more modest increase in non-fatal health loss compared with pre-austerity". Specifically, we observe "a rise in communicable, maternal, neonatal, and nutritional diseases since 2010" 17 A study by Zavras et al. (2016: 5), referring to the early years of the crisis, found that, for the total population, "the odds of unmet needs due to financial reasons were 44% higher in 2011 as compared with 2006".
(ibidem; see also Laliotis et al., 2016). Undoubtedly, it is rather difficult to disaggregate potential root cause factors of these outcomes (i.e. demographic profile, long-standing system specific characteristics, and the effects of austerity measures). Nevertheless, the fact that the worsening of public health takes place in tandem with a sharp reduction in public health spending and provision, makes it highly likely for the latter to have played a major role in the deterioration of the population's health conditions.

CONCLUSION
For a long-time health insurance and healthcare in Greece followed a splintered pattern. In the early 1980s, on a highly fragmented health insurance system, a layer of universalist healthcare was introduced. However, inequalities in the scope and coverage among socio-occupational groups persisted, and the path breaking reform of the introduction of ESY hardly managed to become a driver of wholesale change towards a fully developed national health system. Instead a "disjointed" configuration prevailed. This combined limited application of the principle of universal access with fragmented and unequal health insurance, in tandem with rapidly rising private, out-ofpocket payments. The statist-clientelist mode of socio-political integration that characterized the country for many decades accounts for the consolidation of strong shifting the cost to patients, and b) a two-pronged approach to governance consolidating service providers but also decentralizing administration and management.
Undoubtedly, reforms increased system rationalization but blunt ceilings set by the bailout package drastically compressed the scope, quantity and quality of services.
Seemingly, unification and standardization of health insurance aimed to tackle inequalities in coverage and access. But shrinking public provision runs counter to this.
Unmet need for medical care greatly increased among lower-income groups (with a noticeable rise also among middle-income groups) and inequalities in terms of accessibility to and affordability of services deepened. Mandatory, state-regulated complementary insurance through the market is absent and the risk of catastrophic outof-pocket payments appears to be high, particularly so, as "reforms increasingly coopted universal public healthcare into private operators" (Petmesidou, forthcoming).
Greece's post-bailout commitments stipulating strict fiscal targets for the years ahead, in order for the country to service its huge public debt, leave little room for any policy options, in the near future, which could reverse course and harness the potential of reform for enlarging the scope and improving quality of universal healthcare.

MARIA PETMESIDOU
Emeritus Professor of Social Policy, Department of Social Administration and Political Science, Democritus University of Thrace P. Tsaldari 1, Komotini 69100, Greece Contact: marpetm@otenet.gr