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### Introduction and methodology
- The 2010 sovereign debt crisis prompted reassessment of spending priorities and efficiency in Greece’s healthcare sector.
- Reform tools deployed:
  - cost-saving rationalization of pharmaceuticals;
  - reorganization of primary and secondary healthcare networks;
  - merger of health insurance funds;
  - harmonization of healthcare benefits;
  - changes in copayments and fees;
  - rationalization of public spending and pricing policies.
- Methodology:
  - Narrative description of reforms.
  - Top-down quantitative benchmarking comparing inputs, outcomes, and structural indicators over time and across countries to assess efficiency and equity relative to peers.

### Greece before the crisis (features and baseline inefficiencies)
- System design and delivery:
  - ESY (launched 1983) as main public provider; strong private sector presence.
  - Hospital-centric orientation with weak primary care gatekeeping.
  - Long waiting times led to private practitioner usage reimbursed by SSFs or paid out-of-pocket.
- Coverage and access:
  - Mechanisms to extend coverage to uninsured spouses/children and unemployed (typically extendable for 12 months subject to prior contributions).
  - “Booklet” for the poor targeted individuals with annual family income below EUR 6,000 but was limited by exclusions and narrow benefits.
- Key pre-crisis statistics and inefficiencies:
  - Public healthcare spending accelerated by 2 percent of GDP in the decade up to 2009.
  - Out-of-pocket payments accounted for approximately 30 percent of total health expenditure.
  - In 2009, almost 40 percent of total hospital beds in Greece were private.
  - Public pharmaceutical spending in 2009 was 2.2 percent of GDP versus 1 percent of GDP for the OECD average.
- OECD classification as of 2010: ‘Group 3’ (public insurance for basic coverage, heavy reliance on market mechanisms in service provision, no primary care gatekeeping, little private insurance).

### Overview and sequencing of reforms since 2010
- Reform themes: mix of ‘macro’ measures (price controls, budget caps, rebates/clawbacks) and ‘micro’ structural measures (gatekeeping, e-prescription, generics promotion, DRG introduction).
- Institutional reform: establishment of EOPYY as single payer.
- Sequencing:
  - Early stage (2010–2012): emphasis on macro measures (budget caps, reference pricing).
  - Later stage: emphasis on structural measures expected to gradually replace some macro tools.

### Assessment of macro measures (pharmaceuticals, diagnostics, budget caps)
- Pharmaceutical reference pricing:
  - Ex-factory reference price for on-patent drug set as the mean of its 3 lowest prices in EU countries; market-entry requirement: priced in at least 3 EU countries.
  - Off-patent reference price reduced by 50 percent (or at the mean of the 3 lowest corresponding European prices, whichever lower).
  - Generic reference price set at 65 percent of the off-patent reference price.
  - Pricing revisions:
    - Late 2018: pricing revisions became annual.
    - First half of 2019: prices calculated as mean of the two lowest prices in the Eurozone; products must have been previously priced in at least three Eurozone countries (two for “orphan” drugs); annual price reductions capped at 10 percent until Eurozone mean reached; some price increases allowed.
    - Second half of 2019: annual reduction cap reduced to 7 percent; price increases no longer allowed.
  - Market response issues: resistance from domestic generic producers; substitution toward more expensive medicines as cheaper drugs withdrew; implementation frictions.
- Diagnostic price reductions:
  - Two waves (2013 and 2015); last reduction implied a 43 percent average reduction in price of the 51 most used diagnostic tests and reduced prices of all other exams by 9 percent on average.
  - Despite price cuts and closed budget, expenditure above the ceiling and number of tests continued to increase.
- Budget caps, rebates and clawbacks:
  - Rebates: discounts ranging from 14 to 30 percent in the recent single rebate system applied without ceiling on sale volumes.
  - Admission fee: 25 percent admission fee for products entering the positive list for the first time.
  - Clawbacks: suppliers return revenue above ceilings as cash or write-offs; settled semi-annually; expanded in 2016 to include inpatient pharmaceuticals; past obligations can be settled in up to 120 installments; all clawbacks extended up to 2022 with ceiling indexed to real GDP growth.
  - Clawback on private providers introduced in 2013; expanded in 2017 to all products/services reimbursed by EOPYY with sub-ceilings; collection and auditing faced significant delays and legal challenges.

### Introduction and status of DRGs (inpatient reimbursement reforms)
- Objective: harmonize treatment costs and replace closed daily rates with diagnostic-related groups (DRG).
- Timeline:
  - 2011: first-stage creation of KENs based on Australian DRG system (not properly implemented).
  - 2014: law foresaw full implementation starting January 2017 following German DRG model.
  - Late 2015: pilots took place.
  - 2017: ESAN renamed KETEKNY and changed to public legal nature.
  - 2019: plan for performance-based DRG pilot with 18 hospitals.
  - Status: new framework has not yet been implemented.
- Implementation requirements/challenges: detailed patient registries, regular submissions to ESAN/KETEKNY, privacy concerns, risk of increased readmissions, need for major provider behavioral change.

### Institutional reforms, EOPYY, and public management challenges
- EOPYY creation: consolidated public mandatory health insurance funds to apply universal rules and equal contribution rates and entitlements.
- Financing and collection challenges:
  - Complex financing chain with arrears along SSFs–EOPYY–hospitals/providers.
  - Health-contribution collection still relies on original SSFs; consolidation into EFKA improved transfers but integration of SSC collection into tax administration not implemented.
  - Revenue shortfalls led EOPYY to prioritize payments to private providers while running arrears to public hospitals.
  - EOPYY capacity: historically lacked audit capacity; by end-2017 began in-house audits but personnel shortages persist.

### Primary care, hospitals, and digital reforms
- Primary care reorganization:
  - PEDY established in 2014; gatekeeping legislated but not implemented.
  - 2017 law replaced PEDY units with TOMYs; commitment to roll out e-referral system in 2018 and open 240 primary health centers over next 2 years.
  - Delays due to requirement PEDY doctors quit private practice → strikes and extensions; underfunding and understaffing of PEDY units.
- Hospital network and capacity:
  - 2009–2014: ESY hospital beds reduced by 23 percent; ESY hospitals reduced by 13 percent.
  - Nominal annual expenditure of ESY hospitals declined by a quarter from 2012–2015, largely driven by decreased pharmaceutical costs.
  - Consequences: potential longer waiting times, shortages of medical supplies (including pharmaceuticals), reduced ICU beds concerns, widespread personnel shortages (especially nurses).
- Digital modernization:
  - E-prescription: transition from hand-written (2010) to almost all prescriptions electronic by October 2016; enables monitoring but requires better data use to address induced demand.
  - E-procurement and centralized procurement: EKAPY established in 2017; launched tenders for more than 250 million euros as of May 2021; framework under review with new legislation expected in June 2021.

