The COVID-19 pandemic revealed and exacerbated the global inequalities regarding the availability... more The COVID-19 pandemic revealed and exacerbated the global inequalities regarding the availability and access to vaccines. Many terms have appeared in the academic literature (“vaccine colonialism,” “vaccine nationalism,” “vaccine apartheid”) trying to capture and interpret these inequalities, failing in most cases to realistically explain the upstream causes of the observed injustices. A Marxist perspective on the contrary emphasizes the structural causes of inequalities in capitalism and attributes them to the existence of economic exploitation. “Vaccine imperialism,” which refers to the control that advanced industrialized countries exert on the development, production, and distribution of vaccines at the expense of less-developed economies, can describe and explain in a more realistic way the observed inequalities during the pandemic. Our study proposes a circuit of vaccine imperialism that explains how economic imperialist exploitation takes place via transfers of value from less-developed economies (vaccine recipient countries) to imperialist economies (vaccine producing and patent holder countries) using four different channels: (a) protection of intellectual property (IP) rights (patents), (b) earnings from royalty payments for the use of vaccines (monopolistic prices and profits), (c) exercise of monopoly power on the production and distribution of vaccines (control over the quantity of vaccines supplied, exclusion of competitors through vaccine licensing), and (d) public debt servicing.
Objectives: Refugees and migrants (R&Ms) exhibited higher risk of COVID-19 infection, and higher ... more Objectives: Refugees and migrants (R&Ms) exhibited higher risk of COVID-19 infection, and higher mortality rates during the pandemic. Acknowledging these risks, R&Ms early in the pandemic were identified by WHO as a priority vaccination group in need of protection. The aim of this study was to assess the vaccination roll-out and uptake among R&Ms residing in Reception Identification Centers (RICs) and Reception Sites (RSs) in Greece, relative to the general population.
Study design: Nationwide observational study.
Methods: Retrospective analysis of national vaccination routine data and population census data, collected and triangulated from multiple official/governmental sources. Weekly vaccine roll-out and uptake were calculated for the general Greek population and the R&M population, through the first year of the vaccination programme in Greece (December 2020–December 2021).
Results: Vaccine roll-out among migrants in RICs/RSs started with a 22-week delay, compared to the general population. By the end of the first year of the vaccination programme in Greece in December 2021, the national vaccination uptake among registered R&Ms residing in official reception facilities was 27.3 % for 1st dose and 4.7 % for booster dose; considerably lower compared to the general population (69.5 % uptake for 1st dose, 64.7 % for 2nd dose, and 32.0 % for 3rd dose).
Conclusion: Delayed vaccine roll-out and low vaccine uptake among R&Ms in Greece are signs of low prioritisation and implementation failures in the R&M vaccination strategy. In face of future public health threats, lessons should be learned, and vaccine equity should be insured for all socially vulnerable and high-risk population groups.
Coverage of migrant and refugee data is incomplete and of insufficient quality in European health... more Coverage of migrant and refugee data is incomplete and of insufficient quality in European health information systems. This is not because we lack the knowledge or technology. Rather, it is due to various political factors at local, national and European levels, which hinder the implementation of existing knowledge and guidelines. This reflects the low political priority given to the topic, and also complex governance challenges associated with migration and displacement. We review recent evidence, guidelines, and policies to propose four approaches that will advance science, policy, and practice. First, we call for strategies that ensure that data is collected, analyzed and disseminated systematically. Second, we propose methods to safeguard privacy while combining data from multiple sources. Third, we set out how to enable survey methods that take account of the groups' diversity. Fourth, we emphasize the need to engage migrants and refugees in decisions about their own health data. Based on these approaches, we propose a change management approach that narrows the gap between knowledge and action to create healthcare policies and practices that are truly inclusive of migrants and refugees. We thereby offer an agenda that will better serve public health needs, including those of migrants and refugees and advance equity in European health systems.
