review article

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A political approach to the Greek Health Care finances, and the public/private mix: a hint of hidden inequalities?
Department of Social Adiministration, Democritus University of Thrace, Komotini, Greece

Nikos Polyzos, Costas Dikeos

Analysis of macro-economic indicators is a main element of economic evaluation of health care systems, as to investigate inequalities either among regions, or among sources of health care finance and sectors of care delivery, alongside other social issues. The main purpose of this paper is to examine health expenditures that have continuously increased both in Greece and internationally, despite continuous measures and reforms, in the framework of a party political context alongside the public/private mix in financing health care. The material of this review comes out of national and international data bases. The results notice that public financing has remained almost stable, while private financing has gone up. This has occurred under governance of both parties in the years leading to and just following the EMU effort.

Background

ABSTRACT

Notwithstanding the difficulties in recording the respective statistical data2, this article attempts an approach to the Greek Health System regarding inter alia expansion or contraction and growth or shrinkage in the restrictive environment of the EMU pursuit, in order to deduce relevant conclusions and put forward a proposal which would ameliorate some of its problems alongside making some comments about the public/private mix, within a party political context. International Macro-economic Evaluation based on GDP Analysis Health expenditure currently exceeds 9.2% of the GDP in OECD member states. During the 1974 - 1984 decade there was an impressive rise from 5.7% of the GDP in 1974 to 7.1% in 1982, viz., an overall increase of 25% as seen in table 1 (OECD 2006). The next decade (1984 - 1994) also found health expenditure rising, which, though, was 50% less than that of the previous decade. Finally, in the last ten years expenditure stabilized at the same level of +14% as in the previous one. This trend can be largely attributed to the various cost containment measures that many OECD member states have taken predominantly to improve the efficiency of their health systems. Differences among countries are significant and variously substantiated as some countries have lagged behind whereas others have shown progress in terms of funding. During this 20-year period, it is quite evident that Greece attempted to cover lost ground (caused by a multiple of problems related both to its pre and post war adverse political history) since health expenditure increased by 15% from 1974 to 1984 and by 37% from 1984 to 1994, the latter being one of the highest percentages recorded (Table 1). This boom appears not to be in real terms; rather it is due to the restructuring of Special Accounts just before entry into the European Economic & Monetary Union. A more realistic estimation would be an increase of 7.4% in 1996 and 7.7% in 2005 with an additional percentage of 1.5% credited to underground economy3 which has gone over 2% with the recent GDP revision, i.e., an approximate total of 10%. However, it has been proven that the level of health expenditure, the growth of health systems and the general socioeconomic development of a country are interrelated.4

MATERIALS, METHODS AND RESULTS

Results

Keywords:

Evaluation of health systems based upon their funding constitutes a wide area of international academic interest. On the other hand, politics, both in the sense of party politics and that of setting major political goals such as the EMU, may play a key role in health care financing. It should be additionally noted that indicative conclusions from the relevant bibliography show that health expenditure is expected to increase further in the near future.1 This increase will not only have consequences for the economy in general, but will also trigger difficulties in the management of health care provision and its financing by the state and the Social Security Funds, despite the role of the state being generally thought to develop effective macroeconomic policy, to health directly-, and to social security - indirectly-.

INTRODUCTION

health care system, financing, inequalities, public/private mix, political parties.

IJHS Volume III; Issue 3 July - September 2010

Corresponding author: Dr. Costas Dikeos, Assistant Professor, Department of Social Adiministration, Democritus University of Thrace. 1 P. Tsaldari Str, Komotini, Zipcode 69100 Greece Phone: +30.25310.39419 e-mail: cdikeos@socadm.duth.gr

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Table 1 - Health expenditure in OECD countries as a percentage of GDP, and rate of change

Countries Australia Austria Belgium Canada Denmark Finland France Germany Greece (*) Ireland Italy Japan Luxemburg Netherlands . Zealand Norway Portugal Spain Sweden Switzerland Turkey U.K. USA Average

1974 6,50 5,70 4,70 6,80 7,10 5,80 6,30 7,40 3,30 4,90 7,00 5,90 5,00 3,80 7,00 6,10 5,60 4,10 4,60 7,60 6,20 2,40 5,30 7,80 5,70

1984 7,60 7,90 7,40 8,40 6,40 6,90 8,50 8,70 3,80 6,20 7,80 6,80 6,50 6,00 8,00 6,00 5,90 5,90 5,80 9,30 7,80 2,90 5,90 10,40 7,10