### Contracting, provider behavior, and market reforms
- Over-prescription controls:
  - Electronic pharmaceutical expenditure thresholds disclosed per doctor; exemptions for sensitive groups.
  - 2014: penalties applied only when prescriptions exceeded thresholds by over 20 percent for 3 consecutive months; penalties include fine up to EUR 5,000, prescription embargo up to 12 months, possible contract cancellation.
  - 2017: Ministry enhanced penalties based on prescription protocols.
- Generics policy:
  - Doctors required to indicate active substance (INN); brand-name prescriptions limited to 15 percent of total value of a doctor’s issued prescriptions.
  - Pharmacists must notify patients of cheaper generics and maintain stock; monitoring improved in 2018.
  - Outcomes:
    - Over 98 percent of total value has been prescribed as active substance.
    - By 2017 generic penetration reached approximately 27 percent of actual consumption compared to OECD/EU average of almost 50 percent.
    - Greece has the highest generics average unit price among European countries.
- Pharmacy market liberalization measures and remaining restrictions:
  - Abolished minimum geographical distances, single-license rules, exclusive right to establish a pharmacy, liberalized opening hours, enabled e-pharmacies and electronic applications.
  - Remaining restrictions: only one pharmacy per 1,000 inhabitants; OTC products mainly sold by pharmacies; ownership to non-pharmacists allowed with licensed pharmacist participation at 33 percent.

### Spending compression, private burdens, and unmet needs
- Aggregate spending trends:
  - During 2010–15 health spending declined by 1 percent of GDP (source sections report similar compression: 2010–17 decline of 1.8 percent of GDP).
  - Major public expenditure compression in non-personnel costs; intermediate consumption in health declined by half relative to the average level in Europe.
- Eurostat-based changes 2010→2017 (percent of GDP):
  - Total general government expenditure on health: 6.9 (2010) → 5.2 (2017).
  - Compensation of employees: 1.7 (2010) → 1.5 (2017).
  - Social benefits (including purchased market production): 3.1 (2010) → 2.2 (2017).
  - Intermediate consumption: 2.1 (2010) → 1.4 (2017).
  - Gross capital formation: 0.0 (2010) → 0.1 (2017).
- Functional public expenditure highlights (percent of GDP):
  - Public total expenditure: 6.6 (2010) → 4.7 (2018) in Greece (OECD average: 6.4 in 2010 → 6.6 in 2018).
  - Medical goods (public): 2.3 (2010) → 1.4 (2018) in Greece.
  - Inpatient care (public): 3.0 (2010) → 2.2 (2018) in Greece.
  - Outpatient care (public): 0.7 (2010) → 0.7 (2018) in Greece (remained the lowest among peers).
- Private expenditure and out-of-pocket burdens:
  - 2018 total private expenditure: 3.1 percent of GDP (second highest in peer group after Republic of Korea).
  - Share of private in total health expenditure: 40 percent in 2018 compared to 31 percent in 2010 (highest among peers together with Republic of Korea).
  - Out-of-pocket payments approximately 30 percent of total health expenditure.
- Unmet needs (self-reported, 2014 ELSTAT; due to cost, total sample / q1 poorest 20% / q5 richest 20%):
  - Medical care: 13.8% / 23.8% / 5.4%
  - Doctor-prescribed drugs: 5.3% / 21.6% / 2.4%
  - Dental care: 14.5% / 24.1% / 5.2%
  - Psychiatric care: 2.7% / 2.0% / 9.0%
- Unmet needs trends (selected series):
  - Unmet needs Greece: 5.5 (2008), 5.5 (2010), 8.8 (2018).
  - Unmet needs (lowest income quintile) Greece: 8.8 (2008), 9.0 (2010), 20.6 (2018).
  - Unmet needs (highest income quintile) Greece: 1.8 (2008), 2.1 (2010), 0.8 (2018).
- Conclusion: compression of public healthcare spending disproportionately affected the poor, widening inequalities and raising unmet needs.

### Health outcomes, surveillance, and pandemic response
- Physical and subjective health indicators:
  - Life expectancy at birth (female): 82.5 (2005), 83.3 (2010), 83.9 (2017).
  - Life expectancy at birth (male): 76.8 (2005), 78.0 (2010), 78.8 (2017).
  - Infant mortality: 3.8 (2005), 3.8 (2010), 3.5 (2017).
  - Self-perceived good health (aged 15+): 77.4 (2005), 75.5 (2010), 74.0 (2017).
  - OECD self-reported “bad health” (15+): increased from 9.7 percent in 2010 to 10.4 percent in 2017.
- Mental health:
  - Years lost due to mental and behavioral disorders and intentional self-harm increased after 2012 but remain below EU average.
- Pandemic capacity expansion and financing:
  - ICU beds: 565 at end-February 2020; 840 at end-May 2020; 1,542 by end-April 2021 (including public, military, and requisitioned private clinic beds). As of end-April 2021, 981 ICU beds reserved for Covid-19 and 561 for other cases.
  - Medical staff increases within a year: over 3,000 doctors and nurses; over 10,000 subsidiary personnel (not all permanent).
  - Requisition of 206 private physicians in March 2021.
  - Extraordinary financing:
    - First half of 2020: within range of 200–300 million euros.
    - Total extraordinary financing for 2020: 786 million euros.
      - 200 million euros used to finance wages of newly hired medical staff.
      - 293 million euros allocated to EOPYY.
      - 293 million euros used for procurement of medical equipment and supplies.
    - For 2021, government reserved a 3 billion euro cushion for pandemic expenses.
- Epidemiological performance:
  - Greece outperformed most other European and OECD countries in total confirmed cases and total deaths during first and second waves.
  - Testing capacity (PCR and rapid tests) below EU and OECD average despite increases.
  - Vaccination progress as of early June 2021:
    - over 6 million vaccine doses administered in total.
    - fully vaccinate over 2.5 million citizens.
  - Self-testing initiative: free self-tests for teachers, students, civil servants and some private-sector employees; mandatory for schools and certain sectors with online registration of results.

