Table of Contents. Proposals documents of the Ministry of Health - 2 -

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1 «ΥΓΕΙΑ » Πρόταση Υπουργείου Υγείας ΜΑΪΟΣ 2013

2 Table of Contents 1 SECTION 1: ANALYSIS OBJECTIVES Inequalities and Developmental Needs Analysis Inequalities in the Health Sector Developmental Needs Analysis of the Health Sector Need for interventions relating to other sectors THEMATIC TARGETS INVESTMENT PRIORITIES ACTION CATEGORIES Thematic target 11 Improvement of the institutional capacity and public administration efficiency Thematic target 9 Promotion of Social Integration and Combat of Poverty Thematic target 8 Promotion of Employment and Labor Force mobility support Thematic Target 2 Improvement of the quality, use and access to IΤ Thematic Target 4 Support for the transition to a low CO2 emission economy in all sectors Thematic Target 6 Environmental Protection and promotion of efficient resource utilization Thematic Target 1 Enhancement of research, development of technology and innovation application of horizontal principles and policy targets for the implementation of grnet Implementation of partnership principle Promotion of equality of genders, non discrimination and accessibility (article 7 of the Common Provision Code (KKD)) Proposals documents of the Ministry of Health - 2 -

3 1 SECTION 1: ANALYSIS OBJECTIVES 1.1 INEQUALITIES AND DEVELOPMENTAL NEEDS ANALYSIS Inequalities in the Health Sector Introduction Investing in the health sector is considered to be one of the major development drivers worldwide. In Europe in particular promoting good health is an integral part of the objectives of the Europe 2020 strategy towards a smart non exclusive development, since, beyond its wider moral and social dimensions, promoting good health has extensive positive impact on productivity and competitiveness for the European economy. It is a fact that financing needs increase due to, on the one hand, the continuous demands of the ageing population and, on the other hand, the increased cost of the treatments offered by the multifarious scientific and technological developments in the sector; thus, the efficient use of the always restricted available fiscal resources is of primary significance for every society, both in terms of basic political choices and in terms of administrative capacity. Today the Health Sector in Greece is influenced in numerous ways both by global and international trends, as mentioned above, and by the maladies of the past, as well as, of course, by the serious financial and social crisis in the country. In general terms, before the crisis the country was characterized by rather high total national health expenditures in comparison to the European standards; however per capita public expenditure was low and per capita private expenditure was high, leading to unequal burdens imposed on the poor and the elderly. From this period we have inherited the very well known serious and ongoing structural problems in the sector, i.e. surplus of doctors, surplus of hospital beds, many cases of artificial demand of costly medical services, overconsumption of costly medications, etc. Moreover, considering that the aging of the population runs faster than the European average (from 17.5% in 2009 to more than 22% in 2020 and 35% in 2050), the prospect of a fast and dangerous increase in demand seems serious. In addition, an outcome of the current crisis is the serious degeneration of a series of social financial factors, which, at the international level, are considered to reflect the state of the population s health, such as income and access to social insurance, leading to serious further burdens on the health system. It is well known that the existing fiscal framework, despite the aforementioned needs, will continue imposing strict constraints on the financing available to the National Health System. At the same time, due to the crisis, private expenditures for health services seem likely to be seriously reduced. Considering all the aforementioned points, it is obvious that important structural changes are imperative so that the health system can increase its (financial) performance and (clinical) efficiency and so that it manages to reduce or even set off the loss Proposals documents of the Ministry of Health - 3 -

4 of resources; thus the health system will gradually become more just in terms of providing higher quality services at lower expenditures. Today in Greece the highly problematic critical areas, which require explicitly structural interventions, are as follows: a) Providing citizens with quality hospital healthcare services in line with demand The continuing delay in implementing a series of critical structural changes at NHS hospitals (such as cost focus on fixed, uniform hospitalisation charges, the use of cutting edge IT systems, centralisation of and control over procurement, rationalisation of staff, modernisation of the organisational and operational model, etc) is keeping operating costs very high, despite the major budget cuts, and even though demand for their services is increasing (a 28% increase in NHS admissions between 2010 and 2011, a 6% increase in people treated, and a 6% increase in operations over the same period). Consequently, there is a pressing need to implement major structural changes to increase the efficiency and effectiveness of public healthcare units to ensure both more equitable access to hospital care and the provision of better quality services. b) Operation of the National Healthcare Service Provider (EOPPY) Beyond any doubt, the establishment of the National Healthcare Service Provider (EOPPY) is a positive step. However, the organisation has not been adequately bolstered to allow it to operate it effectively and efficiently, thereby ensuring problem-free financing of the system. Despite the legislative and organisational changes that have been implemented, EOPPY still has to deal with organisational delays in primary healthcare making it difficult for citizens to access medical care or creating discontinuities in care, and making it difficult to curtail demand for hospitals, the low performance ratings in terms of clinical management activities for chronic diseases, and the lack of development of preventative medicine programmes. In light of this, a critical priority must be to strengthen EOPPY. C) Increasing need to provide cutting edge mental health services The mental health sector has made significant progress as part of the psychiatric reform programme (PSYCHARGOS) however, the long-term recession and the very high rates of unemployment have undoubtedly had major negative impacts on the mental health of the population affected by the crisis, especially the unemployed, and a series of indicators would seem to support this hypothesis (such as the estimated increase in the percentage of suicides, the increase in hospital patients developing reactive depression and so on). In addition, the inability to cover costs has led to a significant number of patients who received medical services from the private sector turning to public sector healthcare services. At the same time the fact of an ageing population has visibly worsened the epidemiology of dementia and other mental diseases related to old age. Consequently, the expected increase in demand for mental health services is a new challenge for the sector so as to improve the efficient use of the resources provided by the system and to ensure accessibility to the entire range of services the system may provide. Proposals documents of the Ministry of Health - 4 -

5 In addition, the continuing psychiatric reforms taking place in Greece which will eventually lead to an integrated, sustainable mental health system has more need than ever of interventions which will support the activity and operation of existing and new social structures and which will bolster the organisational and administrative functions of the system, so that the final mental health services to beneficiaries can be evaluated and be of good quality, adequate and effective. d) Increase in public health risks Targeted actions and strategies in past programming periods which contributed to the adoption of healthy lifestyle and habits are being undermined by the new socio-economic reality of the crisis. The increase in unemployment is associated, both internationally and in Greece, among other things with substance addiction and dependence, and more generally speaking with the adoption of unhealthy lifestyles and eating habits, etc. Individuals and families facing poverty run a greater risk of increased morbidity, which is something which prevents their socio-economic integration. Epidemiological changes, infectious diseases which are on the rise, and the abandonment of a healthy lifestyle, coupled with climate change and the degradation in the quality of the environment are new critical issues in the public health sector to which the system must adjust itself in order to improve citizens defences to risks. In order to address the increasing needs more effectively, while at the same time ensuring the sustainability of the system, a complete volte-face from treatment to prevention is required. This will in turn depend on bolstering primary and public healthcare structures and mechanisms which continue to be one of the main problematic areas in the current system. e) Ability of financially-disadvantaged citizens, citizens from remote areas, citizens from vulnerable social groups and citizens with linguistic, religious and cultural special features to access healthcare services The fact that a large portion of the population has lost insurance coverage, that services are shrinking and the fact that there is increasing geographical isolation for the residents of inaccessible or island areas due to a reduction in the regularity of ship itineraries has worsened the already low level of access these people had to healthcare services. In addition, vulnerable social groups (such as Roma, male and female prostitutes, drug users, migrants) and individuals with cultural and/or linguistic special features continue to face difficulties in accessing healthcare services. The health system has to face new facts, by placing particular emphasis on the adoption of new service provision models and innovative diagnosis and treatment methods which utilise new technologies and communications to the full Analysis of the environment in the healthcare sector using indicators Greece s economic situation Unemployment and the risk of poverty Proposals documents of the Ministry of Health - 5 -

6 Having reported high rates of growth up to 2007, the Greek economy showed signs of recession in 2008 as a result of the international financial crisis and from 2009 onwards the recession has significantly intensified because of fiscal inequalities. The need for restructuring led the country to join a tripartite financial support mechanism which involves the EU, the IMF and the ECB. The strict income policy and drastic reduction in public spending over the last 2 years have (as one might expect) had a negative impact on the growth in GDP with the result that GDP declined by 7.1% in 2011 and by 6.4% in The recession is expected to continue in 2013, but less severely, because of the endeavours to reform the economy (to date the decline in GDP recorded is 4.2%). Table 1: Gross Domestic Product Per capita GDP (purchasing power units, EU-27=100) Annual change in GDP in Greece Annual change in GDP in EU- 27 Source: EUROSTAT Until 2008, unemployment in Greece was relatively low and was around 7.6%, which is very close to the Euro/Eurozone Area average. However, from 2009 onwards, unemployment in Greece rose as a result of the international crisis which hit Greece too, and stood at 9.5%, while in 2010 it rose further to 12.5% as a result of the restrictive fiscal policy implemented due to the debt crisis. In 2011 the unemployment rate rose to 17.7% and continued to rise at a rapid pace as a corollary of the more general crisis in the Greek economy and the fiscal consolidation measures that were implemented. According to the latest figures (1 st quarter of 2013) unemployment in Greece is around 27%, with the number of unemployed people over 1.3 million and Greece has become the No. 1 country in the Eurozone Area for unemployment. As a result of unemployment and the general economic situation, a major segment of Greek society today faces the risk of poverty and social exclusion. According to data from the Greek Statistical Service (Living Conditions in Greece, 26 April 2013) the population at risk of poverty and/or social exclusion in 2011 was 3,403,000 (31%) compared to 3,007,000 (27.6%) in 2009 where the population living in households with low intensity work was 979,000 (11.8%) in 2011 compared to 539,000 (6.5%) in Proposals documents of the Ministry of Health - 6 -

7 Table 2: Population at risk of poverty and/or social exclusion People at-risk-of-poverty or social exclusion (2) In thousands % People living in households with very low work intensity (3) In thousands % Source: Population and Labour Market Statistics Division ELSTAT. (1) The data in this table derive from the Survey on Income and Living Conditions (EU - SILC), which is being conducted since (2) People-at-risk-of-poverty or social exclusion: This indicator reflects the share of the population which is either at risk of poverty, or severely materially deprived or lives in a household with a very low work intensity. (3) People living in households with very low work intensity: Share of population aged living in households where the working-age members worked less than 20% of their total work potential during the past year. The work intensity of the household is the ratio of the total number of months that all working-age household members have worked during the income reference year and the total number of months the same household members could theoretically have worked in the same period. A working-age person is a person aged with the exclusion of students in the age group between18 and 24 years. Households which consist only of children, of students aged less than 25 and / or people aged 60 or more are excluded from the indicator calculation. : Νot available. Source: Living Conditions in Greece, ELSTAT 2013 The rise in the risk of poverty from 2011 to today because of the economic crisis, the austerity measures and rising unemployment becomes all the more apparent when one computes the poverty threshold for 2005 in line with inflation using the harmonised consumer price index. The index s figure in 2011 as 22.9 whereas in 2009 and 2010 it was 16.4 and 16.3 respectively. Table 3: Risk of poverty computed using the 2005 poverty threshold (in line with inflation using the harmonised consumer price index) by gender, Total Men Women Source: Population and Labour Market Statistics Division ELSTAT. : Not available (1) Using year N as the base year, the risk of poverty computed using the poverty threshold (in line with inflation using the harmonised consumer price index) for 2005 is defined as the percentage of individuals whose total equivalent available income for the specific year is lower than the poverty threshold computed for 2005, in line with inflation using data from the harmonised consumer price index.(2) The data in this table derive from the Survey on Income and Living Conditions (EU - SILC), which is being conducted since Source: Living Conditions in Greece, ELSTAT 2013 Proposals documents of the Ministry of Health - 7 -