Η επιδημική ετοιμότητα, η ικανότητα δηλαδή πρόληψης, ελέγχου και αντιμετώπισης των επιδημικών απε... more Η επιδημική ετοιμότητα, η ικανότητα δηλαδή πρόληψης, ελέγχου και αντιμετώπισης των επιδημικών απειλών, για πολλά έτη παρέμενε έννοια λησμονημένη και μη συνδεδεμένη με τον στρατηγικό σχεδιασμό και την άσκηση πολιτικής στον χώρο της υγείας. Ακρογωνιαίος λίθος της επιδημικής ετοιμότητας είναι η ετοιμότητα των υπηρεσιών δημόσιας υγείας, η οποία με τη σειρά της περιλαμβάνει την ικανότητα έγκαιρης προειδοποίησης και αποτελεσματικού ελέγχου της διασυνοριακής μετάδοσης των λοιμωδών νοσημάτων, την ικανότητα σχεδιασμού και υλοποίησης στοχευμένων, αναλογικών μη φαρμακευτικών παρεμβάσεων για τον έλεγχο της διασποράς των λοιμωδών νοσημάτων, την επιδημιολογική επιτήρηση, τη διαφανή διαχείριση των επιδημιολογικών δεδομένων, την επιστημονική συνέπεια και τη λογοδοσία των φορέων δημόσιας υγείας. Η πανδημία COVID-19 ανέδειξε, τόσο σε εθνικό όσο και σε υπερεθνικό επίπεδο, τα σοβαρά κενά και τις συστημικές ανεπάρκειες σε όλους τους παραπάνω κρίκους της επιδημικής ετοιμότητας. Οι σύγχρονες και μελλοντικές απειλές της δημόσιας υγείας δεν αφήνουν περιθώρια εφησυχασμού και επιβάλλουν τον ριζικό ανασχεδιασμό των υπηρεσιών δημόσιας υγείας με έμφαση στην οργανική διασύνδεσή τους με συστήματα ολοκληρωμένης πρωτοβάθμιας φροντίδας υγείας και την ενίσχυσή τους με όλους τους αναγκαίους δημόσιους χρηματοδοτικούς πόρους, τις υποδομές και το ανθρώπινο δυναμικό.
International Journal of Health Policy and Management, 2023
Decentralisation is a key element of any healthcare reform that aims to strengthen local healthca... more Decentralisation is a key element of any healthcare reform that aims to strengthen local healthcare systems and make them more responsive to local health and healthcare needs. In this sense the question in policy debate is not whether to decentralise in general or not, but what functions to decentralise and how. Under certain circumstances, decentralising administrative, political, and/or healthcare expenditure powers to subnational authorities can increase local effectiveness. On the contrary decentralising healthcare revenue powers to subnational localities entails too many risks and dangers as theory, pre-pandemic empirical evidence, and the COVID-19 experience in fiscally decentralised health systems actually suggest.
Even in capitalism, redistribution of income and wealth has historically been (under welfarism) and should remain a responsibility of the central, rather than the local, state. Centralised pooling of resources and centralised resource allocation to regions might not be sufficient (depending on tax progressivity and resource allocation equalizers) but are necessary conditions for any meaningful attempt to redistribute income and wealth among individuals and across jurisdictions. Accordingly, rejecting fiscal decentralisation might not be a sufficient option to heal inequities and healthcare deficiencies, but it is a necessary condition for any attempt towards that direction.
International Journal of Social Determinants of Health and Health Services, 2023
The COVID-19 pandemic necessitated the mobilization of all available health care resources, inclu... more The COVID-19 pandemic necessitated the mobilization of all available health care resources, including private, for-profit ones. The aim of this multiple methods study (combination of document and secondary data analysis) was to assess government regulations facilitating the private health sector's participation in the COVID-19 response in Greece.
During the pandemic, the government made three successive increases in private providers’ reimbursement fees, provided additional financial incentives to private providers, and allocated €280 million of emergency funding for the private sector's involvement in the national COVID-19 response. In response, private hospitals made available on average 2.2% of their total bed capacity per epidemic wave for the treatment of COVID-19 patients and 1.7% of their total bed capacity for the treatment of non-COVID-19 patients transferred from National Health System (NHS) hospitals. In 2020 the five largest health care corporate groups maintained their revenues, while in 2021 they increased them by 18.7%—a striking comparison with the 9% recession experienced by the Greek economy in 2020 and its 8.4% recovery in 2021.