1994 8,50 9,70 8,20 9,80 6,60 8,30 9,70 9,50 5,20 7,70 7,90 8,30 6,90 5,80 8,80 7,50 7,30 7,60 7,30 7,70 9,60 4,20 6,90 14,30 8,10

2004 9,60 9,70 9,70 9,80 8,60 7,40 10,50 10,60 7,90 9,40 7,20 8,70 7,80 8,00 9,20 8,40 9,70 9,80 8,10 9,10 11,50 7,70 8,10 15,30 9,20

1974-1984 % 17 39 57 24 -10 19 35 18 15 26 11 15 30 58 14 -2 5 44 26 22 26 21 11 33 25

1984-1994 % 12 23 11 17 3 20 14 9 37 24 1 22 6 -3 10 25 24 29 26 -17 23 45 17 38 14

1994-2004 % 13 0 18 0 30 -11 8 12 52 22 -9 5 13 38 5 12 33 29 11 18 20 83 17 7 14

1974-1994 % 31 70 74 44 -7 43 54 28 58 55 13 41 38 53 26 23 30 85 59 1 55 75 30 83 42

1974-2004 % 48 70 106 44 21 28 67 43 139 92 3 47 56 110 31 38 73 139 76 20 85 220 53 96 14

Source: OECD 2006, * estimation with underground economy

In most OECD countries the largest part of health expenditure derives from public sources. During the 1996 - 2005 decade, countries with national health systems demonstrated an increase in publicly funded health expenditure as seen in table 2 (OECD 2006). Greece, on the other hand, showed the lowest percentage of public funding (especially after 2004 with the percentage falling to 51% in 2005) whereas current OECD data5 that do not take underground economy into account show public health expenditure at 60.8% of total for 2001, 58% for 2002, 59.8% for 2003, 59.1% for 2004, 60,1 for 2005, 62% for 2006 and 60.3% for 2007. These data indicate that if we consider underground economy too, public expenditure in the past years may easily be estimated at less than 50% of total. In recent years, all EU and OECD countries are moving towards the direction of finding economically and socially acceptable ways of controlling the increase of health expenditure.6 Hence the tendency of many countries to impose a limitation process to health expenditure through the application of national stable budgets (the so called global budgets) that take into account selected policies, especially for hospitals that constitute the most expensive service of health care. The

specialization of these policies and the respective distribution of funds to health services are subsequently accompanied by a series of flexible incentives7 which are rendered in the different ways of payment of the providers: per capita in primary health care, per incident in secondary and tertiary health care: the obvious reason being funding restraints and the optimal distribution per region and/or level of health care. Health Care Financing in Greece and the Public/ Private Mix. Research concerning Greece2, 8, 9, 10, 11 has explored the problem estimating the official health expenditure at over 8% during the last two decades by also taking into consideration the National Accounts. The development of health expenditure in Greece, which is based on data of financial reports of the state, social security funds as well as of private payments (estimations by ICAP and family budgets), confirm the high funding rates of the Greek health system. The stabilization of the 1994 - 2004 decade (approximately 4.5% of the GDP), especially in public funding, is attributed to measures of the more general economic policies because of the Economic & Monetary Union as these were particularized for the health sector. The stabiliza-

Table 2 - Public Health expenditure as a percentage of Total Health expenditure in OECD countries

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Countries Australia Austria Belgium Canada Denmark Finland France Germany Greece (*) Ireland Italy Japan Luxembourg Netherlands . ealand Norway Portugal Spain Sweden Switzerland Turkey U.K. USA Average

1996 66,1 68,2 78,3 70,9 82,4 75,8 76,1 82,2 53,0 71,4 71,5 82,8 92,8 66,2 76,7 84,2 67,5 72,4 86,9 54,7 69,2 82,9 45,7 73,0

1997 67,8 70,3 73,8 70,1 82,3 76,1 76,2 80,8 52,8 74,6 71,9 81,5 92,5 67,8 77,3 81,3 68,0 72,5 85,8 55,2 71,6 80,4 45,3 72,9

1998 67,3 69,7 73,1 70,6 82,0 76,3 76,0 80,1 52,1 76,5 71,6 80,8 92,4 64,1 77,0 82,2 70,0 72,2 85,8 54,9 71,9 80,4 44,3 72,7

1999 70,0 70,0 71,9 70,0 82,2 75,3 76,0 79,8 53,4 72,8 70,4 81,1 89,8 62,7 77,5 82,6 69,9 72,0 85,7 55,3 61,1 80,6 43,8 71,9