8 Compared to other EU countries, based on 2011 data, Greece is the No. 1 Euro Area country in terms of population at risk of poverty and No. 5 (along with Hungary) when one takes into account non-euro Area countries. The ranking is as follows: Table 4: Population at risk of poverty or social exclusion in EU countries Countries EU 27 Euro Area Austria Belgium France Germany Greece Estonia Ireland Spain Italy Cyprus Luxembourg Malta Netherlands Portugal Slovakia Slovenia Finland Non-Euro Area Bulgaria Denmark United Kingdom Latvia Lithuania Hungary Poland Romania Sweden Czech Republic Source: Eurostat. (1) The data in this table derive from the Survey on Income and Living Conditions (EU - SILC), which is being conducted in all EU Member States since : Not available. Source: Living Conditions in Greece, ELSTAT 2013 Proposals documents of the Ministry of Health - 8 -

9 Demographic trends Ageing population According to the European Community Health Indicators (ECHI), Greece s population in 2010 was 11,305,118. Of those, 5,597,465 were men and 5,707,653 were women. Over the last 10 years, Greece s total population has risen by 3.7%. Figure 1: Changed in Greece s population by gender No. of individuals Total Women Men Source: ECHI However, this rise in population can primarily be attributed to migration, since reproduction rates among the Greek population are at very low levels. Over the same time period, infant mortality was gradually declining up to 2008, after which there was a small increase in 2009 and 2010, years during which infant mortality rates returned to 2005 levels. Despite this development, the infant mortality rate in Greece over the entire period is lower than the EU-27 average. Figure 2: Infant mortality in Greece and the EU Deaths per 1000 births Greece EU-27 Source: ECHI Proposals documents of the Ministry of Health - 9 -

10 Low infant mortality contributed to an increase in the average lifespan on Greeks. Thus, in 2010 life expectancy at birth was 78.4 years for men and 82.9 years for women, indicating a small but steady upward trend. Figure 3: Life expectancy at birth in Greece by gender (2010) Life expectancy (years) Men Women Source: ECHI Moreover, life expectancy at birth in Greece has been higher than that in the EU-27 over the entire last decade. Figure 4: Life expectancy at birth in Greece and the EU Life expectancy (years) Greece EU-27 Source: ECHI The increase in life expectancy at birth is not only due to the increase in infant mortality. The reduction in mortality among older age groups has become clear from the increase in life expectancy for individuals aged 65. In Greece in 2010 the life expectancy for people aged 65 years old was 19 ½ years which is on a par with the EU-27 average whereas up to 2009 the Proposals documents of the Ministry of Health

11 figure was below average. In 2002 life expectancy in Greece for 65 year olds was 17.7 years compared to 17.9 years for the EU. Figure 5: Life expectancy for 65 year olds in Greece and the EU Life expectancy Greece EU-27 Source: ECHI The reduction in the birth rate coupled with increased life expectancy has resulted in a demographic ageing of the Greek population. Demographic ageing leads to increased demand for healthcare services since the elderly have more health problems. According to available statistical data, the number of people aged up to 14 gradually declined up to 2006 at which time a gradual increase began between 2007 and On the contrary the percentage of the population aged 65 and over has been gradually increasing over the entire last decade. In 2000 the 0-14 age group accounted for 16% of the population whereas in 2010 it accounted for 15%. The over 65 age group accounted for 13.9% in 2010 and 15.1% in Figure 6: Change in Greece s population by age group Source: ECHI Proposals documents of the Ministry of Health

12 No. of individuals Aged 0 to 14 Aged 15 to 64 Aged 65+ Equality of access to public healthcare services The indicator for equality of access to public healthcare services is part of a set of indicators required by the European Strategy for social integration and social protection. More specifically, this indicator relates to the percentage of citizens who need medical examinations or treatments who cannot have those needs met for reasons relating to their economic situation, waiting lists, lack of time, the great distance between the place where they live and the place where diagnostic centres or primary or secondary healthcare units are available, etc. In Greece in 2011 that figure (as a period of being stable) rose to 7.6% when the corresponding figure in the EU (although having risen a little) was no more than 3.4% (i.e. the Greek figure was more than double the EU figure). More generally, the EU has relatively stable inequality levels (3-4%) between 2006 and 2011 as did Greece until 2010 (5.5-6%). Figure 7: Inequality of access to healthcare services indicator Source: ECHI More specifically the indicators that measure the said inequality compared to the educational level of citizens show that there is a direct correlation between these two variables. The percentage of citizens who have experienced some inequality in relation to healthcare services who are at the lowest educational level was 10.7% in Greece and 5% in the EU in The corresponding figures for citizens at the highest educational level were 4.1% in Greece and 1.8% in the EU. It was noted that in 2011 Greece diverged even further from the European average, by presenting figures more than double those of the EU in all the said indicators. Tehre is also a similar picture with indicators that measure inequality of access to healthcare services in relation to citizen income. The percentage of citizens in the lower income bracket who have experienced some inequality is higher compared to the corresponding higher income bracket. The gap between the two income brackets though appears to be smaller compared to that between educational levels. Proposals documents of the Ministry of Health

13 Availability of doctors hospitals beds healthcare centres and nursing staff The change in the number of doctors in all areas of specialisation per 1,000 residents from 2001 to 2011 in Greece is shown in the table below, indicating an increase in other areas of specialisation from 2005 onwards, and a stabilisation of all areas of specialisation from 2006 onwards. Table 5: No. of doctors per 1,000 residents per specialty ( ) Total General medicine Paediatrics Obstetrics and gynaecology Psychiatry Medical group of specialties Surgical group of specialties Other specialties Dentists Source: Health Divisions and Sections attached to prefectures, Athens and Piraeus Medical Association, Dentist Association. (1) General medicine: also including physicians in rural service and specialists in social medicine. Psychiatry: also including neurologists-psychiatrists and child psychiatrics. Medical group of specialties. This group includes the following physicians: cardiologists, endocrinologists, gastroenterologists, TB specialists, oncologists, rheumatologists, allergiologists, neurologists, otorhinolaryngologists, radiologists, medical imaging specialists, nuclear medicine doctors, clinical chemistry doctors, bacteriologists, haematologists, dermatologists, veneriologosits, occupational medicine physicians, hygienic doctors, internists, forensic doctors and pathologoanatomists. Surgical group of specialties: this group of specialties also includes neurosurgery, plastic surgery, orthopaedic surgery, thoracic surgery, vascular surgery anaesthesiology, urology, nephrοlogy surgery, children's surgery, physical medicine and rehabilitation. Other specialties: this category includes all the other physicians with or without specialty, as well as in training physicians. : Νot available. Source: Living Conditions in Greece, ELSTAT 2013 As far as the number of hospitals, health centres, pharmacies and beds is concerned, the following trend can be seen from 2001 to 2011: The number of hospitals has reduced compared to 2004 (from 2.9 to 2.7) while the number of health centres has remained the same. On the contrary, the number of pharmacies has been constantly on the rise (95.2 in 2011 to 92.5 in 2010, and 84.5 in 2007). Proposals documents of the Ministry of Health

14 Table 6: Hospitals, beds, health centres and pharmacies per 100,000 residents ( ) Hospitals Public Private Beds Health Centres Pharmacies Source: Social Statistics Division ELSTAT. : Not available. Source: Living Conditions in Greece, ELSTAT 2013 Spending on health Total spending on health as a % of GDP dropped from 10% in Greece in 2009 to 9% in 2011, as is clear from the data recently published by the Greek Statistical Authority (Press Release of Health spending System of Health Accounts (recent estimates)). Table 7: Spending on health in Greece Spending on health in Greece (in billions) Total public expenditure (as a % of total expenditure) 70% 68% 66% Total private expenditure (as a % of total expenditure) 30% 32% 34% Total expenditure (as a % of GDP) 10% 9.4% 9% Data from the Hellenic Statistical Authority Public health spending dropped by 12.2% in the period and by 12.4% in the period Likewise, private spending in 2001 dropped by 5.6% compared to 2009 and by 4.4% in 2011 compared to Moreover, the public sector contribution to overall spending on healthcare dropped from 70% in 2009 to 66% in Proposals documents of the Ministry of Health

15 Figure 8: Spending on health in Greece (in billions) OECD data Health Data 2012 Total Spending Total private spending Total public spending The annual rate of change in overall healthcare spending and public healthcare spending in Greece compared to developed EU countries such as Germany, Denmark, France and Mediterranean countries which have characteristics similar to Greece such as Portugal, Spain and Italy, are as follows: Table 8: Annual rate of change in healthcare spending in Greece and selected EU countries Annual rate of change in public healthcare spending Annual rate of change in overall healthcare spending Greece 3.8% -9.9% 0.9% -6.5% Denmark 6.4% -1.8% 5.9% -1.7% Germany 4.6% 2.4% 4.1% 2.6% France 3.5% 1.8% 3.3% 1.3% Italy -0.1% 1.5% -1.0% 1.5% Spain 5.9% -1.3% 3.6% -0.6% Portugal 6.2% 0.7% 2.8% 0.6% United Kingdom 8.2% 0.0% 7.0% 0.2% OECD data Health Data 2012 Based on this data one can see that Greece reduced overall healthcare spending by 6.5% in 2010 and public spending by 9.9% while most European countries kept such spending at the same levels as in other years. According to OECD data for 2010, per capita total healthcare spending in US$ PPP and the corresponding per capital public healthcare spending for Greece is much lower compared to developed northern countries such as Germany or Denmark, while the per Proposals documents of the Ministry of Health

16 capita public healthcare spending for Greece is lower than all Mediterranean European states (Italy, Spain and Portugal). Table 9: Per capita overall and public healthcare spending in Greece and selected EU countries Per capita overall healthcare spending (in US$ PPP) Per capita public healthcare spending (in US$ PPP) Greece 2, , Denmark 4, , Germany 4, , France 3, , Italy 2, , Spain 3, , Portugal 2, , United Kingdom 3, , OECD data Health Data 2012 On the contrary, per capita private spending is particularly high in Greece compared to other countries, as is clear from the figures in the table below. Table 10: Per capita private healthcare spending in Greece and selected EU countries Per capita private healthcare spending (in US$ PPP) 2010 Greece 1, Denmark Germany France Italy Spain Portugal United Kingdom OECD data Health Data 2012 As far as total pharmaceutical spending is concerned, there was a rise in the period and in 2009 spending stood at 8.5 billion (3.7% of GDP) which was the highest figure in the period being examined. Over the last 2 years there has been a drop and in 2011 the figure was around 6.8 billion, which equates to an annual drop in the order of 8%. Proposals documents of the Ministry of Health

17 Figure 9: Pharmaceutical spending in Greece (in billions) Total Spending Public Spending Private Spending Data from ICAP Group. A similar picture and change can also be seen for public pharmaceutical spending. In the period spending rose with an annual average rate of growth of around 16%. The State s decision to rationalise and reduce state spending led to repeated reductions in the prices of medicines both in 2010 and 2011, and in conjunction with the change in the VAT rate led to a significant reduction in public pharmaceutical spending which stood at 3.9 billion in 2011 compared to 4.3 billion the previous year. Proposals documents of the Ministry of Health