In a time of an acute public health crisis, private health care providers responded to society's pressing health care needs by insulating their facilities from COVID-19 patients and NHS patient transfers, minimizing their social contribution and safeguarding their revenues and profits.
What has become increasingly apparent during this pandemic is the inverse care law defined by J T... more What has become increasingly apparent during this pandemic is the inverse care law defined by J T Hart in 1971 as the observation that “the availability of good medical care tends to be inversely associated with the need of it in the population served”. In other words, health and social systems in general tend to provide fewer services and of inferior quality to those who need them most, and more services and of superior quality to those who need them less. Enough evidence exists to suggest that refugees and asylum seekers were at increased risk of developing COVID-19 during the pandemic mainly due to their overcrowded living conditions both in camps and in the community. Moreover, they were disproportionately represented in reported COVID-19 deaths. Yet, despite their increased need for protection and increased risk of infection, refugees and asylum seekers in many countries were excluded from national vaccination plans, and if included they were not prioritized.
Data transparency has played a key role in this pandemic. The aim of this paper is to map COVID-1... more Data transparency has played a key role in this pandemic. The aim of this paper is to map COVID-19 data availability and accessibility, and to rate their transparency and credibility in selected countries, by the source of information. This is used to identify knowledge gaps, and to analyse policy implications. The availability of a number of COVID-19 metrics (incidence, mortality, number of people tested, test positive rate, number of patients hospitalised, number of patients discharged, the proportion of population who received at least one vaccine, the proportion of population fully vaccinated) was ascertained from selected countries for the full population, and for few of stratification variables (age, sex, ethnicity, socioeconomic status) and subgroups (residents in nursing homes, inmates, students, healthcare and social workers, and residents in refugee camps). Nine countries were included: Bangladesh, Indonesia, Iran, Nigeria, Turkey, Panama, Greece, the UK, and the Netherlands. All countries reported periodically most of COVID-19 metrics on the total population. Data were more frequently broken down by age, sex, and region than by ethnic group or socio-economic status. Data on COVID-19 is partially available for special groups. This exercise highlighted the importance of a transparent and detailed reporting of COVID-19 related variables. The more data is publicly available the more transparency, accountability, and democratisation of the research process is enabled, allowing a sound evidence-based analysis of the consequences of health policies.
International Journal of Health Policy and Management, 2022
Background: Fiscal decentralisation (FD) is a widely implemented decentralisation policy consisti... more Background: Fiscal decentralisation (FD) is a widely implemented decentralisation policy consisting of the allocation of pooling and spending responsibilities from the central government to lower levels of governance within a country. In 2001, The Italian National Health System (Servizio Sanitario Nazionale, SSN) has introduced a strong element of FD, making regions responsible for their own pooling of resources and for their budgets. Despite the relevance, only few studies exist on health sector-FD in Italy, mostly looking at the effects of FD on infant mortality. Methods: This study performs a fixed-effects panel data analysis of Italian Regions and Autonomous provinces between the years 2001 and 2017, to investigate the effects of health sector-FD on availability, accessibility, and utilisation of healthcare services in Italy. Results: FD decreases availability of staff and hospital beds, decreases utilisation of care, measured by hospitalisation rates, and increases interregional patients' mobility for healthcare purposes, a finding suggesting increased disparities in access to healthcare. These effects seem to be stronger for public-rather than private-services, and are more prominent in poorer areas. Conclusion: This evidence suggest that FD has created a fragmented and unequal healthcare system, in which levels of availability, utilisation of, and accessibility to resources-as well as the extent of public sector's retrenchment-coincide with the wealth of the area.