### Efficiency assessment and fiscal implications
- Efficiency:
  - Analyses indicate overall efficiency improved; Greece moved closer to the efficiency frontier over 2010–18 using different input coverages and life expectancy outcome.
  - Data Envelopment Analysis (DEA) cross-sectional comparisons for 2010 and 2018 suggest improvements in Greece’s efficiency rankings among OECD countries.
- Fiscal compression and social outcomes:
  - Health spending declined by 1.8 percent of GDP during 2010–17 (another section reports 2010–15 decline of 1 percent of GDP).
  - Compression disproportionately affected the poor, with rising out-of-pocket payments and unmet needs.
  - Intermediate consumption in health declined by half relative to average European level.

### Policy priorities and recommendations
- Restore and reprioritize public finance:
  - Higher public spending to address compressed levels and unmet needs.
  - Rebalance public expenditure from pensions toward targeted social protection including healthcare.
- Deepen structural reforms to improve efficiency and equity:
  - Strengthen primary healthcare and establish effective gatekeeping.
  - Reduce out-of-pocket payments (out-of-pocket payments approximately 30 percent of total health expenditure).
  - Eliminate remaining insurance gaps and improve coverage effectiveness (address “booklet” limitations and EUR 6,000 annual family income cutoff).
  - Enhance centralized procurement to reduce overpricing of drugs and medical equipment.
  - Implement DRG framework and ensure required hospital registries and behavioral change.
  - Better use e-prescription data to monitor prescribing behavior and induced demand.
- Contain excess expenditure in specific areas through non-distortionary structural measures (price regulation, rebates, clawbacks, promotion of generics).
- Monitoring and evaluation:
  - Continuous epidemiological surveillance given lagged health effects.
  - Collect and closely monitor data on objective health status, public service utilization and the uninsured to inform reforms and protect vulnerable groups.

*IMF Working Paper WP/21/189 (excerpts).*

### 2010. We find that excess spending was successfully curtailed, elements of the

### wpiea2021189-print-pdf - 2010. We find that excess spending was successfully curtailed, elements of the institutional framework were modernized, and health outcomes have been relatively favorable. However, especially prior to Covid-19, public healthcare spending had been compressed to potentially unsustainable levels, with widening inequalities and large unmet needs, especially among the poor. Higher public spending and advancing structural healthcare reforms are needed to improve the efficiency and equity of the Greek healthcare system, including strengthening primary healthcare, reducing out-of-pocket payments, and eliminating remaining insurance gaps.

### Introduction
- The 2010 sovereign debt crisis triggered a reassessment of spending priorities and efficiency in Greece’s healthcare sector.
- Reforms focused on structural changes and spending-efficiency measures including:
  - cost-saving rationalization of pharmaceuticals;
  - reorganization of primary and secondary healthcare networks;
  - merger of health insurance funds;
  - harmonization of healthcare benefits;
  - changes in copayments and fees;
  - rationalization of public spending and pricing policies.

- Methodology:
  - Narrative approach describing reforms.
  - Top-down quantitative benchmarking comparing inputs, outcomes, and structural indicators over time and across countries to assess efficiency and equity relative to peers.

### Greece’s healthcare system before the crisis (key features and deficiencies)
- System design and delivery:
  - ESY (launched 1983) was the main public provider alongside a vibrant private sector.
  - Orientation around hospitals at the expense of primary care; primary care often provided by public health centers in rural areas and SSF-operated doctor offices in urban centers (especially IKA).
  - Long waiting times in public facilities led patients to private practitioners, reimbursed by SSFs or paid out-of-pocket.

- Coverage and access:
  - ESY was intended to provide universal coverage, with mechanisms to extend coverage to uninsured spouses/children, unemployed (typically extendable for 12 months subject to prior contributions), and access via “booklets” for longer-term unemployed and the poor.
  - Booklet for the poor available for individuals with annual family income below EUR 6,000, but eligibility exclusions and a narrow benefit range limited effectiveness.

- Pre-crisis spending and inefficiencies:
  - Public healthcare spending accelerated by 2 percent of GDP in the decade up to 2009.
  - Out-of-pocket payments accounted for approximately 30 percent of total health expenditure.
  - Fragmentation of social security funds (SSFs) with dozens of mandatory schemes arranged along occupational lines.
  - In 2009, almost 40 percent of total hospital beds in Greece were private.
  - Public pharmaceutical spending in 2009 was 2.2 percent of GDP versus 1 percent of GDP for the OECD average.
  - Perverse incentives included over-prescription of diagnostics and pharmaceuticals, long hospital stays incentivized by per diem payments, under-the-table payments, absence of centralized procurement contributing to overpricing.

- OECD classification:
  - As of 2010, Greece was in ‘Group 3’ (public insurance for basic coverage, heavy reliance on market mechanisms in service provision, no primary care gatekeeping, little private insurance).

### Overview of the healthcare reform since 2010
- Reform themes:
  - Combination of ‘macro’ health policy changes (price controls, budget caps, rebates/clawbacks) and ‘micro’ structural measures (gatekeeping, e-prescription, promoting generics, DRG introduction).
  - Establishment of EOPYY (Single Organization for the Provision of Healthcare Services) as a core structural reform to serve as a single payer.

- Reform sequencing:
  - Early stage (2010–2012): focus on macro measures (budget caps, reference pricing).
  - Later stage: emphasis on structural measures expected to gradually replace some macro tools (e.g., clawbacks).