18 Citizen satisfaction with healthcare sector services Citizen satisfaction with healthcare sector services in Greece compared to the EU-27 average is clearly lower and is captured in the results of the Eurobarometer survey Health and long-term care in the European Union carried out in In QA3.1 Thinking now about your own experiences of health care services and those of people close to you, please tell me if you think that the quality of each of the following is very good, fairly good, fairly bad or very bad citizens responded as follows: QA3.1 Thinking now about your own experiences of health care services and those of people close to you, please tell me if you think that the quality of each of the following is very good, fairly good, fairly bad or very bad. HOSPITALS Very good Fairly good Fairly bad Very bad DK Greece 6% 42% 33% 19% 0% EU 27 15% 56% 20% 5% 4% DENTAL Very good Fairly good Fairly bad Very bad CARE Greece 12% 49% 23% 15% 1% EU 27 22% 52% 15% 6% 5% DOCTORS Very good Fairly good Fairly bad Very bad Greece 14% 56% 21% 8% 1% EU 27 20% 54% 12% 3% 11% Very good Fairly good Fairly bad Very bad GPs Greece 17% 56% 18% 8% 1% EU 27 30% 54% 12% 2% 2% Very good Fairly good Fairly bad Very bad HOME CARE Greece 5% 34% 32% 18% 11% SERVICES EU 27 9% 33% 17% 6% 35% OLD PEOPLES HOMES Very good Fairly good Fairly bad Very bad Greece 3% 21% 38% 27% 11% EU 27 7% 34% 17% 6% 36% Proposals documents of the Ministry of Health

19 SWOT Analysis for health care sector Strengths Weaknesses Opportunities Threats Adequate legislative framework which is being constantly added to and modernised Extensive network of core services and infrastructure Development of regional dimension of NHS (regional healthcare administrations) Satisfactory number of medical staff and high level of training Set up of National Healthcare Service Provider and its establishment as the sole negotiator with healthcare providers Development of Health Charter Promotion of a target-based system of management adoption of targets by the Ministry of Health (relevant Ministerial Decision) Electronic prescribing introduced NHS-net in operation Major progress with psychiatric reform acquisition of relevant experience Set up of an integrated mental health network of deinstitutionalise patients facing mental diseases Creation of social limited liability cooperatives for the mentally disturbed Interventions for socio-economic integration of vulnerable groups Assisted living shelters set up and Limited public private sector partnership and inward-looking focus by system High cost and low competiveness of system Continuing reduction in public healthcare spending healthcare system does not guarantee the continuity of medical care Problems of universal coverage and accessibility due to geomorphology of Greece Medical services system focuses on secondary care reduced emphasis on prevention Lack of GPs and specialists involved in promoting prevention and primary home care Inadequate interface and synergy between primary and secondary healthcare Inability to completely roll out the idea of a GP Ineffectual operation of EOPPY to date Limited preventative medicine and healthcare promotion programmes and check-up programmes for vulnerable population groups Inability to provide emergency and intensive care services Europe s Europe 2020 strategy The formulation of guidelines by the European Commission entitled Investing in Health which highlights the role of the healthcare sector as an integral part of the Europe 2020 strategy while also laying down strategic priorities and investment guidelines for 3 separate pillars. The adoption of a Health for Growth programme by the European Commission, the third multi-annual EU action plan in the healthcare sector for the period The Ministry of Health & Social Solidarity s Health in Action initiative under the coordination of the Prime Minister s Office with the support of the Task Force for Greece and the German Ministry of Health, and the assistance of Greek and foreign experts. The Partnership Agreement Obligations in Greece s MoU relating to the country s commitment to implement reforms and to take actions in the healthcare sector Political will to make reforms in the healthcare sector to ensure the economic viability of the system and its effectiveness / efficiency. Demographic changes (ageing population, population movements, illegal migration and trafficking, social changes and appears of new groups of users, social reactions, society s unwillingness to accept diversity). Increased unemployment which leads to a lack of social security coverage and increased levels of nonaccessibility to healthcare services Continuing economic crisis with impacts on employment and the mental health of citizens (depression, etc.) Social and cultural changes (relaxation of family and other social ties, change in eating habits, increase in smoking and substance use) Epidemiological changes emerging infectious diseases at global level and appearance of risks that know no borders, increase in neuropsychiatric illnesses and appearance of new ones, due to changes in eating and living standards. Environmental degradation with impacts on the population s health Intense climate change - intensification of natural disasters Fiscal limitations Difficulty in finding resources to implement reforms which arise from the Health in Action initiative to prepare action plans for 8 different Proposals documents of the Ministry of Health

20 Strengths Weaknesses Opportunities Threats run to prevent disabled people being institutionalised and stigmatised, setting up of deinstitutionalisation structures for the disabled, implementation of skills development, socialisation and proactive living in society programmes Implementation of a large number of training seminars for staff involved in the healthcare sector on issues of new technologies, national and EU legislation, etc. Adequate number of bodies providing training courses to employees in the public healthcare sector (National Centre for Public Administration & Local Government, Institute of Social & Preventative Medicine, National School of Public Health). Outdated structures and methods for organising and running hospitals Non-universal use of double-entry computer systems at hospitals Low degree of integration of new technologies inadequate development of telemedicine High pharmaceutical spending and non-comprehensive use of electronic prescribing Low levels of innovation, limited research activities and lack of systems to exploit research results in the healthcare and medicines sector Inability to fully utilise data from the Health Charter and feed it back into the system Lack of rational management systems for energy, waste and hazardous waste at hospitals Psychiatric reforms not completed and systemic shortcomings in the mental health sector Limited development of networking and synergy mechanisms between service providers Inadequate staffing of healthcare unit, lack of nursing and paramedical staff Inadequate HRM and development policy in the healthcare sector Low level of training among healthcare professionals non- Political will to maintain social cohesion which entails protecting the health of financially disadvantaged citizens MoU Andor Lykourentzos on Mental Health Utilisation of Greece s role in SE Europe in conjunction with increasing demand for healthcare tourism Improvement of the legislative framework on public private partnerships Utilisation of new ICTs Utilisation of best practices from other EU countries and from the WHO Ability to utilise initiatives from international organisations to combat social exclusion High interest in environmental protection issues which also relate to public health Utilisation of life-long learning for continuing development of HR in the healthcare sector sub-sectors in the healthcare sector (primary healthcare, electronic prescriptions, fixed uniform hospital charges, EOPPY, etc.). Limited involvement of the agencies and bodies involved in implementing development initiatives in the healthcare sector Public administration bureaucracy Limited response to cross-sectoral partnership Delay in legal enshrinement of the principles and content of healthcare sector reforms Objections to modernisation of structures, and the way primary and secondary healthcare services are organised and run Existence of social inequalities in terms of access to online healthcare services Public via low opinion about system s reliability Turn towards the private sector because of public sector s inability to meet demand for specialised diagnostic services Lack of continuity with any changes made to date (primarily in relation to mental health, social solidarity and social inclusion of vulnerable groups and especially the disabled) because of limited financial resources. Reduction in services provided because of inability to bolster the healthcare sector with the necessary human resources (primarily nursing and paramedical staff) or to renew Proposals documents of the Ministry of Health

21 Strengths Weaknesses Opportunities Threats systematic training and career advancement staff in the system because of fiscal constraints Proposals documents of the Ministry of Health

22 1.1.2 Developmental Needs Analysis of the Health Sector Developmental Strategy and Objectives in the Health Sector regarding the period. Health systems in Europe are the cornerstone of not only the provision of high level social security services but also a main market economy actor. The healthcare sector accounts for 8% of the total EU labor market and for 10% of the GDP of the EU. The EU paper entitled «Annual Growth Survey (AGS) 2013» dated acknowledges that investing in health contributes to the Objective «Europe 2020» for a smart, sustainable and inclusive growth, preparing for job-rich growth while also promoting social inclusion and tackling poverty. Public expenditure accounts for nearly 80% of healthcare budgets. In 2010 public expenditure accounted for nearly 15% of overall government expenditure. During the decade prior to the current economic crisis it was one of the fastest growing government expenses in almost all member states, significantly exceeding any GDP rise. However, public expenditure for healthcare and long term care are expected to rise by one third by 2060 mainly due to the increasingly ageing population. In addition, the poor state of health of working age population (18-64) results in significant productivity losses (according to estimations, the lost productive work time varying between 3% and 6% of overall working time, finally account for approximately 2.5% of GDP, in loss of jobs (10% of workers have left their jobs mainly because of health-related problems), or even in early retirement or mortality. An OECD Survey estimates that for every year of increase of life expectancy, GDP could rise by 4%. The actual cost of work accidents and diseases related to work varies between % of GDP in the EU. The existing budgetary constraints should be considered as an opportunity for improving the importance and the effectiveness of reforms in healthcare, as the related money distribution may lead to major savings. OECD evaluates these savings as 2% of GDP on average by Growth strategic priorities for Greece in the health sector are set by taking into account the respective EU directions alongside with the particularly difficult conditions of economic and social recession faced by Greece with an emphasis on the challenges related to the bottom-up restructuring of the health system s efficiency and the quality of the health services delivered in an environment of increased social needs and budgetary constraints. With sights set on growth, it is undeniable that regions providing sufficient healthcare services to European citizens are considered attractive for state of the art investment (knowledge intensive) and residence. Conversely, citizens and jobs leave regions where safety related to sufficient social services has not been secured. Proposals documents of the Ministry of Health

23 The related EU directions are clearly reflected in the Paper drafted by the European Commission Staff Working Document titled «Investing in Health» and are included in the package of measures intended for Social Investment that was approved on 20 February 2013 by the European Commission, Brussels, SWD(2013) 43 final]. The European network highlights the role of health as an integral part of the Europe 2020 strategy, setting strategic priorities and respective investment guidelines structured on three axes: Axis Ι: «Smart investments for Sustainable Health Systems» Axis ΙΙ: «Investing in citizens health» Axis ΙΙΙ: «Investing in reducing inequalities in Health». Concurrently, in Greece the Ministry of Health in collaboration with other Ministries and under the overall coordination of the Prime Minister s Office, responsible for the technical assistance provided to Greece, has been implementing since September 2012 the Health in Action initiative aiming at developing the specific structures and tools required for effectively and efficiently managing the NHS reforms. In the framework of Health in Action, Road Maps and detailed Action Plans are developed for individual structural reforms to be implemented in the Health Sector and recommendations are given on the overall reform process in order to facilitate the attainment of the Financial Adjustment Program for Greece and the Memoranda of Cooperation concluded by Greece, to improve the existing strategic/development plans and optimize the utilization of the NSRF resources firstly, and then of the Partnership Agreement for the period. The key directions and measures recommended by Health in Action have been incorporated in the strategic development priorities are presented below. Apart from the directions arising from the promoted European Strategy and the reforms designed in the context of the Health in Action initiative, the Ministry of Health has taken into account the development Planning of the coming period, the current situation of the Health Sector reflected by the European Common Health Indicators (ECHI) and the comparative prices of the indicators against the respective prices for other EU countries, the investment made in the Health Sector funded by national and/or community resources, the stage of the of the said investment and any gaps/or weaknesses identified alongside the opportunities and threats emerging in the national health sector (see SWOT analysis- CH hereof). Taking the above into consideration the Health Sector Vision for is defined as follows: Improving the health of the population and reducing inequalities in the health sector while ensuring at the same time the National Health System sustainability for future generations. In the context of the Health Sector Vision the following Pillars and Strategic Objectives are set: Pillar 1: Healthcare System Sustainability A precondition for the reform of the Health Sector in Greece is the radical restructuring of the current national model of healthcare services in view to radically improve the cost efficiency ratio that characterizes the current system. The investments to be made in this Sector in the form of jointly funded projects or in other forms should be innovative and smartly specialized to ensure the upgrading of the health services delivered to the citizens, the cost-effective operation and Proposals documents of the Ministry of Health