Objectives: Refugees, asylum seekers, and undocumented migrants globally have been disproportiona... more Objectives: Refugees, asylum seekers, and undocumented migrants globally have been disproportionally impacted by COVID-19. Vaccination has been a major tool to reduce disease impact, yet concerns exist regarding equitable allocation and uptake. Methods: A rapid literature review was conducted based on PRISMA guidelines to determine COVID-19 vaccination acceptance rates and level of access for these population groups globally. Results: Relatively high COVID-19 vaccine acceptance levels were commonly reported in these populations, although, trust in host governments was a frequently expressed concern, especially for undocumented migrants. Outreach efforts and access to comprehensive information from a trusted source and in appropriate language were found to be major determinants of COVID-19 vaccine acceptance. COVID-19 vaccination access and policies varied considerably across host countries despite urgings by international organizations to include migrants and refugees. While most governments endorsed inclusive policies, evidence of successful program implementation was frequently lacking, creating difficulty to better tailor and implement COVID-19 outreach programs. Conclusion: This review identifies impactful improvements to be implemented to ensure equitable COVID-19 vaccinations and to reduce disease burden on refugees, asylum seekers, and undocumented migrants.
Comparison of COVID-19 trends in space and over time is essential to monitor the pandemic and to ... more Comparison of COVID-19 trends in space and over time is essential to monitor the pandemic and to indirectly evaluate non-pharmacological policies aimed at reducing the burden of disease. Given the specific age-and sex-distribution of COVID-19 mortality, the underlying sex-and age-distribution of populations need to be accounted for. The aim of this paper is to present a method for monitoring trends of COVID-19 using adjusted mortality trend ratios (AMTRs). Age-and sex-mortality distribution of a reference European population (N = 14,086) was used to calculate age-and sex-specific mortality rates. These were applied to each country to calculate the expected deaths. Adjusted Mortality Trend Ratios (AMTRs) with 95% confidence intervals (C.I.) were calculated for selected European countries on a daily basis from 17th March 2020 to 29th April 2021 by dividing observed cumulative mortality, by expected mortality, times the crude mortality of the reference population. These estimated the sex-and age-adjusted mortality for COVID-19 per million population in each country. United Kingdom experienced the highest number of COVID-19 related death in Europe. Crude mortality rates were highest Hungary, Czech Republic, and Luxembourg. Accounting for the age-and sex-distribution of the underlying populations with AMTRs for each European country, four different patterns were identified: countries which experienced a two-wave pandemic, countries with almost undetectable first wave, but with either a fast or a slow increase of mortality during the second wave; countries with consistently low rates throughout the period. AMTRs were highest in Eastern European countries (Hungary, Czech Republic, Slovakia, and Poland). Our methods allow a fair comparison of mortality in space and over time. These might be of use to indirectly estimating the efficacy of nonpharmacological health policies. The authors urge the World Health Organisation, given the absence of age and sex-specific mortality data for direct standardisation, to adopt this method to estimate the comparative mortality from COVID-19 pandemic worldwide.
Ο εξευρωπαϊσμός, η διαδικασία δηλαδή διαμόρφωσης και μεταφοράς πολιτικών της Ευρωπαϊκής Ένωσης (Ε... more Ο εξευρωπαϊσμός, η διαδικασία δηλαδή διαμόρφωσης και μεταφοράς πολιτικών της Ευρωπαϊκής Ένωσης (ΕΕ) στα κράτη μέλη, είναι έννοια επίκαιρη, αφορώντας ολοένα και περισσότερα πεδία άσκησης πολιτικής. Σκοπός του άρθρου είναι η διερεύνηση της έκτασης και έντασης του εξευρωπαϊσμού στο πεδίο της πολιτικής υγείας και η δημιουργία ενός θεωρητικού, ταξινομητικού πλαισίου των μηχανισμών μέσω των οποίων αυτός συντελείται. Τα αποτελέσματα της μελέτης δείχνουν, πρώτον, ότι ο εξευρωπαϊσμός στο πεδίο της πολιτικής υγείας ως θεσμική πρακτική υφίσταται και συνεχώς διευρύνεται και, δεύτερον, ότι, ενώ πριν την εκδήλωση της οικονομικής κρίσης επιλέγονταν κύρια οριζόντιοι μη υποχρεωτικοί μηχανισμοί εξευρωπαϊσμού, κατά την περίοδο της κρίσης παρατηρείται μετακίνηση σε κάθετους υποχρεωτικούς μηχανισμούς, που αυξάνουν την ένταση των παρεμβάσεων της ΕΕ στο χώρο της υγείας.
