chapter  10
25 Pages

Interest Groups and Health System Reform in Greece

After the establishment of the National Health System (Εθνικό Σύστημα Υγείας, ESY) in 1984, the next significant attempt to reform the health system in Greece took place almost two decades later. Despite some political and health system characteristics that facilitate the implementation of reform, such as a single-party government and an over-supply of physicians (which may imply a relative decline in the power of the medical profession), there are other features that may impede change, such as clientelistic networks and fragmentation in financing. These characteristics allow stakeholders to block the implementation of health reforms in order to maintain the diverse benefits they derive from the disjointed system. As a result, the Greek NHS (ESY) continues to possess the qualities of a fragmented and regressive funding system, distortions in the allocation of resources (multiple occupational funds with unequal coverage, historically based allocations to hospitals), perverse incentives for providers, and a heavy reliance on expensive inputs. Several analysts of health reform have employed theories highlighting the

role of the medical profession in the reform process. For instance, there is considerable literature linking the declining role of the medical profession with governments’ abilities to enact health care reforms (Salter 2002;

Hassenteufel 1996; Wilsford 1995). Also focusing on the medical professions, Freddi and Bjorkman (1989: 1-5) identify factors in the political and institutional environments of the health system that impact on medical autonomy. The political environment is characterised by the proximity of the health and political systems, the complexity of the environment in which decisions are made, and the actors that play a role in the policy domain (e.g. bureaucrats, politicians and trade unions). Additionally, Tuohy (1999) presents a model of decision-making highlighting the importance of the balance of influence among stakeholders (state actors, private finance and health care professionals – mainly medical professionals) and the mix of social control mechanisms (hierarchical, market-based and collegial). Although elements of these conceptual frameworks are helpful in

understanding the role of institutions and health professionals in health reform, the complexity of the Greek case requires a broader framework of analysis. The significant rise in the number of medical doctors over the past decades has not yet resulted in an expected corresponding decline in their power. Medical autonomy has increased because of the fragmented health system in which multiple interest groups perceive change as a zero-sum game and align their interests against reform. There were two major health reforms in Greece: the first (1983-84) was only partially implemented whilst the second (2000-02) was largely blocked by interest groups, with only some elements being legislated and a stalemate occurring after the first two years. This paper examines the motivations of key stakeholders within a splintered health system, a political environment characterised by clientelistic relationships between the political party in power and certain groups, and fiscal constraints that prevent health care from being placed high on the political agenda. New institutionalist perspectives, such as those put forth by Hacker

(2002) are useful in understanding the motivations of, and mechanisms through which, stakeholders impede reform. Hacker (2002: 303-11) identifies several circumstances where reform is unlikely to be achieved: for example, when policies lead to the creation of institutions with significant set-up costs; when institutions reflect the broader features of the economy; and when existing institutions benefit important organised interest groups, such that the stronger the opposition to change, the more opportunity the groups will have to impede reform and influence policy decisions. These conditions are applicable to the context of Greek health care reform. Rational choice institutionalism can be used to expound the motives of

multiple interest groups in preventing reform. According to this approach, actors have fixed preferences and aim to maximise their ‘utility’ by employing strategic calculations;1 moreover, institutions are created through voluntary agreement between actors, based on an assessment of how much can be gained through cooperation (Hall and Taylor 1996). Rational choice theorists also assume that individuals seek to maximise a set

of goals according to their preferences and that institutions persist because people – or at least those who are most powerful – think that to deviate from them would make them worse off. An institution’s survival, therefore, depends on whether it is perceived by powerful stakeholders to generate greater net benefits than alternative institutional forms and, in practice, institutional frameworks, once decided, are likely to be quite rigid (Rothstein 1996; Shepsle 1986). There are some differences between the reforms of 2000 and 1983-84. The

1983-84 reform represented the first attempt to universalise the health care system; hence there were significant set-up costs. In 1984 the plan to unify the insurance funds was abandoned (because of reactions from key stakeholders) and the focus shifted to expansion, primarily of the hospital sector. The fragmented health insurance system remained and it was not universalised. Thus there were several ‘winners’: hospital doctors and staff (civil servants); privileged insurance funds2 which had access to an expanded hospital sector without bearing the full costs (because of governmental subsidies); and agricultural workers whose coverage was extended to pharmaceuticals. In contrast, the 2000 reform represented an attempt to alter the institutional setting of the health care system and threatened to reduce the privileges of many interest groups. From the perspective of rational choice theory, in this case, interest groups viewed the reform as a zero-sum game; despite their divergent interests, they were motivated to preserve their privileges and oppose the proposed changes. The next section provides a synopsis of the historical development of the

Greek health system followed by a brief description of its current state. The objective of this paper is to analyse the ambitious reform attempt of 2000 through the lens of rational choice institutionalism, identifying the initial goals of the reform, the reactions of the key stakeholders and the legislative outcome. In closing, we discuss future challenges.