24 management of the Ministry s services and its Supervised Entities, the development of accountability (both systemic and individual) regarding services delivered to citizens and the continuous measurement of efficiency and effectiveness(cost/benefit ratio). Moreover, they should balance regional discrepancies by taking into account remote regions and the particular geographic location of the Greek Islands. The Strategic objectives of this particular pillar are as follows: Ensuring the healthcare system s sustainability This Strategic objective can be attained (indicatively) by: Enhancing Budget Planning and Drafting Systems and Systems for Monitoring their Implementation based on the DRGs model by all Health Units, at Regional and Central level: Full implementation of the double-entry system, electronic central monitoring of budget implementation. Enhancing Internal Control Systems and Processes: strengthening existing processes, fostering the internal control process at all administrative levels. Introduction of modern procurement processes centralization of procurement: Enhancement and standardization of procurement processes at central and regional level, regional centralization of hospitals procurement, regional centralization of hospital procurements, compatibility control of supplies with the approved budgets, introduction of electronic procurement systems and price monitoring, warehouse management systems (WMS) and modernization of logistics, control of consumption and stocks. Introduction of new sustainable methods of drugs pricing and reimbursement: Institutionalization leading to full transposition of the related EU Directives, utilization of directions and conclusions drawn from EU (Health Technology Assessments). Modernization of the related pricing duties and responsibilities. Fostering competition during drug supply to the benefit of the system. Modernization of the method used for preparing and applying the positive drugs list, revision of the participation levels and the method of implementation for specialized expensive drugs. Rationalization of profit margins of the actors participating in the drug distribution chain and reexamination of the cooperation practices between the pharmaceutical industry and health professionals. Measures for Controlling and Containing Pharmaceutical Expenditure: Introduction of measures to limit polypharmacy and notably the excessive use of antibiotics, introduction of pricing mechanisms that favor the use of generic drugs, ensuring correct prescription methods, update patients, staff and agencies on the rational use of drugs etc. Improving the efficiency and effectivenessof the Healthcare System and upgrading of the quality of service provision. This Strategic Objective is achieved (indicatively) by: Proposals documents of the Ministry of Health

25 Defining the National Strategy on health Insurance and Strengthening EOPPY: Developing a strategic proposal and determining EOPPY s role in the development of a sustainable health insurance system. Determining the population covered and the coverage packages offered, including the way and level of coverage of the uninsured. Establishing relations with all insurance funds and the EOPPY funding model. Implementation of an efficient model for the EOPPY operation, economic management, organization, human resources development and development of the IT system required for its operation. Special emphasis is placed on management procedures for unpaid contributions and contract conclusion and management with hospitals, medical personnel and other healthcare providers. Introduction of a Quality Assurance System into EOPPY. Improving the Primary Care Service provision aiming at reducing the unnecessary use of Specialist and Hospital care: Improved access to primary care through the restructuring of the services provided (types of services and geographical points for their provision) matching demand and aiming at ensuring a universal and fair access to high quality services and the provision of continuous care. Provision of integrated, effective mental health services and home help. Introducing the General Practitioners and referral system in order to ease the burden of the Emergency Departments and hospital clinics. Improving cooperation between primary care units, home help units and secondary care units. Improving hospital care. Introduction of modern operational business models into hospitals and assessment of the processes applied. Pilot mergers of laboratory and administrative units of neighboring hospitals. Evaluation of the performance. Assessment of the performance of the NHS units compared to its objectives. Introducing Reimbursement Methods for Health Units based on the cost or Quality of the Service provision (Activity Based Costing) on Health Units. Concurrently, the selection of a modern dynamic DRG system aiming at restructuring DRGs, full institutional protection of the system at legislative level and at regulatory level, detailed definition of the of the way and the positions responsible for its implementation. Cost estimate of the new system by developing and implementing the appropriate methodology. Support of its implementation by IT systems and applications. Implementation of a reimbursement system that rewards rare resources savings (e.g. encouraging the use of day surgery instead of patient admission into the hospital). Development and introduction of quality system at hospitals and primary care institutions. Design and implementation of a measurement and assessment system of the of Health Sector effectiveness. Development of Accountability Systems (both systemic and individual) during service provision to citizens Proposals documents of the Ministry of Health

26 Digital modernization of the Healthcare System, promotion of IT technology and health e-services. This Strategic Objective will be achieved (indicatively) by: The introduction of e-health systems and processes: It pertains to the introduction of systems supporting the full cycle of prevention, diagnosis, treatment, monitoring and management of health and general lifestyle issues. It includes among other things: a) Hospital information systems ensuring the necessary interoperability among them and with the IT systems of the rest of the health sector. b) an improved e-prescription system ensuring its financing, effective administration, security, accessibility and by enhancing its processes and roles for controlling its operation and institutional protection of the above. c) Systems for supporting Primary Care, d) Telemedicine systems, e) Creation of personal electronic medical file f) information system of users of health services g) personal fixed and portable communication systems for monitoring and supporting patients and h) Remote care systems (introduction of innovative IT systems for after hospital care and rehabilitation), i) Modernization and creation of patients registers (patients, insured, uninsured, diagnostic tests, acts, medical devices etc.) Development of e-auctions for health products. Upgrading human capital in the Health Sector This Strategic Objective is achieved (indicatively) by: By improving the balanced distribution of personnel among main professional branches and specialties as well as the regional distribution connection with higher education institutions planning. Encouragement of the professional development of the personnel, introducing non-financial incentives (working conditions, career advancement). Detailed depiction and monitoring of all categories of human resources of this Sector by utilizing a Data base in order to support the annual and long-term planning of employment in that context to meet existing needs. Creation of an electronic file for NHS personnel via the digitalization of the existing record. Collecting the necessary demographic, epidemiological and other data to support planning in terms of demand. Development of policies for assessing medical personnel together with assessment methods for the whole of the Sector s personnel. Design and implementation of personnel targeted training programs on scientific subjects, on the new processes and operation systems, structural reforms etc. as well as specific programs of specialized programs of theoretical and practical training. Improving the environmental performance of the Health Sector This Strategic Objective is achieved (indicatively) by: Proposals documents of the Ministry of Health

27 Supporting the energy efficiency and the use of renewable energy resources at the Health Units. Promotion of co-generation of electricity high-efficiency heating at hospitals. Effective management of hospital waste. Effective management of radioactive hospital waste Improving the Healthcare System s Extroversion This Strategic Objective is achieved (indicatively) by: Cross-border cooperation Epidemiological surveillance Development and establishment of health tourism. Pillar 2: Health as an investment in human capital Investing in health is considered, even by strictly financial standards, a productive and growthfriendly type of expenditure, mainly via its positive impact on the productivity of labor by increasing healthy life expectancy. The improvement of the environment and the timely investment in prevention helps the population, remain healthy for longer thus limiting future treatment costs related to diseases. It also contributes to containing the system s maintenance cost and to growth. Typically, an OECD survey estimates that for every year of increase in a population s life expectancy GDP could go up as much as 4% [ Investing in Health, p. 12]. The Ministry of Health will promote the development and monitoring of the Health Safety Net. A series of indicators establishing the emerging and/or prevailing health risks for the whole of the population or specific population groups will enable the Ministry to develop policies for tackling risks, prevention and design and implementation of treatment methods on a case to case basis. Its objective lies in maintaining the health of the population at a satisfactory level allowing its active participation in the productive and social fabric of Greece. Given the above clearly positive anticipated impact of the investment in the Health Sector, it has been possible to define the following General Strategic Objectives: Employability enhancement and active population increase This Strategic Objective will be achieved (indicatively) by: Introducing measures for improving the working environment and reduce work accidents Developing programs of chronic disease management and multimorbidity (hypertension, diabetes mellitus, chronic obstructive pulmonary disease) Proposals documents of the Ministry of Health

28 Improving citizens defense against risk factors for public health This Strategic Objective is achieved (indicatively) by: Conducting information campaigns on the general population regarding important health risks. Design and implementation of bad habit deterrence measures. Implementation of risk identification interventions and promotion of health protection policies in the sectors of health, work, etc. as well as through the activities of social policy agencies operating in the above sectors. Timely prediction of health risks Development of programs of presymptomatic screening for major diseases. Development of management programs of environmental risks impact on the quality of the potable water, the subsoil and the air. Promoting Mental Health This Strategic Objective is achieved (indicatively) by: Organization, support and implementation of Sectorization. Restructuring and modernization of organization, administration, coordination, monitoring and evaluation of the mental health service provision system. Shaping of a single organizational and administrative framework for Mental Health Units and the other community structures linking to the primary care. Development of psychiatric departments in general hospitals and creation of after hospital guest houses in selected areas. Development of mental health services for children and adolescents Development of mental health centers in mental health sectors lagging behind or being inadequate compared to more advanced sectors of mental health. Development of mental health services incorporated in primary care structures (health centres, group practices, EOPPY), alternatively in the development of Mental Health Centres. Developing of the concept of Hosting families". Development and implementation of assessment criteria for the rehabilitation work provided by the Units of Psychosocial Rehabilitation. Ensuring sustainability for the new mental health and rehabilitation structures via the reorganization and the modernization of the service map. Drafting and establishment of treatment protocols and clinical guidelines. Proposals documents of the Ministry of Health

29 Promotion of social economy and social enterprises accompanied by the development of alternative ways new social cooperatives and enhancement of existing ones combined with the development of mental health service beneficiaries. Promotion of the social economy and social enterprises. Development of supporting interventions for the families of the mentally ill. Development and provision of metal health specialized services due to new emerging needs and the creation of specialized structures (Alzheimer s disease, autism). Cooperation with the Ministry of Transparency and Human Rights for reshaping forensic psychiatry and judicial protection issues in relation to the mentally ill and development of the respective mental health units. Enhancing the value of the Health System products for dealing with risk factors and treatment of diseases. This Strategic Objective will be achieved (indicatively) by: Modeling and spinning off of the results of the survey performed within the Healthcare System and related to advanced treatment methods and medical devices aiming at facing risk factors, stabilizing the progression of the disease or curing patients and consequently the protection and improvement of citizens health. Pillar 3: Reducing inequalities in health Currently, population groups with lower income and less education together with many groups termed as vulnerable have lower life expectancy and are less healthy mainly due to their adverse life conditions and the serious obstacles they are faced with when trying to access health services. The great inequalities in health, besides the obvious ethical problem they pose they are also a very significant cause of GDP drop that by conservative estimations varies between 1.5% and 9.5% for EU countries [ Investing in Health, p. 17]. For all the above reasons, investing for reducing inequalities needs to be supported by special interventions. These General Strategic Objectives are as follows: Investing in health structures and other social infrastructures underpinning the reduction of regional inequalities in health This Strategic Objective will be achieved (indicatively) by: Developing specialized structures for pain management, artificial kidney units, rehabilitation and recovery centres, Day Care Units, and other specialized structures in areas where they are not currently in place. Extension and upgrading of current structures and infrastructures Harnessing innovative technologies to ensure access to health services Proposals documents of the Ministry of Health