Objectives: Ensuring access to care for all patients - especially those with life threatening and... more Objectives: Ensuring access to care for all patients - especially those with life threatening and chronic conditions - during a pandemic is a challenge for all healthcare systems. During the COVID-19 pandemic many countries faced excess mortality partly attributed to disruptions in essential healthcare services provision. This study aimed to estimate the utilization of public primary care and hospital services during the COVID-19 epidemic in Greece and its potential association with excess non-COVID-19 mortality in the country.
Study design: Observational study
Methods: Retrospective analysis of national secondary utilization and mortality data from multiple official sources, covering the first nine months of the COVID-19 epidemic in Greece (February 26th to November 30th, 2020).
Results: Utilization rates of all public healthcare services during the first nine months of the epidemic dropped significantly compared to the average utilization rates of the 2017-19 control period; hospital admissions, hospital surgical procedures and primary care visits dropped by 17.3% (95% CI: 6.6%-28.0%), 23.1% (95% CI: 7.3%-38.9%), and 24.8% (95% CI: 13.3%-36.3%) respectively. This underutilization of essential public services – mainly due to supply restrictions such as suspension of outpatient care and cancelation of elective surgeries - is most probably related to the 3,778 excess non-COVID-19 deaths (representing 62% of all-cause excess deaths) that have been reported during the first 9 months of the epidemic in the country.
Conclusions: Greece’s healthcare system, deeply wounded by the 2008-18 recession and austerity, was ill resourced to cope with the challenge of the COVID-19 epidemic. Early and prolonged lockdowns have kept COVID-19 infections and deaths at relative low levels. However, this “success” seems to have been accomplished at the expense of non-COVID-19 patients. It is important to acknowledge the “hidden epidemic” of unmet non-COVID-19 needs and increased non-COVID-19 deaths in the country and urgently strengthen public healthcare services to address it.
Greece recently faced a severe second COVID-19 wave. Despite having enough time to prepare due to... more Greece recently faced a severe second COVID-19 wave. Despite having enough time to prepare due to the few cases until June, and ignoring early calls for urgent investment on epidemiological surveillance and transparency, the system is still failing to collect adequate data and even report minimum indicators. These serious data gaps are not unique in Europe and are mostly related to the lack of prioritization and under-investment in local public health surveillance systems. Given the time needed in order to achieve herd immunity through vaccination, immediate investment in comprehensive epidemiological surveillance is the only way to maintain reduced levels of transmission and avoid resurgences.
Background: Migrants globally, including refugees and asylum seekers, have experienced adverse cl... more Background: Migrants globally, including refugees and asylum seekers, have experienced adverse clinical and socioeconomic impacts of the COVID-19 pandemic. For approximately 56,000 refugees and asylum seekers in Reception and Identification Centers (RICs) and Reception Sites (RS) in Greece, living in severely substandard living conditions, prevention measures have been impossible with limited provision in terms of routine testing, surveillance, and access to healthcare. These migrant populations have experienced prolonged lockdowns and restricted movement since the pandemic began. We aimed to assess the impact of COVID-19 on refugees and asylum seekers in reception facilities in Greece and explore implications for policy and practice. Methods: A retrospective analysis of policy documents and national surveillance data was conducted to identify COVID-19 outbreaks and estimate incidence among asylum seekers and refugees residing in these camps during the first 9 months of the epidemic in Greece (26th February À 15th November 2020). Incidence proportion (IP) of COVID-19 confirmed cases was calculated for three population groups (refugees and asylum seekers in RICs, refugees and asylum seekers in RSs, and the