Insufficient primary care services to the rural population of Greece

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Dear Editor

The aim of the Greek healthcare system is stated to be universal coverage and provision of equal services to all citizens¹. This ambitious aim can hardly be said to have been realised². Primary healthcare in Greece remains poorly organised and highly fractured, as it is delivered by a variety of providers that differ in quantity, quality, effectiveness and efficiency of care provision. As a consequence, Greeks often have unequal access to standard services, depending on factors such as entitlement, geographical accessibility and ability to pay³. This holds particularly true for the large proportion of the Greek population who inhabit rural areas.

Semi-urban and rural populations comprise 30% of the Greek population. In theory, primary care in rural areas is delivered to all citizens without charge by NHS (ESY) rural health centres and rural (provincial) dispensaries, which are expected to provide comprehensive health services (diagnostic, curative, preventive, health promotive and rehabilitative). However, according to the national household survey Hellas Health I³, only 20% of the rural population tends to use NHS rural health services as their main source of primary care (Table 1). The majority chooses to use private or urban primary care services instead. It is notable that 31.8% of rural population uses private doctors as their primary source of health care.

Table 1: Residency and place of primary care consultation (data source: Hellas Health I study³



This pattern of healthcare utilization is attributed primarily to inadequacies in rural primary care services. The services delivered are unilaterally oriented towards acute health problems, and rarely engage in prevention, health promotion, social care and rehabilitation⁴. Moreover, chronic disease management is usually performed in a fragmented way, with the main focus being on prescribing. Consequently, a stable, personal long-term relation between the patient and provider is rarely established. Under these circumstances, it is not surprising that rural populations are highly dissatisfied with delivered healthcare services².

Obviously, the Greek rural population does not have the same opportunities in health care as the urban population. On one hand, rural citizens have fewer healthcare options; they are mostly insured by the OGA insurance fund, which does not have its own healthcare network nor does it provide free access to private doctors, as do other social funds. On the other hand, the lack of satisfactory rural healthcare services means that rural patients often have to travel long distances to find the necessary care, thus incurring large time and travelling costs. Quite often they are forced to seek private care, which may be expensive and burdensome for a limited family budget³. Indeed, rural residents are more likely to consult private doctors or clinics than urban residents (p = 0.006) (Table 1).

Countries with strong primary-care systems are generally associated with better outcomes and lower inequalities⁵. Hopefully, the Greek health authorities will realise the necessity to head towards an integrated, team-based primary care system that will ensure continuity and coordination of care. Adequate investments in human resources and infrastructure are critical in establishing effective rural health services, and these need to be accompanied by structural reforms and updated organizational policies.

Nikolaos Oikonomou, MD and Yannis Tountas, MD, PhD
Centre for Health Services Research
Medical School, University of Athens
Athens, Greece

References

1. Mossialos E, Allin S, Davaki K. Analysing the Greek health system: a tale of fragmentation and inertia. Health Economics 2005; 14: S151-S168.

2. Tountas Y, Karnaki P, Pavi E, Souliotis K. The "unexpected" growth of the private health sector in Greece. Health Policy 2005; 74: 167-180.

3. Tountas Y, Oikonomou N, Pallikarona G, Dimitrakaki C, Tzavara C, Souliotis K et al. Sociodemographic and socioeconomic determinants of health services utilisation in Greece: the Hellas Health I study. Health Service Management Research 2011; 24(1): 8-18.

4. Oikonomou N, Mariolis A. How is Greece conforming to Alma-Ata's principles in the middle of its biggest financial crisis? British Journal of General Practice 2010; 60(575): 456-457.

5. Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. The Milbank Quarterly 2005; 83(3): 457-502.