### Assessment of ‘Macro’ healthcare reforms (selected measures and impacts)
- Reference pricing for pharmaceuticals:
  - Ex-factory reference price for an on-patent drug set as the mean of its 3 lowest prices in EU countries; products entering the market must have been priced in at least 3 EU countries.
  - When a drug becomes off-patent, reference price reduced by 50 percent (or at the mean of the 3 lowest corresponding European prices, depending on which method produces the lowest price).
  - Reference price of a generic drug set at 65 percent of the off-patent reference price.
  - Profit mark-ups for wholesalers and pharmacies varied by EOPYY compensation status, prescription vs OTC, and public hospital use.
  - Market responses and implementation issues:
    - Strong resistance due to larger perceived price cuts for generics (many generics produced by Greek firms).
    - Continuous price reductions and budget caps may have led to substitution toward more expensive medicines as cheaper drugs were withdrawn from the market or reimbursement list.
    - Pricing mechanism revisions in late 2018 and 2019:
      - Late 2018: pricing revisions became annual.
      - First half of 2019: drug prices for on- and off-patent products calculated as mean of the two lowest prices in the Eurozone (previously mean of three lowest in the EU); products must have been previously priced in at least three Eurozone countries (two for “orphan” drugs). Price reductions were annually capped at 10 percent (until Eurozone mean reached); some price increases allowed.
      - Second half of 2019: annual reduction cap reduced to 7 percent; price increases no longer allowed.

- Diagnostic price reductions:
  - Prices of diagnostic exams were reduced in two waves (2013 and 2015).
  - The last reduction led to a 43 percent average reduction in the price of the 51 most used diagnostic tests and reduced prices of all other exams by 9 percent on average.
  - Complemented by a closed budget on public expenditure for diagnostic tests.
  - Despite price cuts, both expenditure above the ceiling and the number of diagnostic tests continued to increase during the examined period.

- Other macro measures:
  - Rebates and clawbacks for pharmaceuticals aimed to lower overall pharmaceutical expenditure, but initial implementation faced delays and above-the-ceiling expenditure was difficult to contain.
  - Clawbacks on private service providers intended to lower medical service expenditure were more challenging than pharmaceutical clawbacks and faced supply constraints.

### Structural/reform implementation issues and lessons
- Single payer (EOPYY):
  - Intended to create uniform rules and larger bargaining power.
  - Faced financing chain challenges.

- Primary care reorganization and gatekeeping:
  - Gatekeeping expected to avoid unnecessary expenditure and better serve an ageing population.
  - Implementation delays and opposition from doctors occurred.

- Hospital mergers:
  - Aimed at improving efficiency and accommodating ageing.
  - If not managed well, mergers may result in longer waiting times and provision gaps.

- E-prescription and e-procurement:
  - E-prescription enables monitoring and regulation, but deeper data analysis is needed to better utilize the system.
  - E-procurement delayed; seen as a public-sector reform to reduce corruption in procurement contracts.

- Limits on over-prescription and prescription by active substance:
  - Measures to prevent over-prescription met strong opposition; sanctions possibly not imposed diligently.
  - Requiring prescription by active substance increased generic penetration, but generic penetration remains low.

- Regulation of pharmacies to promote generics:
  - Generic penetration has increased, but remains low.

### Spending compression, unmet needs, and reform priorities (high-level findings)
- Despite reforms and curtailed excess spending, especially prior to Covid-19:
  - Public healthcare spending had been compressed to potentially unsustainable levels.
  - Widening inequalities and large unmet needs, especially among the poor, were observed.
- Policy priorities identified:
  - Higher public spending to address compressed levels and unmet needs.
  - Advancing structural healthcare reforms to improve efficiency and equity, including:
    - Strengthening primary healthcare and establishing effective gatekeeping;
    - Reducing out-of-pocket payments (out-of-pocket payments were approximately 30 percent of total health expenditure);
    - Eliminating remaining insurance gaps and ensuring more effective coverage (e.g., limitations of the “booklet” system and eligibility issues such as the EUR 6,000 annual family income cutoff);
    - Enhancing centralized procurement to reduce overpricing of drugs and medical equipment;
    - Better use of e-prescription and related data to monitor prescribing behavior.

### Conclusion (summary points)
- Excess spending was successfully curtailed and elements of the institutional framework were modernized.
- Health outcomes have been relatively favorable.
- However, prior to Covid-19, compression of public healthcare spending, widening inequalities, and large unmet needs—particularly among the poor—undermine sustainability and equity.
- Policy recommendations emphasize restoring adequate public spending levels and deepening structural reforms to strengthen primary care, reduce out-of-pocket payments, and close insurance gaps.

*IMF Working Paper WP/21/189 (excerpts).*

### Introduction of DRGs

### Introduction of DRGs

### Modernizing reimbursement mechanism for inpatient care
- Reform objective: harmonize treatment costs and introduce a common reimbursement mechanism — diagnostic-related groups (DRG) — to replace closed daily rates per specialized case.
- DRG system design and implementation timeline:
  - 2011: first stage foresaw creation of reimbursement system using single closed hospitalization fees (KENs) based on the Australian DRG system, but was not properly implemented.
  - 2014: new law foresaw full implementation starting January 2017, following the German DRG model with adjustments to Greek specifics.
  - Late 2015: pilots took place.
  - 2017: ESAN was renamed (KETEKNY) and its legal nature changed from private to public.
  - 2019: plan to launch a new, performance based DRG pilot with the participation of 18 hospitals across Greece.
  - Status: the new framework has not yet been implemented.
- Implementation requirements and challenges:
  - Hospitals and clinics must save detailed patient information in a registry and submit it regularly to ESAN/KETEKNY.
  - Privacy concerns and opposition cited risks of increased readmissions and post-hospitalization.
  - Need for major behavioral change by providers.

### Budget caps (pharmaceuticals and providers)
- Pharmaceutical budget cap introduced through rebates and a clawback mechanism; complex system since 2011:
  - Rebates: discounts imposed on pharmaceutical companies and pharmacies once certain ceilings of pharmaceutical sale volumes are exceeded; applied monthly or quarterly.
  - Recent rebate system: single rebate system with discounts ranging from 14 to 30 percent applied without any ceiling on sale volumes.
  - Admission fee: a 25 percent admission fee was introduced for products entering the positive list for the first time.
  - Clawbacks: suppliers return any revenue above the ceiling either as direct cash returns to EOPYY or as write-offs of EOPYY accounts payable; settled semi-annually.
  - 2016: pharmaceutical clawback mechanism expanded to include inpatient pharmaceutical expenditure.
  - Government changes shifted an additional 10 percent of the burden to the companies responsible for the excess while the remaining 90 percent is still calculated using the old method.
  - Recent legislation allows pharmaceutical companies to settle past clawback obligations in up to 120 installments.
  - In 2018, all clawbacks were extended up to 2022 with the ceiling indexed to real GDP growth.
  - Observation: measure initially intended as stop-gap may have become a permanent feature.
- Clawback on private hospitals, clinics, diagnostic centers:
  - Introduced in 2013 with a budget cap on public expenditure for outpatient and inpatient care provided by private entities.
  - 2017: expanded to cover all products and services reimbursed by EOPYY with expenditure sub-ceilings specified for every product or service category.
  - Settlement mechanics: overall expenditure ceiling set annually starting in 2013; settlements every six months; each private entity’s own budget cap calculated based on number of invoices they submitted, total invoices submitted to EOPYY, and overall expenditure ceiling.
  - Collection challenges:
    - More private providers than pharmaceutical companies; services harder to monitor than drugs.
    - Significant delays due to legal challenges to 2013 clawback, delayed auditing of 2014 clawback, and suspensions of 2015 clawback.
    - Greek courts have rejected appeals against clawback and rebate mechanisms; installment schemes available to facilitate settlement on a monthly basis.
    - Conclusion: clawback mechanism may not be very effective in regulating numerous small service providers.

