Speech – Policy Dialogue on Primary Health Care Reform in Greece

Opening remarks by Dr Zsuzsanna Jakab, WHO Regional Director for Europe

9–10 May 2016, Athens, Greece

Your Excellency, Prime Minister Alexis Tsipras,
Minister Andreas Xanthos,
Ladies and gentlemen,

I am very pleased to be with all of you here today. I would first of all like to thank Minister Xanthos and his team for organizing and hosting this important policy event and also to express my appreciation for the courageous steps taken lately by Greece for fundamental transformation of its health system, with a move towards universal health coverage and people-centredness.

We are gathering at a unique moment in history, now that all the member states of the United Nations have adopted the Sustainable Development Goals (SDGs). Their aims are to bring peace, prosperity and protection to the planet and its people by fostering partnerships, leaving no one behind and working towards a socially, financially, environmentally sustainable society in which health and universal health coverage are recognized as cross-cutting elements for the achievement of all the other goals. The SDGs reflect the values and principles of the European Health Policy Framework Health 2020, which sets out a vision whereby Europe can achieve its greatest potential in health and well-being. Our work on Health 2020 is fully aligned with the objectives of the SDGs, demonstrating that our policies and strategies are well thought through and well formulated. The integrated nature of Health 2020 also supports the intention of the SDGs for greater policy coherence, new forms of governance for more horizontal, networked actions via whole-of-government and whole-of-society approaches and reaching all stakeholders.

The SDGs are universal. Therefore, I am convinced that Greece will also review its own development plan to ensure that its priorities are in line with the SDGs. We look forward to working with you in this important undertaking, as health is a key contributor to and an indicator of development.

In this spirit, let me commend the Government of Greece for its vision on health and health systems reform, expressed in the Ministry of Health's 5-year reform plan, "Greece's health sector beyond austerity: the 100 actions plan for universal coverage". The 100-point action plan addresses the contemporary challenges faced by Greece, which reflect the challenges confronted by Europe in general.

The health landscape in Europe is changing drastically, with the rapid ageing of the population, increasing incidences of chronic conditions and multiple comorbidity due to various determinants of health, pressures from the financial and economic environment, migration, potentially revolutionary technologies and an assertive population that is active in the social media. Collectively, the challenges make the health reform agenda both more relevant and more urgent than ever. We have evidence from our extensive work on the impact of the financial crisis on health and health systems that austerity measures alone, reflected in significant reductions of Government's health expenditure, fail to deliver the expected results.

In Greece, the austerity measures were accompanied by reduced health service coverage of the population, a significant increase in unmet needs for medical care, which almost doubled between 2009 and 2013 (from 4.0% to 7.8%), and an increase in private health expenditure from 30.3% to 35.6% of total health expenditure (Hellenic Statistical Authority, 2015); thus, people themselves pay more for health services.

The population of Greece is ageing more rapidly than those of the other European Union countries, with 20% of people over the age of 65 years. Health status in Greece has for a long time been among the best in the WHO European Region, with an increase of 7 years of life expectancy in recent decades; however, there is an important divide. While male life expectancy is similar to that of 15 countries of the European Union, that of females is 1 year less. Overall, health status is now increasing at a slower pace than in the other countries of the European Union, particularly with regard to circulatory diseases and cancer, a trend that began even before the current economic crisis. The contributory factors include the determinants of health; therefore, the upstream approach with intersectoral components that is advocated in Health 2020 and the SDGs will have to be used. We should therefore identify the components of the health policy that address those determinants and review the available policy tools for creating a supportive environment for health. This will help to identify any gaps in policies and their implementation.

A crucially important component of this work – which I fully support – is the three-pronged approach of the 100 actions plan for universal coverage to enhance timely reform of the health sector:

Enhance universal access to health services of sufficient quality to be effective.
Improve the transparency, inclusiveness and modernization of health governance through an efficient, effective public administration.
Improve the financial sustainability of the health system, with universal coverage of financial protection against the costs of ill health.

Since the Alma Ata Declaration on Primary Health Care in 1978, we know that the stepping-stone towards better health, equity and universal health coverage is building and strengthening a sustainable, integrated primary health care (PHC) system. I am therefore really glad to witness the consensus emerging in this country in this regard. Since my last visit to Greece, significant progress has been made in moving from the vision and conceptualization of the future PHC system towards an agreed plan for building a network of neighbourhood family health units. Such a plan requires extensive preparation, and I am aware of the work being conducted to provide the necessary framework for establishing the network, the package of services to be provided, the contractual arrangements to ensure delivery of services and initial training of future staff. This 2-day event will offer an important opportunity not only to exchange views on the remaining strategic issues but also to discuss in greater detail and to achieve consensus on the framework before pilot studies are conducted and the new PHC system is launched.

A reform of such a scale would take significant time and resources in any country and will require broad stakeholder support, including that of the general population. Experience in our Region shows that this is both do-able and worth the effort. Experience with large-scale health system transformations in other countries in the Region and globally shows that not only leadership but also clear, simple communication to all stakeholders, especially the population, are key factors in gaining popular and political support to pursue structural reforms.

We have in this room a group of renowned experts from other European countries who will share with us good practices and lessons learnt from PHC reform. I am happy to see among the list of participants representatives of key actors at national level, whose contribution is critical for implementing the reforms, including the Prime Minister's Office, the Ministry of Health and its institutions and other ministries, State agencies, professional associations, patients' associations and representatives of civil society. A solid platform is being formed, providing an opportunity for dialogue and ensuring that the reform process is transparent.