30 This Strategic Objective will be achieved (indicatively) by: Telemedicine development Development and implementation of telecare systems (introduction of innovative Information Systems for continuing post hospital care and rehabilitation.) Developing a new service delivery model to facilitate access of vulnerable social groups to quality health services This Strategic Objective will be achieved (indicatively) via: New models for service provision (e.g. home help, etc.) to facilitate access to quality health services of the financially weaker and socially vulnerable groups and to mitigate language and cultural discrepancies, that may rely on volunteers or even use alternative ways of financing. Creation of a coverage package for vulnerable social groups by EOPPY. Enhancing the role of patients in managing their health and adopting a patient-centered model of health service provision Reducing the impact of the social and economic crisis on the health of Selected Social Groups This Strategic Objective will be achieved (indicatively) by: Shaping interventions of preventive medicine to children's health especially targeted on children coming from weaker social groups. Developing health assistance and promotion programs, chronic diseases management programs, presymptomatic screening, vaccination programs, prenatal screening and other programs on selected population groups at higher risk of social and economic exclusion. Developing the social sensitization of the health sector personnel (medical, nursing and paramedical) aiming at eradicating any discrimination related to the delivery of services to selected social groups. Proposals documents of the Ministry of Health

31 Developmental Strategic Objectives Relevance to European and National Policies Pillar 1: Healthcare System Sustainability Pillar 2: Health as an investment in Human Capital Pillar 3: Reducing Inequalities in Health General Strategic Objectives of the Health Sector for Ensuring sustainability the health system s Improving the efficiency and effectivenessof the Healthcare System and upgrading of the quality of service provision Digital modernization of the Healthcare System, promotion of IT technology and health e-services Upgrating human capital in the Health Sector Improving the environmental performance of the health sector Improving Extroversion the Healthcare System Employability enhancement and active population increase Improving citizen\s defence against a risk factors for public health Promotig Mental Health Enhancing the value of the Health System products for dealing with risk factors and treatment of diseases. Investing in health structures and other social infrastructures underpinning the reduction of regional inequalities in health Harnessing innovative technologies to ensure access to health services Developing a new service deliver model to facilitate access o Reducing the impact of the social Thematic Objectives «Europe 2020» 1 Strengthening research, technological development and innovation 2 Enhancing access to, and use and quality of, information and communication technologies 3 Supporting the shift to low carbon economies in all sectors 4 Protecting the environment and promoting resource efficiency Proposals documents of the Ministry of Health

32 Pillar 1: Healthcare System Sustainability Pillar 2: Health as an investment in Human Capital Pillar 3: Reducing Inequalities in Health and economic crisis on the health Ensuring the healthcare system;s sustainability Improving the efficiency and effectivenessof the Healthcare System and upgrading of the quality of service provision Digital modernization of the Healthcare System, promotion of IT technology and health e-services General Strategic Objectives of the Health Sector for Upgrading Health Sector Human Capital in the Improving the environmental performance of the health sector Improving Extroversion the Healthcare System Employability enhancement and active population increase Improving citizen\s defence against a risk factors for public health Promotig Mental Health Enhancing the value of the Health System products for dealing with risk factors and treatment of diseases. Investing in health structures and other social infrastructures underpinning the reduction of regional inequalities in health Harnessing innovative technologies to ensure access to health services Developing a new service deliver model to facilitate access o vulnerable social groups to qualit Reducing the impact of the social of Selected Social Groups 5 Promoting employment and supporting labor mobility 6 Promoting social inclusion and combating poverty 7 Enhancing institutional capacity and an efficient public administration ς «Investing in Health» Paper- Pillars 1 Investing in sustainable health system 2 Investing in peple s health as human capital 3 Investing in reducing health inewalities Proposals documents of the Ministry of Health

33 Pillar 1: Healthcare System Sustainability Pillar 2: Health as an investment in Human Capital Pillar 3: Reducing Inequalities in Health and economic crisis on the health Ensuring the healthcare system;s sustainability Improving the efficiency and effectivenessof the Healthcare System and upgrading of the quality of service provision Digital modernization of the Healthcare System, promotion of IT technology and health e-services General Strategic Objectives of the Health Sector for Upgrading Health Sector Human Capital in the Improving the environmental performance of the health sector Improving Extroversion the Healthcare System Employability enhancement and active population increase Improving citizen\s defence against a risk factors for public health Promotig Mental Health Enhancing the value of the Health System products for dealing with risk factors and treatment of diseases. Investing in health structures and other social infrastructures underpinning the reduction of regional inequalities in health Harnessing innovative technologies to ensure access to health services Developing a new service deliver model to facilitate access o vulnerable social groups to qualit Reducing the impact of the social of Selected Social Groups «Health for Growth» paper of the third multi-annual of EU action in the field of health for the period Objectives 1 To develop common tools and mechanisms at EU level to address shortages of resources, both human and financial and to facilitate uptake of innovation in healthcare in order to contribute to innovative and sustainable health systems 2 To increase access to medical expertise and information for specific conditions also beyond national borders and to develop shared solutions and guidelines to improve healthcare quality and patient safety in order to increase access to better and safer healthcare for EU citizens Proposals documents of the Ministry of Health

34 General Strategic Objectives of the Health Sector for Pillar 1: Healthcare System Sustainability Pillar 2: Health as an investment in Human Capital Pillar 3: Reducing Inequalities in Health Ensuring the healthcare system;s sustainability Improving the efficiency and effectivenessof the Healthcare System and upgrading of the quality of service provision Digital modernization of the Healthcare System, promotion of IT technology and health e-services Upgrading Health Sector Human Capital in the Improving the environmental performance of the health sector Improving Extroversion the Healthcare System Employability enhancement and active population increase Improving citizen\s defence against a risk factors for public health Promotig Mental Health Enhancing the value of the Health System products for dealing with risk factors and treatment of diseases. Investing in health structures and other social infrastructures underpinning the reduction of regional inequalities in health Harnessing innovative technologies to ensure access to health services Developing a new service deliver model to facilitate access o vulnerable social groups to qualit Reducing the impact of the social 3 to identify, disseminate and promote the up-take of validated best practices for costeffective prevention measures by addressing the key risk factors, namely smoking, abuse of alcohol and obesity, as well as HIV/AIDS, with a focus on the cross border dimension, in order to prevent diseases and promote good health 4 to develop common approaches and demonstrate their value for better preparedness and coordination in health emergencies in order to protect citizens from crossborder health threats Proposals documents of the Ministry of Health

35 Pillar 1: Healthcare System Sustainability Pillar 2: Health as an investment in Human Capital Pillar 3: Reducing Inequalities in Health Ensuring the healthcare system;s sustainability Improving the efficiency and effectivenessof the Healthcare System and upgrading of the quality of service provision Digital modernization of the Healthcare System, promotion of IT technology and health e-services General Strategic Objectives of the Health Sector for Upgrading Health Sector Human Capital in the Improving the environmental performance of the health sector Improving Extroversion the Healthcare System Employability enhancement and active population increase Improving citizen\s defence against a risk factors for public health Promotig Mental Health Enhancing the value of the Health System products for dealing with risk factors and treatment of diseases. Investing in health structures and other social infrastructures underpinning the reduction of regional inequalities in health Harnessing innovative technologies to ensure access to health services Developing a new service deliver model to facilitate access o vulnerable social groups to qualit Reducing the impact of the social European Commission Position Paper priorities 1 Increase of labour market participation through improved employment, active inclusion and education/skill development policies 2 Sustainable infrastructure for growth and jobs 3 Environment friendly and resourceefficient economy for growth and jobs 4 Administrative reform for an efficient and accountable administration Proposals documents of the Ministry of Health

36 Pillar 1: Healthcare System Sustainability Pillar 2: Health as an investment in Human Capital General Strategic Objectives of the Health Sector for Pillar 3: Reducing Inequalities in Health Ensuring the healthcare system;s sustainability Improving the efficiency and effevtivenessof the Healthcare System and upgrading of the quality of service provision Digital modernization of the Healthcare System, promotion of IT technology and health e-services Upgrading Health Sector Human Capital in the Improving the environmental performance of the health sector Improving Extroversion the Healthcare System Employability enhancement and active population increase Improving citizen\s defence against a risk factors for public health Promotig Mental Health Enhancing the value of the Health System products for dealing with risk factors and treatment of diseases. Investing in health structures and other social infrastructures underpinning the reduction of regional inequalities in health Harnessing innovative technologies to ensure access to health services Developing a new service deliver model to facilitate access o vulnerable social groups to qualit Reducing the impact of the social National Reform Program 1 Implementation of the agreed frontloaded fiscal consolidation and subsequantly the preservation of a large primary surplus to reduce debt and improve public finance sustainability 2 Aim for R&D: 2% of GDP will be invested in R&D Proposals documents of the Ministry of Health

37 Pillar 1: Healthcare System Sustainability Pillar 2: Health as an investment in Human Capital Pillar 3: Reducing Inequalities in Health Ensuring the healthcare system;s sustainability Improving the efficiency and effectivenessof the Healthcare System and upgrading of the quality of service provision Digital modernization of the Healthcare System, promotion of IT technology and health e-services General Strategic Objectives of the Health Sector for Upgrading Health Sector Human Capital in the Improving the environmental performance of the health sector Improving Extroversion the Healthcare System Employability enhancement and active population increase Improving citizen\s defence against a risk factors for public health Promotig Mental Health Enhancing the value of the Health System products for dealing with risk factors and treatment of diseases. Investing in health structures and other social infrastructures underpinning the reduction of regional inequalities in health Harnessing innovative technologies to ensure access to health services Developing a new service deliver model to facilitate access o vulnerable social groups to qualit health services Reducing the impact of the social 3 20% renewable energy participation into the energy balance 15% drop of energy consumption in line with the anticipated levels for 2020 by enhabcing energy efficiency. Drop of greenhouse gases by 4%. 4 Objective for poverty: people at risk of poverty less European Council Regulation on ESF and ERDF investment initiatives 1 Promoting employment and supporting labour Mobility 2 Investing in education, skills and lifelong learning 3 Promoting social inclusion and combating poverty Proposals documents of the Ministry of Health

38 Pillar 1: Healthcare System Sustainability Pillar 2: Health as an investment in Human Capital Pillar 3: Reducing Inequalities in Health Ensuring the healthcare system;s sustainability Improving the efficiency and effectivenessof the Healthcare System and upgrading of the quality of service provision Digital modernization of the Healthcare System, promotion of IT technology and health e-services General Strategic Objectives of the Health Sector for Upgrading Health Sector Human Capital in the Improving the environmental performance of the health sector Improving Extroversion the Healthcare System Employability enhancement and active population increase Improving citizen\s defence against a risk factors for public health Promotig Mental Health Enhancing the value of the Health System products for dealing with risk factors and treatment of diseases. Investing in health structures and other social infrastructures underpinning the reduction of regional inequalities in health Harnessing innovative technologies to ensure access to health services Developing a new service deliver model to facilitate access o vulnerable social groups to qualit Reducing the impact of the social and economic crisis on the health 4 Enhancing institutional capacity and an efficient public administration 5 Enhancing access to, use and quality of information and communication technologies 6 Supporting the shift towards a low-carbon economy in all sectors 7 Protecting the environment and promoting resource efficiency 8 Strengthening research, technological development and innovation 2 nd Circular on Designing and Preparing Developmental Planning for Developing and adding value to human potential skills- active social inclusion Proposals documents of the Ministry of Health