### Supply constraints and pharmaceutical policy
- Positive list and HTA:
  - Positive list for pharmaceuticals in place since 2010; revised regularly.
  - Health Technology Assessment (HTA) committee legislated; new reimbursement criteria adopted for pharmaceuticals by EOPYY:
    - Drugs must circulate in at least nine (9) Eurozone countries for EOPYY to reimburse them.
    - They must be reimbursed in at least two thirds of Eurozone countries in which they circulate.
    - Half of the countries that reimburse them must have an HTA system in place.
    - Other criteria: unmet medical need, therapeutically added value versus existing therapies, credibility of clinical trials, cost-benefit considerations.
- Generics policy and outcomes:
  - Doctors required to indicate the active substance (INN); brand-name prescriptions limited to 15 percent of total value of a doctor’s issued prescriptions.
  - Pharmacists required to notify patients of cheaper generic alternatives and maintain sufficient stock of generics; improvements in monitoring in 2018.
  - Penalties for violations: pharmacy fine up to EUR 5,000 and suspension of EOPYY contract up to 6 months.
  - Key statistics:
    - Over 98 percent of total value has been prescribed as active substance.
    - By 2017 generic penetration had only reached approximately 27 percent of actual consumption compared to the OECD/EU average of almost 50 percent.
  - Additional finding: Greece has the highest generics average unit price amongst other European countries.

### Public management and coordination
- Creation and role of EOPYY:
  - EOPYY created as a single payer by consolidating all public mandatory health insurance funds (list of merged SSFs provided).
  - Universal rules applied to all EOPYY members with equal contribution rates and entitlements.
  - Expected advantages: stronger bargaining power on price setting and easier system regulation and performance assessment.
- Key challenges for EOPYY:
  - Complex financing structure reflected in arrears along SSFs–EOPYY–hospitals/other providers chain.
  - Health-contribution collection still relies on original SSFs; recent consolidation into a single pension fund (EFKA) improved transfers but a medium-term reform to integrate SSC collection into tax administration has not yet been implemented.
  - Revenue shortfalls compromise EOPYY’s role; in liquidity constraints it prioritizes payments to private providers, but has run arrears to public hospitals.
  - EOPYY historically lacked human and financial resources to conduct audits; by end-2017 it gradually became able to conduct such audits in-house, but personnel shortages and administrative problems persist.

### Primary care, hospitals, and digital reforms
- Primary care reorganization and gatekeeping:
  - PEDY established in 2014 to consolidate regional health centers and Athens IKA doctor offices into a national primary healthcare network; gatekeeping legislated but not implemented.
  - 2017 law replaced PEDY units with TOMYs; commitment to fully roll out e-referral system in 2018 and open 240 primary health centers over the next 2 years.
  - Delays caused by:
    - Requirement that PEDY doctors quit private practice → strong opposition and strikes; government extended private practice allowance; many doctors chose private practice → PEDY units underfunded and understaffed.
    - Delays in contracting/registering population with family doctors; skepticism about low compensation and large reference population per doctor; concerns about increased access barriers.
- Hospital mergers and capacity:
  - 2009–2014: number of ESY hospital beds reduced by 23 percent; number of ESY hospitals reduced by 13 percent.
  - Nominal annual expenditure of ESY hospitals declined by a quarter from 2012–2015, largely driven by decreased pharmaceutical costs.
  - Consequences: possible longer waiting times, shortages of medical supplies including pharmaceuticals, concerns about reduced ICU beds, and widespread personnel shortages (especially nurses).
  - Note: coronavirus pandemic indicated urgent need to address these shortages.
- Digital reforms that modernized system:
  - E-prescription:
    - 2010: prescriptions were hand-written with no database.
    - Reform requires online registration of all doctors and saving prescriptions in electronic database.
    - By October 2016, almost all prescriptions were issued electronically.
    - Enabled monitoring, regulation, and audits; challenge is to utilize collected data to address induced demand for tests and pharmaceuticals.
  - E-procurement and centralized procurement:
    - E-procurement legislated; implementation slow.
    - 2017: centralized procurement agency (EKAPY) established.
    - EKAPY launched tenders for an overall value of more than 250 million euros as of May 2021.
    - Framework under review; new legislation on the agency expected in June 2021.

### Contracting reforms and provider behavior
- Measures to prevent over-prescription:
  - Post-reform doctors can prescribe medicines only up to a pharmaceutical expenditure threshold disclosed electronically based on specialty, geographic location, number of patients, and seasonality.
  - Exemptions for sensitive groups (cancer patients, transplant patients).
  - 2014 modification: penalties imposed only when a doctor’s prescription exceeded the threshold by over 20 percent for 3 consecutive months; penalties include a fine up to EUR 5,000, a prescription embargo up to 12 months, and possible cancellation of the EOPYY employment contract.
  - 2017: Ministry of Health enhanced over-prescription penalties based on prescription protocols.
- Promoting generics (see Supply constraints section for outcomes).

### Market mechanism and demand-side reforms
- Pharmacy market liberalization:
  - Abolished: minimum geographical distances between pharmacies; one pharmacy license per pharmacist; exclusive right of licensed pharmacists to establish a pharmacy; liberalized opening hours; electronic applications for establishing a new pharmacy and e-pharmacies for online sales; partial liberalization of OTC prices.
  - Recent legislation adopted to open up the pharmacists’ profession despite strong resistance.
  - Remaining restrictions:
    - Only one pharmacy is allowed per 1,000 inhabitants.
    - OTC products still de facto sold mainly by pharmacies.
    - Ownership allowed to non-pharmacists with compulsory participation of a licensed pharmacist at 33 percent.

