Greece’s economic crisis has deepened since it was bailed out by the international community in 2010. The country underwent the sixth consecutive year of economic contraction in 2013, with its economy shrinking by 20% between 2008 and 2012, and anaemic or no growth projected for 2014. Unemployment has more than tripled, from 7.7% in 2008 to 24.3% in 2012, and long-term unemployment reached 14.4%…

Two main strategies can reduce deficits in the short term: cutting of spending and raising of revenue. The Greek Government used both at the behest of the [European Commission, the European Central Bank, and the International Monetary Fund (collectively known as the Troika)], albeit with an emphasis on reduction of public expenditure. Three years ago, we drew attention to the effects of the austerity measures on the health of the Greek people.

Greece has been an outlier in the scale of cutbacks to the health sector across Europe. In health, the key objective of the reforms was to reduce, rapidly and drastically, public expenditure by capping it at 6% of GDP. To meet this threshold, stipulated in Greece’s bailout agreement, public spending for health is now less than any of the other pre-2004 European Union members. In 2012, in an effort to achieve specific targets, the Greek Government surpassed the Troika’s demands for cuts in hospital operating costs and pharmaceutical spending. The former Minister of Health, Andreas Loverdos, admitted that “the Greek public administration… uses butcher’s knives [to achieve the cuts].” The negative effects of these cuts are already beginning to manifest…

Through a series of austerity measures, the public hospital budget was reduced by 26% between 2009 and 2011, a substantial drop in view of the fact that expenditure should have increased through automatic stabilisers. Evidence of the health effects of these cuts, at a time of increasing demand, is scarce, but staff workloads have increased and waiting lists have grown according to some accounts. Rural areas have particular difficulties, with shortages of medicines and medical equipment.

Another key cost targeted by the Troika was publicly funded pharmaceutical expenditure, for which reform was necessary because of very high rates of prescription of branded drugs. The stated aim was to reduce spending from €4.37 billion in 2010 to €2.88 billion in 2012 (this target was met), and to €2 billion by 2014. However, there have been many unintended results and some medicines have become unobtainable because of delays in reimbursement for pharmacies, which are building up unsustainable debts. Many patients must now pay up front and wait for subsequent reimbursement by the insurance fund. Findings from a study in Achaia province showed that 70% of respondents said they had insufficient income to purchase the drugs prescribed by their doctors. Pharmaceutical companies have reduced supplies because of unpaid bills and low profits…

Another concern is the erosion of health coverage. Social health-insurance coverage is linked to employment status, with newly unemployed people aged 29–55 years covered for a maximum of 2 years. Rapidly increasing unemployment since 2009 is increasing the number of uninsured people. Those without insurance are eligible for some health coverage after means testing, but the criteria for means testing have not been updated to take into account the new social reality. An estimated 800,000 potential beneficiaries are left without unemployment benefits and health coverage. To respond to unmet need, several social clinics (primary care practices stalled by volunteer doctors) have sprung up in urban centres. Médecins du Monde has scaled up operations in Greece, and reports increasing numbers of Greek citizens receiving health services and drugs from their clinics as the economic crisis deepens; before the crisis, such services mostly targeted immigrant populations…

If the policies adopted had actually improved the economy, then the consequences for health might be a price worth paying. However, the deep cuts have actually had negative economic effects, as acknowledged by the International Monetary Fund. GDP fell sharply and unemployment skyrocketed as a result of the economic austerity measures, which posed additional health risks to the population through deterioration of socioeconomic factors.

Mental health services have been seriously affected…Public and non-profit mental health service providers have scaled back operations, shut down, or reduced staff; plans for development of child psychiatric services have been abandoned; and state funding for mental health decreased by 20% between 2010 and 2011, and by a further 55% between 2011 and 2012. Austerity measures have constrained the capacity of mental health services to cope with the 120% increase in use in the past 3 years. The available evidence points to a substantial deterioration in mental health status. Findings from population surveys suggest a 2.5 times increased prevalence of major depression, from 3.3% in 2008 to 8.2% in 2011, with economic hardship being a major risk factor. Investigators of another study reported a 36% increase between 2009 and 2011 in the number of people attempting suicide in the month before the survey, with a higher likelihood for those experiencing substantial economic distress. Deaths by suicide have increased by 45% between 2007 and 2011, albeit from a low initial amount. This increase was initially most pronounced for men, but 2011 data from the Hellenic Statistical Authority also suggest a large increase for women.

Greece’s austerity measures have also affected child health, because of reduced family incomes and unemployment of parents…The latest available data suggest a 19% increase in the number of low-birthweight babies between 2008 and 2010. Researchers from the Greek National School of Public Health reported a 21% rise in stillbirths between 2008 and 2011, which they attributed to reduced access to prenatal health services for pregnant women. The long-term fall in infant mortality has reversed, rising by 43% between 2008 and 2010, with increases in both neonatal and post-neonatal deaths. Neonatal deaths suggest barriers in access to timely and effective care in pregnancy and early life, whereas postneonatal deaths point to worsening of socioeconomic circumstances…

The experience of other countries in dealing with crises could have helped to guide policy makers. For example, after Iceland’s acute crisis in 2008, the country rejected advice from the International Monetary Fund to slash its health-care and social services budget and instead opted to maintain welfare policies crucial to support its citizens, with no discernible effects on health…

Two developments hold promise. In July, 2013, the Greek Government signed an agreement with WHO for support in the planning of health sector reforms; the government needs to use the skills of WHO with the urgency demanded by the present health situation. In September, 2013, the government launched a new health voucher programme financed from European Union structural funds to cover 230,000 beneficiaries for 2013-14. The programme was designed to address some health needs of very poor patients losing access to care, especially the growing number of people unemployed for 2 years or more. Uninsured individuals can apply for a voucher that can be used for up to three visits for a predetermined set of primary care services in a 4-month period, and includes prenatal examinations for pregnant women.

Alternative responses to the crisis would have allowed Greece to pursue difficult structural reforms, while preventing devastating social consequences. Experiences from other countries that have survived financial crises (eg, Iceland and Finland) suggest that by ring-fencing health and social budgets, and concentrating cuts elsewhere, governments can offset the harmful effects of crises on the health of their populations.

Alexander Kentikelenis
Alexander Kentikelenis is the Junior Research Fellow in Politics at Trinity College. Before taking up this post, he completed a Ph.D. in Sociology and an M.Phil. in Development Studies at the University of Cambridge (King's College).
Marina Karanikolos
Marina Karanikolos is a Research Fellow at the European Observatory on Health Systems and Policies based at the London School of Hygiene and Tropical Medicine.
Martin McKee
Martin McKee is Professor of European Public Health at the London School of Hygiene and Tropical Medicine.
Aaron Reeves
Aaron Reeves is an Associate Professorial Research Fellow at the International Inequalities Institute, London School of Economics and Political Science.
David Stuckler
David Stuckler is a Professor of Policy Analysis and Public Management at Bocconi University.  

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