39 Pillar 1: Healthcare System Sustainability Pillar 2: Health as an investment in Human Capital Pillar 3: Reducing Inequalities in Health Ensuring the healthcare system;s sustainability Improving the efficiency and effectivenessof the Healthcare System and upgrading of the quality of service provision Digital modernization of the Healthcare System, promotion of IT technology and health e-services General Strategic Objectives of the Health Sector for Upgrading Health Sector Human Capital in the Improving the environmental performance of the health sector Improving Extroversion the Healthcare System Employability enhancement and active population increase Improving citizen\s defence against a risk factors for public health Promotig Mental Health Enhancing the value of the Health System products for dealing with risk factors and treatment of diseases. Investing in health structures and other social infrastructures underpinning the reduction of regional inequalities in health Harnessing innovative technologies to ensure access to health services Developing a new service deliver model to facilitate access o vulnerable social groups to qualit Reducing the impact of the social and economic crisis on the health 2 Protecting the environment and shifting to an environment friendly economy 3 Enhancing institutional capacity and an efficient public administration; Proposals documents of the Ministry of Health

40 1.1.3 Need for interventions relating to other sectors The Health Sector, in the framework of its developmental strategic targets for the period , identifies the need for interventions that are relevant to the Environmental Sector and the Research and Technology Sector. In particular, it has been promoted the environmental performance of the Health Sector via the support of the environmental performance and the use of renewable energy sources in the Health Care Units and the use of high performance heat and electricity cogeneration in hospitals. Such interventions shall contribute to the achievement of the thematic target of the Environmental Sector that involves the Support for a CO 2 low emission economy in all sectors. Moreover, it promotes the environmental risk management in the health sector via the development and implementation of efficient management systems for the infectious wastes and radioactive pollutants of hospitals, thus contributing in the achievement of the target which is relevant to the Environmental Protection and the promotion of an efficient utilization of resources. Finally, it promotes the cooperation with the Secretariat General for Research and Technology regarding the funding of research activities within the Health Sector. Such research aims at the development of new diagnostic and screening methods, new advanced pharmaceuticals, upgraded medical devices and products that help in dealing with risk factors and to the stabilization, and in certain cases to the improvement, of the condition of patients with chronic and neurological diseases (autism, multiple sclerosis, Parkinson and Alzheimer diseases etc). The aim of the Health Sector is to operate on a supplementary basis and to contribute in terms of the standardization of the specific research results and their corresponding applications. 1.2 THEMATIC TARGETS INVESTMENT PRIORITIES ACTION CATEGORIES The present section presents the correlation between the developmental targets of the health sector and the thematic targets and investment priorities of Europe 2020 strategy per EU Structural Investment Fund (ΕSIF) concerning the actions that shall contribute in the achievement of the targets of the new programme period. The central target of the policy of the Health sector is: Promotion of the safety and quality of the health care services provided by enhancing the cooperation between the health care services beneficiaries, the health care and welfare professionals, the administration staff and the community (local societies), the ultimate goal being the modernization of the health care system and the improvement of its performance. The thematic targets that have been selected on the basis of the developmental needs analyzed in the previous section are as follows: Thematic target 11 Improvement of the institutional capacity and public administration efficiency European Social Fund Proposals documents of the Ministry of Health

41 Objectives Pursued: The increase of efficiency, quality and effectiveness of the Health Care System, which shall ensure the sustainability of the system as well as the citizens satisfaction with regard to the services they are supplied. Α.1. Investment Priority Investment concerning the institutional capacity and efficiency of the public administration and public services in order to achieve the reforms required, better regulation and good governance. Special target Ensuring the financial sustainability of the health care system. Action Type 1: Enhancement of the Programming Systems and the Drafting of Budgets as well as of the Follow-up of their execution by all Health Care Units, at Regional and Central Level: Application of a double-entry system, central electronic monitoring of the execution of budgets. Main beneficiaries (target groups): The entire population of the country (as taxpayers) ans patients or potential citizen-patients (as health care services receivers) Indicative beneficiary categories: The Ministry of Health and the bodies supervised by the said Ministry, the Health Care Regions, the Primary, Secondary and Tertiary Health Care Units, the NHS Services. Action Type 2: Enhancement of Internal Audit Systems and Procedures: Enhancement of the existing procedures, significant strengthening of the internal auditing operation at all administrative levels (Focus on the application of a uniform approach) Main beneficiaries (target groups): The entire population of the country, EOPYY, HCR, Public Health Care Units Administration Indicative beneficiary categories: The Ministry of Health and the bodies supervised by the said Ministry, the Health Care Regions, the Primary, Secondary and Tertiary Health Care Units, the NHS Services. Action Type 3: Introduction of modern Procurement Procedures Centrally based Procurements: Enhancement and standardization of procurement procedures at central and regional level, regionally based procurement for hospitals, procurement compliance control against approved budgets, introduction of electronic procurement systems, warehouses management (WMS), stock and consumption control. Main beneficiaries (target groups): The entire population of the country (as taxpayers) ans patients or potential citizen-patients (as health care services receivers), EOPYY, health care units suppliers Indicative beneficiary categories: The Ministry of Heath, EOPYY, HCR. Action Type 4: Introduction of new sustainable drug pricing and reimbursement methods: Institutionalization, which shall eventually lead to full incorporation of the relevant European Directives; utilization of the guidelines and conclusions of the European Health Technology Assessments. Definition of the relevant pricing responsibilities and competences. Enhancement of the competition in the drug procurement process in favor of Proposals documents of the Ministry of Health

42 the System. Modernization of the composition and application of the positive list, review of the participation levels as well as of the method for its implementation with regard to specialized expensive drugs. Rationalization of the profit margin of those involved in the drug distribution chain and re-examination of the cooperation practices between the drug industry and the health care professionals. Main beneficiaries (target groups): The entire population of the country (as taxpayers) and patients or potential citizen-patients (as health care services receivers), EOPYY, health care units suppliers, Drug suppliers, Primary Health Care Units, Public Hospitals, Mental Health Care Units, Specialized Structures Indicative beneficiary categories: The Ministry of Health, EOPYY, National Organization for Medicines etc. Action Type 5: Pharmaceutical expenditure control and squeeze measures: Introduction of measures for restricting the excessive consumption of drugs and particularly the irrational use of antibiotics. Introduction of measures favoring the use of generics, ensuring correct prescribing methods. Full implementation of the electronic prescriptions, updating of patients, personnel and insurance funds regarding the rational use of drugs etc. Main beneficiaries (target groups): The entire population of the country (as taxpayers) and patients or potential citizen-patients (as health care services receivers), EOPYY, health care units suppliers, Drug suppliers, Primary Health Care Units, Public Hospitals, Mental Health Care Units, Specialized Structures Indicative beneficiary categories: The Ministry of Health, EOPYY, National Organization for Medicines, etc. Special target Improvement of the efficiency and efficacy of the Health Care System and upgrading of the quality of the supplied services Action Type 1: Definition of the National Strategy for Health Care Insurance and Enhancement of EOPYY: Development of a strategic proposal and definition of the role of EOPYY in the design of a sustainable health care insurance system. Definition of the population covered and of the packages offered as well as of the method and health care levels for uninsured people. Relations with all the insurance funds and the EOPYY funding method. Implementation of an efficient operation, finacial management and human resources development model for EOPYY as well as the development of the IT System required for its operation. Particular emphasis on the management of arrears as well as signing and management of contracts with hospitals, physicians and other health care providers. Introduction of A Quality Assurance System for EOPYY. Main beneficiaries (target groups): The entire population of the country and patients or potential citizen-patients, EOPYY, Primary health care units, Health Care Providers having contracts with EOPYY, Insurance Funds Indicative beneficiary categories: The Ministry of Health and EOPYY Proposals documents of the Ministry of Health

43 Action Type 2: Improvement of the Primary Health Care Services so as to avoid the need for Specialized Hospital Services: Improvement of the access to the primary health care via rearrangement of the services supplied (types of services and geographical service points) according to the demand, so that it is ensured universal and equitable access to high quality services and the supply of continuing care. Provision of integrated, friendly and efficient mental health care services and Home Care services. Introduction of the GPs institution and of a graduated referral system to avoid the over loading of Intensive Care Units and hospital clinics. Improvement of the cooperation between the primary health care units, home care units and secondary health care units. Development of mental health care services within the context of the primary health care (HCC, EOPYY polyclinics) as an alternative to the of Mental Health Care Centers. Main beneficiaries (target groups): The entire population of the country and patients or potential patients, EOPPY, Primary health care units, the human resources employed in the primary Health Care. Indicative beneficiary categories: The Ministry of Health and the bodies supervised by the said Ministry, Health Care Regions, Primary Health Care Units. Action Type 3: Improvement of Hospital Care: Introduction of modern business models in the hospitals, evaluation of the processes applied. Pilot mergers of labs and administration units in neighboring hospitals. Development of psychiatric departments in general hospitals. Main beneficiaries (target groups): The entire population of the country and patients or potential patients, Public health care units, hospital staff. Indicative beneficiary categories: The Ministry of Health and the bodies supervised by the said Ministry, Health Care Regions, Hospitals, the NHS Services.. Action Type 4: Introduction of reimbursement methods for Health Care Units on the basis of cost or the Quality of the Supplied Services: Introduction of Activity Based Costing for health Care Units. In the same time, selection of a modern dynamic DRGs system in order to reform DRGs on a hospital cost based orientation. Full institutionalization of the system at a legislative and regulation level, detailed definition of the accountability method and roles with regard to its implementation. Costing of the new system by means of development and implementation of an appropriate methodology. Support of its implementation by IT systems and applications. Reimbursements that reward the saving of rare resources (e.g. encourage the use of day care surgeries instead of patients hospitalization). Main beneficiaries (target groups): The entire population of the country and patients or potential patients, Public Hospital care units, hospital staff. Proposals documents of the Ministry of Health

44 Indicative beneficiary categories: The Ministry of Health and the bodies supervised by the said Ministry, Health Care Regions, Primary, Secondary and Tertiary Health Care Units, the EOPYY Services as well as bodies of Ministries and the Local Authorities that have a supplementary role with regard to the NHS, societe anonyme, financial and social partners., Action Type 5: Improvement of the organization, administration, coordination, follow-up of the Mental Health Care System so as to improve its efficiency: Establishment of a unique organizational and administrative framework for the Mental Health Care Centers. Drafting of Viability Plans for the new mental health care and rehabilitation structures by means of restructuring and modernization of the services map. Elaboration and establishment of therapeutic protocols and clinical guidelines. Main beneficiaries (target groups): Patients suffering from mental diseases, the entire population Indicative beneficiary categories: The Ministry of Health and the bodies supervised by the said Ministry, Health Care Regions, Mental Health Care Units, Hospitals, and PLLP. Action Type 6: Development and introduction of quality systems in the hospitals and the primary health care. Main beneficiaries (target groups): The entire population Indicative beneficiary categories: The Ministry of Health and the bodies supervised by the said Ministry, Health Care Regions, Hospitals, Primary Health Care Units, the NHS Services, as well as bodies of Ministries and the Local Authorities that have a supplementary role with regard to the NHS, financial and social partners. Action Type 7: Design and implementation of an Efficiency Measurement and Evaluation System for the Health Sector. It involves the development and application of assessment criteria regarding the rehabilitation mission and outcome of the Psyco-social rehabilitation Units. Β Main beneficiaries (target groups): The entire population Ε Indicative beneficiary categories: The Ministry of Health and the bodies supervised by the said Ministry, Health Care Regions, Hospitals, Primary/Secondary and Tertiary Health Care Units, Mental Health Care Units and the NHS Services.. Action Type 8: Development of Accountability Systems (systemic and individual) in the supply of health care services to the citizen Main beneficiaries (target groups): The entire population Indicative beneficiary categories: The Ministry of Health and the bodies supervised by the said Ministry, Primary/Secondary and Tertiary Health Care Units and the NHS Services Action Type 9: Improvement of the efficiency in the utilization of human resources in the Health Sector: Improvement of a balanced staff allocation between main professional Proposals documents of the Ministry of Health