2000 68,4 69,9 71,1 70,3 82,4 75,1 75,8 79,7 52,6 73,3 72,0 81,3 89,3 63,1 78,0 82,5 72,5 71,6 84,9 55,6 62,9 80,9 44,0 72,1

2001 67,5 69,5 71,0 69,9 82,7 75,9 75,9 79,4 55,5 75,6 74,3 81,7 89,8 62,8 76,4 83,6 71,5 71,2 84,9 57,1 68,2 83,0 44,8 72,7

2002 67,5 70,5 70,6 69,6 82,9 76,3 78,1 79,3 54,1 75,2 74,2 81,5 90,3 62,5 77,9 83,5 72,2 71,3 85,1 57,9 70,4 83,4 44,8 73,0

2003 67,5 70,3 71,6 70,2 82,7 76,2 78,3 78,7 53,6 78,0 73,7 81,5 90,6 63,1 78,3 83,7 73,4 70,4 85,4 58,5 71,6 85,6 44,6 73,4

2004 67,5 70,7 71,1 69,8 82,3 77,2 78,4 76,9 52,8 79,5 75,1 81,0 90,4 62,4 77,4 83,5 71,6 70,9 84,9 58,5 72,3 86,3 44,7 73,3

2005 67,8 70,8 70,8 69,6 82,3 77,8 79,1 77,2 51,3 80,6 75,8 80,7 90,8 65,7 78,0 83,0 72,7 70,2 84,9 58,7 71,4 87,1 44,8 73,5

Source: OECD 2006, * estimation with underground economy

tion of the private sector in recent years (approximately 3,5% of GDP) can also be explained by the significant fall of households purchasing power. However, two factors should be noted which relatively restrict these estimations: 1. The increasing deficits of the hospitals of the National Health System (0.4% of the GDP per year during the last decade) which are notionally not included in the shaping of the total cost and are not a healthy control measure of the expenditure and, 2. Part of the percentage of the underground economy (which increased by 1.5% of GDP per year during the last decade) has not been calculated.

Independently, though, of the real level of health expenditure, important are the following factors that are associated with health expenditure: 1. The extent of public funding is important because the dependence of a health system on private expenditure potentially means limited access to certain services for a significant part of the population and, 2. the distribution of the onus for funding public health expenditure has important consequences on the equity level of the system, especially in countries with a high degree of tax evasion.

Public Health Expenditure (tax-based) In regards to the seven-year period of 1998 - 2004, there is a corresponding pattern that ends to the result of high concentration of public money through the Ministry of Health (as seen in table 3). It should be noted that data regarding public investment were not officially available when this paper was written. The main conclusion is that during the election years of 2000 (year also of the Economic & Monetary Union) and of 2004 the expenditure from the state budget increased significantly. The following general political conclusions can be inferred from the distribution of public health expenditures of the preceding decade: 1. Public investments increased in the beginning of the respective government tenures of the conservative party of Nea Demokratia (1991) and the socialist party PASOK (1994). 2. the expenditure of the prefectures, e.g. funding of hospitals, doubled biannually until 1990, then stabilized and

The funding of various health services in Greece also demonstrates the reduced emphasis given to primary health care services in contrast to hospital care on which public expenditure in Greece focuses.10,12

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Table 3 - Analysis of State Budget Health Expenditure 1998-2004 (.000 euro, in current prices)

1998 From MoH (*) From districts From MoH (*) From districts
(*) Ministry of Health

1999 1.368.646 1.014.183 58 -54

2000 1.869.004 1.354.132 37 34

2001 2.083.943 1.605.048 12 19

2002 2.298.881 1.684.381 10 5

2003 3.131.070 1.948.942 36 16

2004 3.439.363 3.251.299 10 67

868.287 2.213.004 % change % change

Table 4 - State Budget for Health per Region (% distribution 1998-2004 - per capita 2003-4)