general population in Greece) during three time periods (first wave, second wave, and overall across the 9-month period). Findings: Twenty-five COVID-19 outbreaks were identified in refugee and asylum seeker reception facilities, with 6 (85.7%) of 7 RICs and 18 (56.3%) of 32 RSs reporting at least one outbreak during the study period. The overall 9-month COVID-19 IP among refugee and asylum seeker populations residing in RSs on the Greek mainland was 1758 cases per 100,000 population; in RICs the incidence was 2052 cases per 100,000 population. Compared to the general population the risk of COVID-19 infection among refugees and asylum seekers in reception facilities was 2.5 to 3 times higher (p-value<0.001). The risk of acquiring COVID-19 infection was higher among refugee and asylum seeker populations in RSs on the Greek mainland (IP ratio: 2.45; 95% CI: 2.25À2.68) but higher still among refugee and asylum seeker populations in RICs in the Greek islands and the land border with Turkey (IP ratio: 2.86; 95% CI: 2.64À3.10), where living conditions are particularly poor. Interpretation: We identified high levels of COVID-19 transmission among refugees and asylum seekers in reception facilities in Greece. The risk of COVID-19 infection among these enclosed population groups has been significantly higher than the general population of Greece, and risk increases as living conditions deteriorate. These data have immediate implications for policy and practice. Strategies are now needed to ensure refugee and asylum seeker populations are included in national response plans to reduce transmission in atrisk groups for COVID-19, alongside inclusion in plans for COVID-19 vaccine roll out.
Economic crises carry a substantial impact on population health and health systems, but little is... more Economic crises carry a substantial impact on population health and health systems, but little is known on how these transmit to health workers (HWs). Addressing such a gap is timely as HWs are pivotal resources, particularly during pandemics or the ensuing recessions. Drawing from the empirical literature, we aimed to provide a framework for understanding the impact of recessions on HWs and their reactions. We use a systematic review and best-fit framework synthesis approach to identify the relevant qualitative, quantitative and mixed-methods evidence, and refine an a priori, theory-based conceptual framework. Eight relevant databases were searched, and four reviewers employed to independently review full texts, extract data and appraise the quality of the evidence retrieved. A total of 57 peer reviewed publications were included, referring to six economic recessions. The 2010–15 Great Recession in Europe was the subject of most (52%) of the papers. Our consolidated framework suggests that recessions transmit to HWs through three channels: (1) an increase in the demand for services; (2) the impacts of austerity measures; and (3) changes in the health labour market. Some of the evidence appeared specific to the context of crises; demand for health services and employment increased during economic recessions in North America and Oceania, but stagnated or declined in Europe in connection with the austerity measures adopted. Burn-out, lay-offs, migration and multiple jobholding were the reactions observed in Europe, but job opportunities never dwindled for physicians during recessions in North America, with nurses re-entering labour markets during such crises. Loss of motivation, absenteeism and abuse of health systems were documented during recessions in low-income countries. Although the impacts of recessions may vary across economic events, health systems, labour markets and policy responses, our review and framework provide an evidence base for policies to mitigate the effects on HWs.
Early introduction of social distancing/isolation measures has successfully controlled the first ... more Early introduction of social distancing/isolation measures has successfully controlled the first wave of Covid-19 epidemic in Greece. Immediate decongestion of refugee camps, full integration of refugee care in the national healthcare plan, and effective epidemiological surveillance and contact tracing systems for the entire population are public-health prerequisites for sustaining this success.