45 sectors and specialties as well as in terms of regional allocation. Encouragement regarding the professional development of the personnel, introduction of non financial criteria (working conditions, carrier planning). Detailed registration and monitoring of all human resources in the sector by means of a data base in order to achieve better annual and long term employment planning according to the needs. Collection of the required demographic and epidemiological data as well as of other data that may support demand-focused planning. Development of medical staff assessment policies as well as assessment methods for the entire staff of the Sector. Main beneficiaries (target groups): The entire population of the country, patients and potential patients Indicative beneficiary categories: The Ministry of Health and the bodies supervised by the said Ministry, Health Care Regions, Primary/Secondary and Tertiary Health Care Units and the NHS Services Special target Improvement of openness in the Health Care System Action Type 1: Cross-border cooperation Main beneficiaries (target groups): the population of Greece and its neighboring countries, focusing on the people living in border areas. Indicative beneficiary categories: the Ministry of Health, HCR, the National School of Public Health, Supervised bodies, primary and secondary health care Units. Action Type 2: Epidemiological surveillance Main beneficiaries (target groups): the population of Greece and its neighboring countries, focusing on the people living in border areas Indicative beneficiary categories: The Ministry of Health and the bodies supervised by the said Ministry, Health Care Regions, KEELPNO, the National School of Public Health, Primary/ Secondary and Tertiary health care Units, the NHS Services, finanacial and social partners and NGOs.. Action Type 3: development of medical tourism. Main beneficiaries (target groups): Health Care Services Receivers in Greece and other countries Indicative beneficiary categories: The Ministry of Health, HCR, Financial and Social Partner, NGOs. Proposals documents of the Ministry of Health

46 Α.2. Investment Priority Capacity building of bodies providing employment, education and social policies as well as sectoral and territorial agreements relating to the mobilization in favor of reforms at a national, regional and local level. Special target Upgrading of Human Resources in the Health Sector ΤAction Type 1: Design and implementation of educational and capacity building programmes: Education of the Health Sector personnel (central services e.g. The Ministry, EOPYY e.g. HCR and Primary/ Secondary and Tertiary health care Units) regarding structural reforms, the new legislative framework, the new procedures and systems as well as the implementation of special individualized theoretical and practical training programmes. Main beneficiaries (target groups): the entire Health Care Sector Personnel and indirectly the entire population of the country Indicative beneficiary categories: the Ministry of Health, HCR, the National School of Public Health, ΕΚDDΑ, EOPYY, Bodies supervised by the Ministry of health, Primary/ Secondary and Tertiary Health Care Units, Social Partners and NGOs Thematic target 9 Promotion of Social Integration and Combat of Poverty Εuropean Regional Development Fund (ΕRDF) Objectives Pursued: Halting the barriers regarding the access to health care services of vulnerable social groups, economically weak people (poor people), people of different cultural background or living in remote areas. Β.1. Investment priority Investments in health care and social infrastructure which contribute to the national, regional and local development by reducing the inequalities in the health sector and enhance the transfer from central to local based delivery of services Special target Investments in health care and other social infrastructure which alleviate regional inequalities in the health sector. Action Type 1: Development of specialized health care structures: Development of structures for pain management, dialysis, rehabilitation centers, Day Care Units in areas where such structures do not exist. Development of specialized structures (Alzheimer disease, autism etc). Post hospitalization hostels for mentally ill people in selected areas. Development of Mental Health Care Units in Mental Health Care Sectors that fall behind or are inadequate compared to other MHCS that more developed. Main beneficiaries (target groups): Vulnerable social groups, people that are threatened with poverty, uninsured people, people living in remote areas (islands and border areas included) Proposals documents of the Ministry of Health

47 Indicative beneficiary categories: The Ministry of Health and the bodies supervised by the said Ministry, Health Care Regions, PLLP Action Type 2: Expansion and Upgrading of existing structures and health care infrastructure. Main beneficiaries (target groups): Vulnerable social groups, people that are threatened with poverty, uninsured people, people living in remote areas (islands and border areas included) Indicative beneficiary categories: The Ministry of Health and the bodies supervised by the said Ministry, Health Care Regions, NGOs European Social Fund (ΕSF) Objectives Pursued: Halting the barriers regarding the access to health care services of vulnerable social groups, economically weak people (poor people), mentally ill people, people of different cultural background or living in remote areas. Γ.1. Investment Priority Improvement of access in terms of affordable, viable and high quality services, including health care services and social services of general interest Special Target Development of a new service delivery model Acton Type 1: Development of a new health care services delivery model (e.g. home care etc): Actions for the development and application of alternative health care delivery that may facilitate the access of economically weak people, vulnerable groups to quality health care services in terms of linguistic and cultural inequalities. Such models may be supported by volunteers or utilize alternative funding methods. EOPYY shall formulate a package of services for less favored social groups. Development of the Host Family Institution. Main beneficiaries (target groups): economically weak people, vulnerable social groups as well as people of a different linguistic and cultural background. Individuals with mental health problems. Indicative beneficiary categories: The Ministry of Health and the bodies supervised by the said Ministry, financial and social partners, Action Type 2: Enhancement of the role of the patient regarding the management of his/her health and adoption of a patient focused health care services delivery model: Support to patients so that they may handle independently and actively their health problems and assess the services delivered as well as get involved in the drawing-up of the legislation and the new primary health care services. Main beneficiaries (target groups): economically weak people, vulnerable social groups as well as people of a different linguistic and cultural background. Individuals with mental health problems. Proposals documents of the Ministry of Health

48 Indicative beneficiary categories: The Ministry of Health and the bodies supervised by the said Ministry, financial and social partners, NGOs. Action Type 3: Integration of Mental Health Care Services: Development and delivery of specialized mental health care services due to new emerging needs (unemployed people etc). Development of supportive interventions for the families of mentally ill persons. Development of mental health care services for children and adolescents. Development of mental health care services in primary health care structures, development of local mental health care centers.. Main beneficiaries (target groups): people suffering from mental illnesses and their families. Indirectly, the entire population. Indicative beneficiary categories: The Ministry of Health and the bodies supervised by the said Ministry, financial and social partners, NGOs. Special target Addressing the impact of the socio-economic crisis in terms of Vulnerable Social Groups health care. Action Type 1: Interventions relating to Prevention: Development of preventive medical care interventions for children, focusing on the children of less favored social groups. Development of Health education and health promotion, chronic disease management, pre-symptomatic control, vaccination programmes etc for selected social groups (SCG) which are faced with increased risk of social exclusion. Main beneficiaries (target groups): children, SCG children, SCG adults, general polpulation Indicative beneficiary categories: The Ministry of Health and the bodies supervised by the said Ministry, National School of Public Health, ΚΕΕLPNO, financial and social partners, NGOs Action Type 2: Development of Social awareness actions for the staff of health sector (medical, hospital and paramedical) so as to eliminate discriminations in terms of services delivery to SCG. Main beneficiaries (target groups): Vulnerable social groups, the staff of the Health Sector Indicative beneficiary categories: The Ministry of Health and the bodies supervised by the said Ministry, Health Care Regions, Primary/Secondary and Tertiary Health Care Units, the NHS Services, financial and social partners, NGOs. Γ.2. Investment Priority Promotion of social economy and social enterprises Special Target Promotion of Mental Health Care Action Type 1: Empowerment of Social Cooperatives for mentally incapacitated persons: Development of new S.C. Ltd and enhancement of the existing ones combined Proposals documents of the Ministry of Health

49 with the development of alternative employment and professional rehabilitation methods for receivers of Mental health Care Services. Main beneficiaries (target groups): Mentally ill patients and the general population. Indicative beneficiary categories: The Ministry of Health and the bodies supervised by the said Ministry, Health Care Regions, SC. Ltd and NGOs Thematic target 8 Promotion of Employment and Labor Force mobility support European Social Fund (ΕSF) Objectives Pursued: Improvement of the defense of citizens against public health risk factors so that they maintain or increase their employability and remain healthy while ageing, which may allow them to remain active in terms of social and working activities. Δ.1. Investment Priority Active and Healthy Aging Special Target Enhancement of employability and increase of the active population Action Type 1: Introduction of measures for the improvement of the Working Environment and for Limiting Occupational Accidents. Main beneficiaries (target groups): The entire population Indicative beneficiary categories: The Ministry of Health and the bodies supervised by the said Ministry, Health Care Regions, Action Type 2: Development of chronic diseases and multiple morbidity management programmes (e.g. hypertension, diabetes, chronic obstructive lng disease) Main beneficiaries (target groups) : Patients with chronic and degenerating diseases Indicative beneficiary categories: The Ministry of Health and the bodies supervised by the said Ministry, Social Partners, NGOs Special Target Improvement of the defense of citizens against public health risk factors Action Type 1: General Population Information Campaigns regarding significant health risks: Design and Implementation of Measures so that it abstains from harmful addictions. Realization of targeted interventions for detecting risks and the promotion of health protection policies in the fields of education, in the workplace etc as well as by means of coordinating the actions of various social policy bodies that are involved in the above fields. Proposals documents of the Ministry of Health

50 Main beneficiaries (target groups): The entire population of the country Indicative beneficiary categories: The Ministry of Health and the bodies supervised by the said Ministry, National School of Public Health, ΚΕΕLPNO, Financial and Social Partners, NGOs Action Type 2: Timely Prognosis of Health Risks and Development of Presymptomatic Control Programmes in relation to severe diseases Main beneficiaries (target groups): The entire population of the country Indicative beneficiary categories: The Ministry of Health and the bodies supervised by the said Ministry, National School of Public Health, ΚΕΕLPNO, Financial and Social Partners, NGOs, University hospitals Action Type 3: Development of environmental risk impact management programmes relating to the quality of drinking water, subsoil and air Main beneficiaries (target groups): The whole society Indicative beneficiary categories: The Ministry of Health and the bodies supervised by the said Ministry, National School of Public Health, ΚΕΕLPNO, Financial and Social Partners, NGOs, University hospitals Thematic Target 2 Improvement of the quality, use and access to IΤ European Regional Development Fund (ΕRDF) Objectives Pursued: Digital modernization of the health system; Promotion of IT technology and e-health services. Ε.1. Investment Priority Enhancement of IΤapplications regarding e-governance, e- learning, e-inclusion, e-culture and e-health Special Target Digital modernization of the health system. Promotion of IT technologies and e-health services Action Type 1: Introduction of e-health systems and procedures: Introduction of systems that support a full health care and life style cycle which deals with prevention, diagnosis, treatment, monitoring and management and involves among others: a) IT systems in the hospitals ensuring the necessary interoperability between them and between the IT systems of the entire health sector b) Improved electronic prescription system by means of guaranteed funding, effective administration, safety of access as well as by strengthening control procedures and roles in terms of operation and institutional status of all the above c) Systems supporting the Primary Health Care d) Telemedicine systems e) establishment of personal medical e-files f) information system for health care services users g) personal wearable and portable communication systems for monitoring and Proposals documents of the Ministry of Health

