POLICY MEMO n.11 – Gennaio 2020 – Di Stella Christou, Scuola Normale Superiore
World Health Organisation’s (WHO) International Conference on Primary Care in 1978 resulted in the Alma-Ata Declaration, which sees citizen participation as both a right and a duty for healthcare policy making and implementation. Since then, a number of studies and proposals have been discussed concerning the involvement of citizens (or patients) in informing, evaluating and adopting decisions in primary and public health.
In their literature review concerning the four Southern European countries, Matos and Serapioni (2017) point to the formal, institutional – yet hardly ever practical – citizen participation in the first three countries and its absence in the case of Greece. They conclude that this absence “illustrates the inability in the last 30 years, to implement the reform as designed in the law [1397/1987], including the promotion of health system decentralisation, strengthening primary care, adoption of measures to improve health services efficiency and overcoming the fragmentation of the National Health Service […]”.
In the years of the crisis in Greece and the concomitant austerity policies imposed by the MoUs1, health expenditure shrank significantly, with the Hellenic Statistical Authority reporting a 36.6% decrease between 2009-2014. In addition, formal unemployment grew dramatically to an estimated 25% (Eurostat Database, 2015). The economic and social consequences of the crisis took a toll on the National Health System, creating problems of coverage – as a third of the population was left uninsured – as well as financing, resulting in severe shortages in medical equipment and pharmaceuticals. As such, the WHO report on healthcare in the country, published in 2018, considers voluntary associations as one of the main providers of primary care in Greece, especially for the uninsured and migrant population(s).
Voluntary associations, including a wide array of NGOs, municipal authorities as well as grassroots activist circles, became prevalent during the years of the crisis, intervening on the basis of the “humanitarian crisis”, resulting from austerity, with the provision of free primary care services and pharmaceuticals to those in need. Commonly cited indicators were the rising levels of infant mortality rates, the 16-fold increase of HIV infections and the spread of tuberculosis and malaria to unprecedented levels for the country (Economou, 2019). In addition, reports witness the rise of suicides by 40% between 2010 and 2011 alone (Economou et al., 2011).
Among those actors providing free primary care and pharmaceuticals to patients (as well as hospitals, prisons and refugee camps) were the solidarity clinics-pharmacies (Kinonika Iatreia- Farmakeia) operating as a movement-network of volunteers, advocating for health reform. Direct citizen involvement in the provision of services and pharmaceuticals, as well as the in running of the clinics, raised awareness on population and community health needs while stirring innovation in an otherwise stagnant policy field. Among the most important innovations were:
− The development of multidisciplinary health teams, including psychologists, psychiatrists, dieticians and social workers: this strategy secured a holistic approach to patient care, contained within the space of the clinic that facilitated coordination and continuation of care between specialties.
− The recycling network of pharmaceuticals by donations: in a period characterized by shortages in pharmaceuticals, while co-payments were strenuous for a large segment of the population, the informal recycling network would cover needs on the ground whilst alleviating pressures faced by hospitals in the provision of medicines.
−The critique of the healthcare system as inaccessible, inherently hyper-specialized hierarchical and potentially racist. This sparked alternative visions of healthcare in general, whilst offering safe spaces for people excluded by the healthcare system.
It is important to note here that the clinics wished to incorporate these demands into healthcare policy, rendering themselves obsolete.
The success of the clinics is witnessed by their formal inclusion in the drafting of two major health care laws, which altered the inertia (or path-dependency) of healthcare policy in the country. More specifically, Law 4368/2016 allowed the admission of all uninsured patients with a Social Security Number to the NHS, while Law 4486/2017 saw the restructuring and decentralization of primary health care. These reforms have been discussed since the very establishment of the NHS, but no steps were made towards their full actualization. The Law dictated the introduction of a family doctor, and the establishment of primary health centres that would provide health care services. Volunteers would offer themselves in assisting in the implementation of the reform, by acting as ‘watchdogs’ for its level of implementation, checking on services and guaranteeing admission of patients to the NHS, and as an information point, redirecting citizens from their facilities to the appropriate Local Health Units.
As seen in the case of Greece, non-institutionalized citizen’s participation in primary care can have a potent impact in affecting a paradigmatic shift in decision making. Under conditions necessitating intervention in the form of direct action, citizen participation constituted a bright example of how to improve primary care, whilst giving confidence to citizens to articulate their demands in an otherwise inaccessible and expert dominated policy field. While the reform is under way it is therefore important to enhance and secure those channels of participation, communication and evaluation of the reform for and by citizens. This can be achieved through the Local Health Units, themselves operating as a space for public deliberation, improving transparency and encouraging accountability while also stimulating civil society participation around pressing local issues. Reach-out strategies could include the connection of the Local Health Units to welfare and social services, community programs, patient groups, local schools and pharmacies. Such a strategy would not only increase the presence of civil society in primary care, but shall facilitate connection with people, improving health education and disease prevention.
In Spain, Italy and Portugal, where channels connecting primary care to civil society exist, conscious efforts should be made on the part of regional authorities to move away from legalistic and/or discursive limitations in order to activate civil society in the domain of primary care both in policy-making and implementation.