*Source: wpiea2021189-print-pdf - Introduction of DRGs*

### 26.      The reform aimed to increase copayments to reduce excessive consumption,

### wpiea2021189-print-pdf - 26.      The reform aimed to increase copayments to reduce excessive consumption,

### Health‑care cost‑sharing reform measures and immediate outcomes
- Copayment rate for pharmaceuticals increased from 10 percent to 25 percent of the lowest price available (usually the generics price).
- Copayments reduced for low‑income pensioners and patients of certain medical status (e.g., HIV and transplant patients, pregnant women).
- A 1-euro fee was introduced for each prescription.
- Fees for each visit to public hospitals or health centers increased from 3 euros to 5 euros.
- A 25-euro admission fee was introduced per inpatient care case.
- Exemptions for vulnerable groups also applied.
- Political/resistance outcomes:
  - The 25-euro inpatient admission fee was abolished after less than two weeks of implementation in 2014.
  - The 5-euro fee for visits to hospitals was abolished in April 2015.
- 2018 legislative change:
  - Legislation adopted in 2018 exempts patients suffering from chronic conditions from the copayment of generics.
  - The measure is financed through a rebate on pharmacists’ sales of off-patent drugs and is aimed at further promoting generics.

### Benchmarking framework and analysis approach (Section IV)
- Framework compares:
  - Inputs: spending on health (total spending in percent of GDP or per capita in PPP terms), broken down by public and private expenditure and by functional and economic classifications.
  - Outcomes: health status (average length and quality of life, objective and subjective indicators) and distribution of outcomes across income levels (equity).
  - Structural (intermediate) indicators: physical resources, human resources, medical services provided.
- Purpose: assess remaining priorities to improve efficiency and equity of the Greek healthcare system.

### Aggregate spending trends and equity implications
- As of 2018 (PPP terms), both total spending and public spending per capita are at the bottom of Group 3 countries (Appendix Figure 1 as of 2018).
- During 2010–15:
  - Health spending declined by 1 percent of GDP.
  - Intermediate consumption in health declined by half relative to the average level in Europe.
- IMF historical observations cited:
  - July 2013: “Greece has reduced healthcare expenditures significantly since 2010, to well below the average for EU countries” and “going forward, there is limited scope for additional fiscal savings from public health spending” (IMF, 2013).
  - 2014: Fund emphasized protecting low‑income households and continuing structural reforms to reduce inefficiencies while expanding coverage to low‑income households (IMF, 2014).
- Current unmet needs:
  - Largest share of unmet needs recorded for medical and dental care, disproportionately concentrated at the lower end of the income distribution.
  - Priority areas for additional financing: prevention, primary care, and addressing access disparities.
- Fiscal policy implication:
  - A premium on rebalancing public expenditure from pensions towards targeted social protection including in the healthcare sector, while containing excess expenditure in specific areas (e.g., pharmaceuticals) through non‑distortionary structural measures.

### Public expenditure composition and dynamics (economic classification)
- Major public expenditure compression occurred in non‑personnel healthcare costs.
- Eurostat‑based changes 2010→2017 (percent of GDP):
  - Total general government expenditure on health: 6.9 (2010) → 5.2 (2017).
  - Compensation of employees: 1.7 (2010) → 1.5 (2017).
  - Social benefits (including purchased market production): 3.1 (2010) → 2.2 (2017).
  - Intermediate consumption: 2.1 (2010) → 1.4 (2017).
  - Gross capital formation: 0.0 (2010) → 0.1 (2017).
- As of 2017, Greece spent less on social benefits than most European peers in Group 3 and the Euroarea average.

### Functional composition of public health expenditure and priorities
- Functional comparison (selected highlights, percent of GDP):
  - 2010 public total expenditure: 6.6 (Greece) vs 6.4 (OECD average).
  - 2018 public total expenditure: 4.7 (Greece) vs 6.6 (OECD average).
  - Medical goods (public): 2.3 (2010) → 1.4 (2018) in Greece.
  - Inpatient care (public): 3.0 (2010) → 2.2 (2018) in Greece.
  - Outpatient care (public): 0.7 (2010) → 0.7 (2018) in Greece (remained the lowest among peers).
- Interpretation:
  - Outpatient, long‑term and preventive care are areas where Greece spends relatively little compared to peers.
  - Medical goods expenditure (presumably mostly medicines) declined by almost 1 percent of GDP during 2010–2018 but remains above peers.
  - Inpatient care expenditure declined by 0.8 percent of GDP.
  - Anemic development of the primary healthcare network implies outpatient/primary care will be a priority for additional resource allocation.

### Private expenditure, out‑of‑pocket burdens and access gaps
- Private expenditure trends:
  - 2018 total private expenditure: 3.1 percent of GDP (second highest in the peer group after the Republic of Korea).
  - Share of private in total health expenditure: reached 40 percent in 2018 compared to 31 percent in 2010 (highest among peers together with the Republic of Korea).
- Drivers and implications:
  - Increased copayment rates and new fees introduced during reform contributed to higher private spending.
  - Widening gaps in health coverage driven by unemployment; households inadequately protected from health‑related expenditure and shocks.
  - Although private expenditure on medical goods and inpatient care increased, private expenditure on outpatient care decreased—this may mask increasing unmet needs.

### Unmet need for healthcare services (Self‑reported unmet need, 2014; ELSTAT National Health Survey, weighted)
- Due to cost considerations (Total sample / q1 poorest 20% / q5 richest 20%):
  - Medical care: 13.8% / 23.8% / 5.4%
  - Doctor‑prescribed drugs: 5.3% / 21.6% / 2.4%
  - Dental care: 14.5% / 24.1% / 5.2%
  - Psychiatric care: 2.7% / 2.0% / 9.0%
- Due to other reasons:
  - Due to waiting list: 12.8% / 13.9% / 8.4%
  - Due to distance: 2.9% / 8.7% / 1.3%
- Conclusion: unmet needs—especially for medical care and dental care—are markedly higher among the poorest quintile.