Regions

% 1998

% 1999 6,05 17,31 2,08 5,32 5,44 2,39 4,66 4,69 38,15 4,58 2,51 0,45 6,37 100,00

% 2000 5,44 15,00 2,11 2,84 7,73 3,78 4,94 5,06 37,21 4,61 1,97 2,19 7,12 100,00

% 2001 4,12 15,12 1,59 4,98 4,92 2,42 6,15 3,35 44,29 2,88 1,44 1,63 7,11 100,00

% 2002 4,14 15,37 1,71 4,40 5,36 2,05 6,00 3,36 44,76 3,17 1,27 1,71 6,71 100,00

% 2003 4,00 19,51 1,32 4,11 5,46 1,88 5,53 2,99 43,53 2,94 1,19 1,64 5,89 100,00

% 2004 5,97 11,77 0,95 5,11 8,01 1,75 8,45 1,92 43,30 2,42 1,34 1,06 7,95 100,00

% Popu- Per capita Per capita lation 2003 2004 5,56 16,66 2,85 3,31 7,16 1,89 6,92 5,68 34,73 5,92 1,94 2,12 5,26 100,00 127 207 82 220 135 177 141 93 222 88 109 137 198 177 317 209 99 456 331 274 361 100 369 121 204 148 447 296

East D 7,38 Cent. D 25,58 West D 2,63 EPIRUS THESSALIA ISLANDS West GREECE A North AEGEAN South AEGEAN CRETE Total 5,59 4,96 2,56 7,87 27,80 2,37 0,89 4,47 100,00

Central GREECE 2,94 PELOPONNESOS 4,95

Source: Ministry of Health

consequently decreased in 1994 - the year when the criteria of the Treaty of Maastricht commenced 3. while an increase of public expenditure and a decrease of the expenditure of social insurance funds was a political target in the 80s, in the beginning of the next decade the opposite occurs mainly due to the change in the policy of hospital pricing. Table 4 presents the regional distribution of the state budget expenditure where the inequalities in funding and distribution are apparent, especially in favour of the two large urban regions, as well as Epirus and Crete (in 2004 favored regions also included Thessaly and Western Greece due to the operation of teaching hospitals in these areas). This evaluation, however, also presents methodological weaknesses; the most significant is the non-examination of health needs in conjunction with capital outflows. The most basic finding of the above is that Attiki (the Athens region) absorbs a disproportionally large amount of public funding (as do other regions) and that

Central Greece, Western Macedonia and the Peloponnese receive much smaller public funding (subsidies) in relation always to the size of their population. Social Insurance Funds Health Expenditure: a matter of latent inequalities? As presented in table 5, health expenditure of social security funds can generally be grouped only at level of health services - there is no data for regional distributions. Subsequently, the respective expenditure of 1998 - 2006 is evaluated biannually. Hospital expenditure decreased approximately 20% while pharmaceutical expenditure respectively increased. This, to some extent, is notional since the prices of hospital procedures and fees remained stable whereas not the same occurred with pharmaceuticals. On the other hand, the need for containing this expenditure is pivotal. Noteworthy is also the slight decrease of expenditure for primary and dental health care (approximate total 15%) while other expenditure and subsidies remain stable (approximately 16%).

Table 5 - Health expenditure per level of care of Social Insurance Funds 1998 - 2006 (in million euro)

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1998 Hospital Care Primary Health Care Pharmaceutical " Dental Other Allowances etc. Total
Source: Social Budgets

% 34,3 15,6 32,5 1,3 6,6 10,6 100,0

2000 385,0 169,0 321,5 11,3 102,9 107,3 1,097,0

2002 1,291,2 609,4 1,331,1 35,5 370,6 371,0 3,637,7

2004 2,066,7 790,9 1,866,2 32,0 380,5 427,9 5,136,3

2006 1,805,3 887,7 2,566,1 35,8 498,2 540,0 6,333,1

% 28,5 14,0 40,5 0,6 7,9 8,5 100,0

311,5 141,6 294,9 11,5 60,3 88,0 907,7

" "

Table 6 - Per capita health expenditure in the largest Sickness Funds 1994 & 2006 (in euro)

Level of Care Primary Health and Out-hospital Care Hospital Care Drugs Other Total

1994 30 63 60 17 170

2006 102 160 232 56 550

G (*) 1994 23 100 68 9 200

G (*) 2006 55 240 360 25 680

VE-TAE 1994 20 25 30 10 85

OAEE (**) 2006 80 100 110 60 350

Public 1994 PAD 2006 82 79 78 11 250 250 150 290 60 550

* estimation includes NHS Health Centers ** V+, 200 thousand pensioners of are covered by