The success of PHC reform will depend on thorough planning, design, monitoring and evaluation during the pilot stage. It is also important that the population and the health workers in the areas selected for pilot testing see a positive difference once a proper system is in place, which ensures timely access to a comprehensive set of primary health services of high quality for everyone. But, to ensure good outcomes, primary care providers should be the first points of contact with the health system for everyone, so that they can ensure that all the population's health needs are met and that care received from other health care providers is fully coordinated and appropriately followed up. PHC reform does not occur in a vacuum. Every reform should be linked to other care settings, such as modernized hospitals and long-term, community and social care.

We are therefore working on a new vision for coordinated, integrated health system delivery at regional level, centred on people as the guiding focus. The European Framework of Action on People-centred, Integrated Health Service Delivery will be on the agenda of the Regional Committee in September this year in Copenhagen. It is well aligned with the other strategies and action plans that will be discussed, such as noncommunicable diseases and control of multi-drug-resistant tuberculosis, which will speed up their implementation. This is relevant for Greece as well, conforming to the Tallinn process. One of the main conclusions of the WHO high-level meeting on the fifth anniversary of the Tallinn Charter in 2013 was that countries should approach health system reform comprehensively, transform service delivery and align it with financial policy reforms for the move towards universal health coverage; these should be underpinned by a sustainable workforce, including limiting migration and a "brain drain", ensuring access to cost-effective medicines and technologies and better health information. All these directions should be supported by good governance and leadership. I repeat that this broad health system agenda is highly relevant for Greece. You have many experts in this field, and I am committed to providing further experts in each of these areas of work so that we can work hand in hand as we have done successfully over many years.

Most people at some time in their lives have one or more chronic diseases or conditions, like hypertension, heart disease, cancer or diabetes. These diseases are often silent for a long time after they develop and, once fully developed, require significant input from both primary care providers, patients and their families to ensure good clinical outcomes. It is therefore critical that true partnerships be formed between individuals, their families and the PHC team. Without such relationships, it is impossible to prevent invalidating complications like heart attack or stroke in the case of hypertension and heart disease and blindness, kidney failure or amputation in the case of diabetes, which are very costly to treat in hospital, and are, in fact, avoidable. People centredness goes beyond listening to patients' voices. It involves recognizing that people have a say in how new models of care are designed and used, as co-producers of their own care.

The pattern of diseases in the world has changed over time. Therefore, significant changes in the perceptions and preferences of both patients and health care providers will be required to ensure the best possible health outcomes. The population must be informed that the new PHC provider teams will be better able to ensure that patients receive the coordinated, comprehensive services they need to prevent premature disability or death due to chronic diseases. They should therefore change their current preference for care from narrow specialists and diagnostic centres. Hospital care should be limited to patients who are truly in need of such care. Health care providers will also have to change. Young doctors should be motivated to choose family medicine as a specialization, and all health care providers should recognize that good outcomes require a multi-disciplinary team approach, in which patients and their families play a critical role in ensuring good outcomes. Throughout the Region, we see an expanding role for nurses and midwives, the largest health workforce in the Region, although they are still an untapped potential, often due to the conservative thinking of the medical workforce.

Significant results can be achieved at the population level only if establishment of a new PHC system is complemented by initiatives to reduce the proportion of the population in which chronic noncommunicable diseases develop in the first place. This too will require new approaches, with a greater focus on promotion of healthy life styles and disease prevention and their social and environmental aspects. It will also require new services to rehabilitate patients after treatment of acute complications, so that they can return to full vigour. We must not forget the inequalities in health observed today. To address them, we must tackle the social determinants of health. Equally important are the environmental determinants, which are responsible for 25% of the disease burden. This will require intersectoral action and population-based interventions, such as those advocated in the European policy framework Health 2020. This will not be an easy task, but WHO is ready to provide whatever assistance it can. This year and next year, two ministerial conferences will be organized to bring together various sectors to address the determinants of health, also reaching out at local level and to other stakeholders.

Let me remind you of the key lesson from the high-level meeting on the impact of the crisis on health and health systems, which was generously hosted by the Norwegian Directorate of Health in 2013. The lesson was brought as a resolution to the Regional Committee:

The most important message about the inter-play of health and fiscal policies is that governments have a choice. They can choose where to allocate more or fewer funds, even within a more restricted overall funding envelope. This means that priorities matter; and priorities can be influenced by good intersectoral dialogue, evidence and listening to the voice of the people.

So where should governments invest their funds?

in areas and services that encourage economic growth (Reigniting economic growth and reducing unemployment is good health policy and should be a priority for all health ministers.) and
in areas and services that reinforce solidarity and equity, such as health, employment, social benefits and education.

We look forward to fruitful discussions during the coming 2 days and hope that Greece will soon be able to share its own good practices in building a sustainable, integrated, people-centred PHC system as part of its move towards universal health coverage.

I am well aware of the wide expertise in this country. WHO uses several excellent experts from Greece to assist other countries in the Region. You know the challenges and also the solutions.

Commitment of Greece to health reform means a genuine commitment to implementation and operationalization of the concepts. We need everyone on board, and we need to reassure them that everyone has a role, both in the current health system and in the new models of care.

I commit myself, Mr Prime Minister, Minister Xanthos and the Greek people, to continue to provide the best possible support to you in implementing PHC reform for the better health of the people and for ensuring that Greece maintains its leadership in health in the European Region! Thank you for your attention, and I wish you success in achieving your challenging tasks!