### Access expansion since 2014–2016 and remaining gaps
- Measures introduced to protect uninsured (2014):
  - Admission in public hospitals for inpatient care once approved by hospitals’ boards.
  - Receipt of pharmaceuticals based on e‑prescription issued by ESY and PEDY doctors, subject to same copayment rates as insured patients.
- 2016 provisions:
  - Uninsured individuals required only to show social security number to receive examination and hospitalization in public hospitals and health centers.
  - Authorities wrote off past debt of uninsured citizens towards public hospitals for surgeries and other services.
- Despite universal coverage offered since 2016 (including the unemployed), additional resources are needed to address remaining access gaps that persisted because public health coverage previously depended on employment status.

### Health outcomes and surveillance priorities
- Average physical health status:
  - Overall physical health indicators have been better than the OECD average before and after 2010.
  - Life expectancy improved compared to 2010 (indicators available up to 2016 or 2017).
  - Infant mortality and AIDS incidence have been constant, though Greece’s margins over OECD averages have shrunk.
- Emerging risks and evidence:
  - Public spending to prevent communicable diseases has been chronically low.
  - Appendix Figure 2 (referenced) indicates increase in infectious and communicable diseases after 2010–2012.
  - Studies report deterioration in all‑cause mortality after 2015 in some analyses.
  - Consensus: crisis did not have a noticeable negative impact on average physical health status initially, but deterioration may have emerged as the crisis progressed; health effects can manifest with a lag and require continuous epidemiological monitoring.
- Subjective health status:
  - OECD self‑reported “bad health” (population 15+): increased from 9.7 percent in 2010 to 10.4 percent in 2017.
  - Proportion self‑reporting “good/very good health” declined (exact figures for “good/very good” not provided in the supplied text).

### Policy priorities and recommendations (implied by analysis)
- Prioritize additional financing toward:
  - Prevention and communicable disease control.
  - Primary and outpatient care—strengthening the primary healthcare network.
  - Targeted protection to reduce high out‑of‑pocket healthcare payments, benefiting the poor most.
- Fiscal rebalancing:
  - Rebalance public expenditure from pensions toward targeted social protection including healthcare.
- Supply‑side and efficiency measures:
  - Contain excess expenditure in specific areas (e.g., pharmaceuticals) through non‑distortionary structural measures (price regulation, rebates, clawbacks, promotion of generics).
- Monitoring and evaluation:
  - Continuous assessment of epidemiological trends given lagged health effects from fiscal shocks and crises.

*Italic: Source — Excerpt from the cited IMF chapter text (provided content).*

### 75.5 percent in 2010 to 74.0 in 2017. In contrast, data from ELSTAT’s National Health

### wpiea2021189-print-pdf - 75.5 percent in 2010 to 74.0 in 2017. In contrast, data from ELSTAT’s National Health

### Health status and self-perceived health
- Proportion reporting “bad/very bad health” declined from 8.1 percent in 2009 to 7.0 percent in 2014 (ELSTAT’s National Health Survey).
- OECD data: proportion reporting “good/very good health” for the poorest quintile increased from 67.8 percent in 2010 to 75.3 percent in 2017.
- OECD data: proportion reporting “good/very good health” for the richest quintile decreased from 87.6 percent in 2010 to 81.8 percent in 2017.
- After standardizing for age and gender, ELSTAT’s National Health Survey indicates health status appears broadly resilient between 2009 and 2014 for all income categories and might even have improved after controlling for gender and age (see Appendix Table 3).

### Mental health indicators
- Years lost due to mental and behavioral disorders and intentional self-harm inched up after 2012, suggesting a possible adverse effect of the crisis on average mental health.
- These indicators remain well below the EU average and many other Eurozone countries, including Germany, France, and Spain.
- Findings align with studies linking the crisis to deterioration in mental health status in Greece (Economou et al, 2013; Economou et al, 2011; Kondilis et al, 2013).

### Pandemic response and capacity expansion
- Available ICU beds:
  - 565 at end-February 2020
  - 840 at end-May 2020
  - 1,542 by end-April 2021
  - Note: total includes ICU beds in public and military hospitals, as well as requisitioned beds in private clinics. As of end-April 2021, 981 ICU beds were exclusively reserved for Covid-19 and 561 for other cases (figures are based on statements by the Minister of Health in April 2021).
- Medical staff increases within a year:
  - over 3,000 doctors and nurses
  - over 10,000 subsidiary personnel
  - Not all new hirings will be permanent.
- Requisition actions:
  - In March 2021, the government proceeded to the requisition of 206 private physicians (pneumonologists, GPs and internists).

### Extraordinary financing for Covid-19
- Extraordinary financing in first half of 2020: within the range of 200–300 million euros.
- Total extraordinary financing for 2020: 786 million euros.
  - 200 million euros used to finance wages of newly hired medical staff.
  - 293 million euros allocated to EOPYY.
  - 293 million euros used for procurement of medical equipment and supplies.
- For 2021, the government reserved a 3 billion euro cushion for various pandemic expenses.

### Epidemiological performance and testing/vaccination
- Greece outperformed most other European and OECD countries in epidemiological outcomes (total number of confirmed cases and total number of deaths) during both first and second waves.
- Testing capacity (PCR and rapid tests) has been below the EU and OECD average despite increases.
- Self-testing initiative: self-tests provided free-of-charge to teachers, students, civil servants and some private-sector employees; self-testing mandatory for schools and sectors such as retail and transport with results registered in an online database.
- Vaccination progress as of early June 2021:
  - over 6 million vaccine doses administered in total
  - fully vaccinate over 2.5 million citizens
  - Vaccines are administered free-of-charge and on a voluntary basis and fully vaccinated persons receive a vaccination certificate.
- Greece re-opened tourism-related activities in May 2021 with simultaneous end of second nationwide lockdown (imposed on November 7, 2020).