Table 6 presents an evaluation of health expenditure per capita and per incident of various social insurance funds where inequalities among them are obvious (the mean value is close to 550 Euros). In the last twelve years, the total expenditure per capita for the fund that covers public servants (OPAD) more than doubled while the funds that cover white- and bluecollar workers (IKA), the agricultural population (OGA), and merchants, manufacturers and owners of small businesses (OAEE) more than tripled. The last fund (OAEE, which covers traders and self-employed mostly non-professional and is the result of other funds such as TEVE, TSA etc coming together), which does not provide directly or indirectly its own services (doctors, etc.), presents the highest per capita out-of-hospital expenditure compared to the other funds. The fund that covers the agricultural population (OGA) presents the highest per capita expenditure for hospitals and pharmaceuticals - especially for the latter the costs increased five-fold. The lowest per capita expenditure in total as well as in hospital and pharmaceutical costs is found in the OAEE fund. It is almost certain that the problem is more generally associated with the organization of health insurance (e.g., between the OAEE and OGA funds), the distribution mechanisms of health care (e.g. between IKA and OAEE on one hand, and between OGA and OPAD on the other) and by extension the moral hazard that

the insured patients can cause through doctors and the other providers of health services. In conclusion, the lack of planning by the Insurance Funds and the state instigates the inefficient distribution of monetary funds, concerning technical and distributive efficiency. This, consequently, brings about inequalities in the access and use of health services between social insurance funds, in total and at health care level, which, nevertheless, include populations of the same social and professional background9, as well as between regions with regards to state expenditure, a fact which internationally is a popular field of research and health policy intervention.12 Private Health Expenditure: a matter of more explicit inequalities? Private health expenditure is the third but comparatively larger source of the funding of the system. Traditionally, this expenditure has been high. A significant factor that contributes to the high private expenditures is the disproportionately great number of doctors and diagnostic centres in Greece.13,14,15 The level of private health expenditure in Greece, as a percentage of the total expenditure, is one of the highest in Europe. This could be a result of the public system weakness to cover the health needs of the population or the expectations of the Greeks for immediate access to health services. Various

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Table 7. Health expenditure per capita (euro) and % GDP (2005)

Countries Australia Austria Belgium Kannada Denmark Finland France Germany Greece Ireland Italy
Source: OECD 2006

Per capita 2699 2302 2827 3001 2763 2118 2903 2996 2011 2451 2258

% GDP 9,3 7,5 9,6 9,9 9,0 7,4 10,1 11,1 9,9 7,4 8,4

Countries Japan Luxemburg . ealand Netherlands Portugal Spain Sweden Switzerland Czech Republic UK USA

Per capita 2139 3705 1886 2976 1797 1835 2703 3781 1298 2231 5635

% GDP 7,9 6,9 8,1 9,8 9,6 7,7 9,4 10,9 7,5 7,7 15,0

Table 8. Per capita health expenditure in Greece 2006 (in euros)

Level of care Source of finance State Social Insurance Funds Private payments (*) Total %

Hospitals 320 250 390 960 40

PHC (**) 30 120 570 720 30

Drugs 20 300 160 480 20

Other 30 130 80 240 10

Total 400 800 1200 2400 100

% 17 33 50 100

Source: Self estimation, * including physicians payments, ** primary health care.

recently conducted studies (reviewed in 8 references in the section of this paper concerning public/private mix in Greece) estimate private health expenditure close to 5% of the GDP. The increase of the private health industry became possible also because of the significant increase of the private health insurance market that was observed during the 1985 - 1994 decade.13,15 However, there is a paradox since the private health insurance market shows clear signs of fatigue due to the very fact that insurance companies have become aware that the uncontrolled increase of expenditure threatens their viability. The outcome of this is that private health insurance companies are continuously looking to establish agreements, especially with major players of the Greek private health industry in order to contain costs. On the other hand it can be claimed that the key cause of changes in the public/private health expenditure share are the wider opportunities given to private sector entities such as maternity clinics (with quality hotel standards), and diagnostic centres (with shorter waiting periods).13,14 These entities are preferred mainly by the better off, have high charges and get a large part of expenses. Therefore the said changes relate rather to growth of the private sector, while the public sector is not underfunded. Overall, in 1991 the average Greek family spent for health

It should be noted that PASOK has been the prevalent party for most of the post 1983 (year of GR-NHS establishment) period. Policy change regarding public health care provision and accessibility concentrated upon issues concerning health centres management and hospital investment. The Nea Demokratia legislation on the other hand concentrated on giving more opportunities for private practice without necessarily undermining the existence of public provision or public pay-