51 supporting patients h) tele-care systems (introduction of innovative IT for continuing posthospitalization tele-care and rehabilitation i) Modernization and creation of registers for: (patients, insured and uninsured people, diagnostic tests, procedures, medical devices etc). Main beneficiaries (target groups): The entire population, patients in remote areas having difficulties in accessing the health care services, hospitals, Primary Health Care Units. Indicative beneficiary categories: The Ministry of Health and the bodies supervised by the said Ministry, Health Care Regions, EOPYY, Primary Health Care Units, Hospitals.. Action Type 2: Development of e-auctions for health care products. Main beneficiaries (target groups): The entire population, Primary/Secondary and Tertiary Health Care Units, Health Care Providers, HCR, EOPYY Indicative beneficiary categories: The Ministry of Health and the bodies supervised by the said Ministry, Health Care Regions, EOPYY, Primary Health Care Units, Public Health Care Units Thematic Target 4 Support for the transition to a low CO2 emission economy in all sectors European Regional Development Fund (ΕRDF) Objectives Pursued: Energy saving, increased utilization of RES and reduced CO2 emissions by Health Care Units Ε.1. Investment Priority: Support regarding energy performance and use of RES in public infrastructure, including public buildings, and the housing sector. Special Target Improved environmental performance of the Health Care Sector Action Type 1: Promotion of the use of RES by Hospitals Main beneficiaries (target groups): The entire population and the Hospitals. Indicative beneficiary categories: The Ministry of Health and the bodies supervised by the said Ministry, Health Care Regions, the Public Hospitals Action Type 2: Promotion of high performance electricity and heat cogeneration in Hospitals: Commission, installation and operation of Cogeneration Units for electric energy generation and simultaneous recovery of the heat to cover the relevant energy needs of hospitals. The Units shall operate with natural gas ensuring energy saving and environmental protection by limiting the emission of greenhouse gases and pollutant substances. Main beneficiaries (target groups): The entire population and the Public Health Care Units. Proposals documents of the Ministry of Health

52 Ε Indicative beneficiary categories: The Ministry of Health and the bodies supervised by the said Ministry, Health Care Regions, Public Health Care Units Thematic Target 6 Environmental Protection and promotion of efficient resource utilization European Regional Development Fund (ΕRDF) Objectives Pursued: Management of hospitals hazardous wastes by innovative and effective methods ensuring the quality of air, subsoil and water. ΣΤ.1. Investment Priority Promotion of innovative technologies for the improvement of the environmental protection and efficient use of resources in terms of wastes, water, soil protection and reduction of air pollution. Special Target Improvement of the environmental performance of the Health Care Sector ΤAction Type 1: Promotion of hospital hazardous wastes effective management systems: Infectious wastes and radioactive pollutants management Systems Main beneficiaries (target groups): The entire population and the Public Health Care Units. Indicative beneficiary categories: The Ministry of Health and the bodies supervised by the said Ministry, Health Care Regions, Public Health Care Units Thematic Target 1 Enhancement of research, development of technology and innovation European Regional Development Fund (ΕRDF) Objectives Pursued: Productive utilization of the results of the research conducted within the Health Care System and promotion of innovative products to improve prevention and/or diagnosis and/or treatment and /or patients rehabilitation. ΣΤ.1. Investment Priority Promotion of investments in R&D and connection and synergies between the enterprises, the R&D Centers and the Universities, particularly regarding the development of products, the transfer of technology, social innovation and applications in the supply of public services, enhancement of demand, networking, clusters, open innovation via smart specialization by supporting technological and applied research, pilot lines, product validation actions, Key Enabling Technologies and diffusion Special Target Utilization of the products of the research in the Health Care System to address risk factors and to treat illnesses Action Type 1: Standardization and spin off of the results of the research conducted within the Health Care System regarding advanced diagnostic and treatment methods as Proposals documents of the Ministry of Health

53 well as medical devices that may address risk factors, stabilization of the development or treatment of illnesses and as a result protect and improve the health of citizens. Main beneficiaries (target groups): The entire population, the researches in the health care system, medical devices providers, pharmaceutical companies, Universities, Technical Educational Institutes. Indicative beneficiary categories: The Ministry of Health and the bodies supervised by the said Ministry, University Hospitals, the National School of Public Health, National Organization for Medicines etc 1.3 APPLICATION OF HORIZONTAL PRINCIPLES AND POLICY TARGETS FOR THE IMPLEMENTATION OF GRNET Implementation of partnership principle Partnership has been characterized as one of the most important principles for the implementation of the Funds of the EU Common Strategic Framework. The aim is the achievement of a multi level governance approach in the preparation, implementation, follow-up and evaluation of programs by utilizing the experience and knowhow of partners. It involves namely the coordinated actions in the EU, the states, and the local and regional authorities at a national, regional and local level in the member states as well as between them and non governmental participants from the private sector and the civil society (social and financial partners, NGOs, non profit organizations). In article 5 of the Proposal for a Regulation COM 2011/615 final 2 of the European Parliament and the Council on laying down Common Provisions for the European Regional Development Fund, the European Social Fund, the European Agricultural Fund for Rural Development and the European Fishery Fund, every member state organizes partnerships with the following partners: a) the competent regional, local, civil and other public authorities b) financial and social partners c) bodies representing the civil society, including environmental partners, non governmental organizations and agencies that are responsible for promoting equality and combat discriminations. Moreover, according to the multilevel governance approach the member states promote the participation of partners in the drafting of partnership agreements and progress reports as well as in the preparation, implementation, monitoring and evaluation of programmes. Ensuring a partnership in the design of developmental policies and priorities in the health Care Sector for the period is reflected on the following initiatives/actions undertaken: (i) Appointment of social partners, who have been invited to contribute and express their opinion regarding the Main Development Priorities in the Health Sector in the context of Supplementing Section 4 according to Circular 1 of the Ministry of Development, Competitiveness, Infrastructure, Transports and Networks. On the other hand they shall be invited to participate to the sectoral thematic meeting (conference) which shall take place on Proposals documents of the Ministry of Health

54 22/4/2013 and shall focus on the consultation of strategic objectives and guidelines as well as on highlighting (identification) interventions of major importance. Those are as follows: 1) Ministries and the bodies supervised by the said Ministries that, due to their competences, they are synergy with the developmental priorities of the health Care Sector (in descending oreder), namely: The Ministry of Development, Competitiveness, Infrastructure, Transports and Networks The Ministry of Labor, Social Insurance and Welfare The Ministry of Environment, Energy and Climatic Change The Ministry of Education, Religious Affairs, Culture and Sports The Ministry of Administrative Reform and Electronic Governance The Ministry of Tourism The Ministry of Rural Development and Food The Ministry of Justice, Transparency and Human Rights Secretariat General for Research and Technology (GGΕΤ) Hellenic Food Authority (ΕFΕΤ) Hellenic Tourism Organization (ΕΟΤ) 2) Supervised bodies and Legal Persons under the Ministry of Health. Health Care Regions (HCR) National Emergency Medical Services Center (ΕΚΑΒ) National Organization for medicines (ΕΟF) National Organization for the Delivery of Health Care Services (ΕΟPΥΥ) Center for Illnesses Control and Prevention (ΚΕΕLPΝΟ) Organization against Drugs (ΟΚΑΝΑ) National School for Public Health (NSPH) Child Health Institute, Children s Hospital "Agia Sofia" National Center for the Research, Prevention and Treatment of Diabetes and its Complications (ΕΚΕDΙ) National Transplant Organization (Ε.Ο.Μ.) PASTEUR Hellenic Institute Biomedical research Foundation Academy of Athens (ΙΙΒΕΑΑ) Therapy Center for Addicted Individuals Κέντρο (ΚΕTHΕΑ) National Blood Donation Center (ΕΚΕΑ) 3) Societés Anonymes that implement strategic decisions of the Ministry of Health such as: Public Enterprise for the Construction of Hospital Units (DEPANOM.) S.A. Health Care Units Societe Anonyme S.A. (Α.Ε.Μ.Υ. S.A.) 4) the 13 regions given that the Regional Programmes of the Programme Period must include actions which involve developmental priorities of the health sector and particularly actions that mitigate inequalities in terms of quality health care access. 5) Social and Financial Partners such as: Panhellenic Medical Association Proposals documents of the Ministry of Health

55 Greek Dentists Federation Panhellenic Pharmacists Association Nursing Staff Association of Greece Panhellenic Physiotherapists Association 6) Bodies representing the civil society and NGOs such as: National Federation of People with Impairment (ΕSΑEΑ) Social Cooperatives of Limited liability (S.C. Ltd) etc (ii) (iii) The Special Agency of the Health Care and Social Solidarity Sector participated to the Regional Conferences organized and realized in 2013, and expressed on one hand the developmental needs of the Health Care Sector that need to be taken into account in the strategic planning for the Regions and on the other hand to get information regarding the particular needs of regions and eventual regional inequalities that must be considered in the developmental programme of the health care sector. In 22 May 2013, a Sectoral Conference on Health is organized with the participation of representatives from all the aforementioned categories. The aim of this conference is to develop a consultation platform on the strategic developmental priorities of the healthcare sector as those have been expressed by the competent Ministry and collect remarks, feedback and updated proposals by all partners. Such views shall be evaluated on the basis of their substantiation and shall be utilized for the finalization of the strategic choices of the sector Promotion of equality of genders, non discrimination and accessibility (article 7 of the Common Provision Code (KKD) According to article 7 of the Proposal for a Regulation COM 2011/615 final2 of the European Parliament and the Council on laying down Common Provisions for the European Regional Development Fund, the European Social Fund, the European Agricultural Fund for Rural Development and the European Fishery Fund, the member states and the Commission ensure the equality between men and women and integrate the dimension of gender in the preparation and implementation stages of the programs. The member states and the Commission take the necessary measures to avert any discrimination due to sex, racial or ethnic origin, religious or other beliefs, impairment, age or sexual orientation in the elaboration or implementation of such programs. In the context of the design of the present developmental strategy of the Health Care Sector the issues relating to equality constitute inherent components. Particularly the principle of equality refers to the access of all citizens to health care services, the use of such services according to the needs and the delivery of high quality care to all citizens. At a second stage, the principle of equality involves the equitable on the basis of financial capacity participation of citizens in the funding of health care services. Proposals documents of the Ministry of Health

56 Taking into account the impact of the financial crisis in Greece, the increased unemployment which leads to the absence of social insurance and consequently to limited access to health care services together with the limited access to health care services by immigrants, people with different linguistic or cultural or religious background, people living in remote areas where there are no health care centers, people with impairment and other groups particularly exposed to risk factors due to their living conditions (e.r. Roma, female prostitutes or victims of trafficking), it has been decided that the third Pillar of the Present Strategic Developmental Programme for the Health Care Sector for the next Programme Period shall exclusively involve the Reduction of inequalities in the health care sector. Such choice is full in line with the Commission s guidelines that are reflected in the Document Investing on Health and promotes the development of health care and social infrastructure, the utilization of innovative technologies (e.g. telemedicine), the development of new service delivery methods (e.g. home care, the delivery of services on a volunteer basis, use of alternative funding tools, pro bono etc). Moreover, the present developmental programme seeks to apply the principle of non discrimination by enhancing, modernizing and further developing the primary health care services as well as via prevention mechanisms that focus on, but not limited to, vulnerable social groups. In addition, the rational of the principle of gender equality is incorporated in the target relating to the enhancement of employability by means of improving the defense of the citizens against health risk factors. The promotion of equality is achieved as well with the upgrading of the operation and the expansion of social care structures and social support services that allow/facilitate the access and participation of women to the labor market as they free them from the increased family, social etc responsibilities. Finally the upgrading of human resources in the health care sector which is relevant to their allocation depending on the real needs and the forecasts of epidemiological studies as well as to the enhancement of specific segments (e.g. care for elderly people, Parkinson disease patients, patient suffering from Alzheimer disease, mentally ill patients etc) shall take into account and shall respect the principle of equality between men and women. Proposals documents of the Ministry of Health

57 Proposals documents of the Ministry of Health