### Structural resource indicators and utilization
- Relative resource shortages:
  - More physicians and pharmacists in Greece than OECD average, but significantly fewer nurses per 1,000 inhabitants in both public and private providers.
  - Number of hospital beds declined from around the OECD average in 2009 to below average by 2017.
- Table 8 and Figure 9 highlight utilization patterns (selected series and years preserved in source):
  - Life expectancy at birth (female) Greece: 82.5 (2005), 83.3 (2010), 83.9 (2017).
  - Life expectancy at birth (male) Greece: 76.8 (2005), 78.0 (2010), 78.8 (2017).
  - Infant mortality Greece: 3.8 (2005), 3.8 (2010), 3.5 (2017).
  - AIDS incidence Greece: 0.9 (2005), 0.9 (2010), 1.0 (2017) (Incidence per 100,000 population).
  - Malignant neoplasms Greece: 213.2 (2005), 196.5 (2010), 199.2 (2017) (Deaths per 100,000 population).
  - Cerebrovascular diseases Greece: 162.5 (2005), 111.6 (2010), 81.5 (2017) (Deaths per 100,000 population).
  - Ischemic heart diseases Greece: 109.5 (2005), 84.4 (2010), 76.8 (2017) (Deaths per 100,000 population).
  - Self-perceived health status, good health for aged 15+ (Greece): 77.4 (2005), 75.5 (2010), 74.0 (2017).
  - Self-perceived health distribution by quintile (good health aged 15+):
    - Lowest income quintile Greece: 67.7 (2005), 67.8 (2010), 75.3 (2017).
    - Highest income quintile Greece: 88.6 (2005), 87.6 (2010), 81.8 (2017).
  - Unmet needs Greece (2008, 2010, 2018): 5.5 (2008), 5.5 (2010), 8.8 (2018).
  - Unmet needs (lowest income quintile) Greece: 8.8 (2008), 9.0 (2010), 20.6 (2018).
  - Unmet needs (highest income quintile) Greece: 1.8 (2008), 2.1 (2010), 0.8 (2018).
- Figure 9 series (testing, vaccinations, utilization) and Table 9 (healthcare resources per thousand inhabitants) provide additional context in source figures and tables.

### Reforms, efficiency, and fiscal implications
- Since 2010 Greece underwent broad-based and comprehensive healthcare sector reform including:
  - Centralization of the health insurance system through establishment of EOPYY.
  - Reorganization of primary care entities and hospitals (more challenging).
  - Budget caps and price controls to contain excessive spending.
  - Structural reforms: contracting providers, e-prescription, promotion of generic drugs.
- Assessment of efficiency:
  - Various analyses indicate overall efficiency of Greek healthcare system has improved.
  - Greece has moved closer to the efficiency frontier over 2010–18 based on comparisons using different input coverages and life expectancy as outcome.
  - Data Envelopment Analysis (DEA) for cross-sectional data conducted for 2010 and 2018 suggest improvements in Greece’s efficiency rankings among OECD countries.
  - DEA limitations are noted (Hernandez and San Sebastian, 2014; Stefko et al, 2018; Hollingsworth, 2016).
- Fiscal compression and social outcomes:
  - During 2010–17, health spending declined by 1.8 percent of GDP.
  - Health spending compression disproportionately affected the poor, evidenced by rising share of out-of-pocket payments and unmet needs among the poor.
  - Intermediate consumption in health declined by half relative to the average level in Europe.
- Policy priorities and recommendations:
  - Undo spending compression by rebalancing fiscal policy to protect the poor more effectively and ensure truly universal access.
  - Rebalancing the fiscal policy mix would free up resources for more targeted social protections, including in the healthcare sector.
  - Priority areas include further strengthening the public primary healthcare network and reducing out-of-pocket health payments through improved service provision in primary and secondary care, including by delivering truly universal access.
  - Health spending de-compression should move in tandem with continued efforts to address remaining institutional inefficiencies.
  - Collect and closely monitor data about objective health status, public service utilization and the uninsured to inform future reforms and enhance protection for most vulnerable groups.

*Italic: Source — wpiea2021189-print-pdf (IMF).*

### Appendix I Figure 2. Selected Physical and Mental Health Outcome Indicators

### Appendix I Figure 2. Selected Physical and Mental Health Outcome Indicators

### Infectious and Parasitic Diseases
- Measure: Standardized rate of deaths per 100,000 population
- Time axis labels: 2000 2002 2004 2006 2008 2010 2012 2014 2016
- Reference year indicated: 2017
- Vertical axis tick values shown: 0 5 10 15 20 25 30
- Countries / comparator series plotted: France, Germany, Greece, Spain, OECD average
- Source: OECD

### Diseases of the Nervous System
- Measure: Standardized rate of deaths per 100,000 population
- Time axis labels: 2000 2002 2004 2006 2008 2010 2012 2014 2016
- Reference year indicated: 2017
- Vertical axis tick values shown: 0 5 10 15 20 25 30 35 40 45
- Countries / comparator series plotted: France, Germany, Greece, Spain, OECD average
- Source: OECD

### Diseases of the Respiratory System
- Measure: Standardized rate of deaths per 100,000 population
- Time axis labels: 2000 2002 2004 2006 2008 2010 2012 2014 2016
- Reference year indicated: 2017
- Vertical axis tick values shown: 0 20 40 60 80 100 120
- Countries / comparator series plotted: France, Germany, Greece, Spain, OECD average
- Source: OECD

### Diseases of the Digestive System
- Measure: Standardized rate of deaths per 100,000 population
- Time axis labels: 2000 2002 2004 2006 2008 2010 2012 2014 2016
- Vertical axis tick values shown: 0 5 10 15 20 25 30 35 40 45 50
- Countries / comparator series plotted: France, Germany, Greece, Spain, OECD average
- Source: OECD

### Mental and Behavioral Disorders
- Measure: Years lost per 100,000 population
- Time axis labels: 2000 2002 2004 2006 2008 2010 2012 2014 2016
- Reference year indicated: 2017
- Vertical axis tick values shown: 0 20 40 60 80 100 120 140 160 180 200
- Countries / comparator series plotted: France, Germany, Greece, Spain, OECD average
- Source: OECD

### Intentional Self-Harm
- Measure: Years lost per 100,000 population
- Time axis labels: 2000 2002 2004 2006 2008 2010 2012 2014 2016
- Vertical axis tick values shown: 0 50 100 150 200 250 300 350 400 450 500
- Countries / comparator series plotted: France, Germany, Greece, Spain, OECD average
- Source: OECD

*Source: OECD. (Figure reproduced as presented in the source PDF.)*

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_Source: https://www.imf.org/-/media/files/publications/wp/2021/english/wpiea2021189-print-pdf.pdf_