DISCUSSION

care about 1.200 Euros (400 to 800 Euros per person). According to the 2004 prices, it is estimated that each Greek household spends more than 1.600 Euros - depending on the number of family members, this figure corresponds to 600 1000 Euros per person without it being possible to know the percentages for insurance and health care. The unequal distribution of this expenditure follows the income criterion and amounts to 1.5 months of wages per household. The distribution of these costs are 20% for pharmaceuticals, 30% for dental work, 25% for doctors, 12% for hospital care and 13% for other health services (OECD 2006). Therefore it seems that family budgets cover the lack of funding by the state and the health insurance funds in dental and more generally primary health care (more than 50%).

ment themselves. This lead to reciprocal law annulling over such issues in a framework of consensus regarding the very existence of a GR-NHS and public accessibility to health care, a point made by Davaki and Mossialos16 as well who mention that despite several changes since its establishment, the overall objectives of the Greek health care system have remained relatively unchanged. Turning to public expenditure for health in standard (2000) prices17, and its annual rate of change (for way of calculation see18,19 we observe that it grows gradually during the almost twenty year period of 1987-2005, despite the bad beginning of 1987 (PASOK), and the relatively lower periods of growth under Nea Demokratia, since PASOK especially after 1993 scores an average of 5,75% per annum, and Nea Demokratia an average of 1,93% per annum for 1990-93 and shows negative growth in its first years of governance after 2004. In a nutshell as far as a solo and not a comparative approach is under question, we can overall observe both similar and different decisions as regards public health expenditure by both parties. Nevertheless, this article wishes to claim inter alia that regardless the tug-of-war upon legislation (moreover regulating matters of minor importance), on the fiscal and financial front (public) expenditure approximates an average 4.5% of the GDP indicating a tug-together, which has not been much influenced by the efforts towards the EMU goal.20 Turning to a comparative approach, table 7 summarizes total health expenditure per capita and as a percentage of the GDP for 22 developed countries. Although Greece lags behind only the USA (15%), Germany (11.1%), Switzerland (10.9%) and France (10.1%), equaling with Canada at 9.9%, as far as total health care expenditure as a percentage of the GDP is under question, in regards to per capita expenditure it only exceeds New Zealand, Spain, Portugal, and the Czech Republic, (a country which has the highest per capita health expenditure of all former Eastern European countries). Irrespective of this, Greece (2,011 Euro) is quite close to countries with developed health systems like the United Kingdom (2,231), Japan (2,139), Finland (2,118), Italy (2,258) and Austria (2,302) making the leap, for better or for worse, in recent years. It could therefore be claimed that Greece is in parity with most of its European piers alongside some other OECD member states. However, this picture changes once we turn to the public/private mix as seen earlier (in table 2). The most significant fact of this apparent inequality in the distribution and management of funds is that Greece displays the highest level of private funding, being in second place behind the USA, while at the same time the smaller part of the so-called public expenditure is covered by the state budget (about 17% of the total) and the larger part by the social security funds (about 33 % of the total) as depicted in table 8 bellow. Table 8 also indicates that 40% of total expenditure is devoted to hospital expenses, whereas 60% of aggregate hospital expenses is public (budget and social security funds combined)

During the last 15 years, the health system of Greece under governments of both political parties has been mainly based on public payments while the private sector of health has a considerable share as well (more in out-of-hospital care and less in hospital care), whereas the organization of the public health services is dominated by hospitals. Therefore, whilst Greece is in parity with most European countries regarding expenditure, and it indicates a cross party consensus on health care provision and funding, it shows inequalities between various insurance funds as per capita expenditure is concerned. Moreover it falls out of parity with most European countries as far as the public/private mix is under question tending closer to USA figures. These said inequalities (especially the inequalities due to a variety of reasons such as speedy access and hotel services of public hospitals) relate to (and require a) need of strengthening Primary Health Care Provision and funding and better public hospital management probably taking into account issues like user satisfaction, global budgets, efficiency, effectiveness and social accountability upon generally acceptable criteria.21 Evaluating the above, the policy proposal by which the provision of public health services, and especially public hospital health care, should be empowered in the context of a monopsonistic financing separated from a monopolistic provision is pertinent. Such action would achieve regulation of access, and a more just and effective distribution of funds. Most importantly, though, the success of this endeavor needs adequate, central but also regional, management as well as the development of local hospital tools which would relate costs and prices.

CONCLUSIONS AND PROPOSALS

expenses, whilst hospital expenses constitute 80% of budget expenses. On the other hand, primary health care expenditure covers about 30% of the total (predominantly private with public lagging far behind at a mere 21% of PHC exp). Last, pharmaceuticals are below 20% (with about 66% of it being public expenses) and the remaining 10% is allocated to other expenses (with about 66% of it being public expenses too).

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