Introduction: Fiscal federalism and fiscal decentralization are distinct policy options in public... more Introduction: Fiscal federalism and fiscal decentralization are distinct policy options in public services in general and healthcare in particular, with possibly opposed effects on equity, effectiveness, and efficiency. However, the pertinent discourse often reflects confusion between the concepts or conflation thereof. Methods: This paper performs a narrative review of theoretical literature on decentralization. The study offers clear definitions of the concepts of fiscal federalism and fiscal decentralization and provides an overview of the potential implications of each policy for healthcare systems. Results: The interpretation of the literature identified three different dimensions of decentralization: political, administrative, economic. Economic decentralization can be further implemented through two different policy options: fiscal federalism and fiscal decentralization. Fiscal federalism is the transfer of spending authority of a centrally pooled public health budget to local governments or authorities. Countries like the UK, Cuba, Denmark, and Brazil mostly rely on fiscal federalism mechanisms for healthcare financing. Fiscal decentralization consists of transferring both pooling and spending responsibilities from the central government to local authorities. Contrarily to fiscal federalism, the implementation of fiscal decentralization requires as a precondition the fragmentation of the national pool into many local pools. The restructuring of the pooling system may limit the cross-subsidization effect between high-and low-income groups and areas that a central pool guarantees; thus, severely affecting local equality and equity. With the limited availability of local public resources in poorer regions, the quality of services drops, increasing the disparity gap between areas. Evidence from Italy, Spain, China, and Ivory Coast-countries with a strong fiscal decentralization element in their healthcare services-suggests that fiscal decentralization has positive effects on the infant mortality rate. However, it decreases healthcare resources as well as access to services, fostering spatial inequities. Conclusion: If public resources are and remain adequate, allocation follows equitable criteria, and local communities are involved in the decision-making debate, fiscal federalism-rather than fiscal decentralization-appear to be an adequate policy option to improve the healthcare services and population's health nationwide and achieve health sector economic decentralization. HIPPOKRATIA 2020, 24(3): 107-113.
Introduction During economic recessions, health professionals face reduced income and labour oppo... more Introduction During economic recessions, health professionals face reduced income and labour opportunities, hard conditions often exacerbated by governments’ policy responses to crises. Growing evidence points to non-negligible effects on national health workforces and health systems—decrease in motivation, burnout, migration—arising from the combination of crisis-related factors. However, no theoretical conceptualisation currently exists framing the impacts recessions have on human resources for health (HRH), or on their reactions. Methods and analysis This paper lays out a protocol for a systematic review of the existing qualitative, quantitative and mixed-method evidence on the economic recessions and HRH; results from the review will be used to develop a conceptual framework linking existing theories on recessions, austerity measures, health systems and population health, with a view of informing future health policies. Eight relevant databases within the health, health systems, multidisciplinary and economic literature will be searched, complemented by secondary searches and experts’ input. Eligible studies will present primary quantitative or qualitative evidence on HRH impacts, or original secondary analyses. We will cover the 1970–2019 period—the modern age of global economic recessions— and full texts in English, Spanish, Italian, French, Portuguese or Greek. Two reviewers will independently assess, perform data extraction and conduct quality appraisal of the texts identified. A ‘best-fit’ framework synthesis will be applied to summarise the findings, using an a priori, theoretically driven framework. That preliminary framework was built by the research team to inform the searches, and will be appraised by external experts.
The General Agreement on Trade in Services (GATS), established in 1994, has been a key element of... more The General Agreement on Trade in Services (GATS), established in 1994, has been a key element of market liberalization of health care services. Brazil had the provision of health care services partially protected from international competition until 2015, when a constitutional change opened the national health care market to international provision. We performed a retrospective and prospective policy analysis based on a systematic policy document review, general literature review, and secondary data analysis mapping, describing and analyzing the international trade agreements signed by Brazil with the World Trade Organization (WTO) and the available legislation relevant to health care services. The provision of health care services was not included in the WTO commitments signed by Brazil during the analyzed period (1994-2018). Financing of private health insurance was part of the agreement since 1994. There was a mild liberalization of the private health insurance sector, while provision of health care services was forbidden to foreign investors until 2015. The mode 3 of GATS presents the greatest potential impact as it exposes health care provision to international competition. The international liberalization of the provision of health care services in Brazil
The COVID-19 pandemic revealed and exacerbated the global inequalities regarding the availability... more The COVID-19 pandemic revealed and exacerbated the global inequalities regarding the availability and access to vaccines. Many terms have appeared in the academic literature (“vaccine colonialism,” “vaccine nationalism,” “vaccine apartheid”) trying to capture and interpret these inequalities, failing in most cases to realistically explain the upstream causes of the observed injustices. A Marxist perspective on the contrary emphasizes the structural causes of inequalities in capitalism and attributes them to the existence of economic exploitation. “Vaccine imperialism,” which refers to the control that advanced industrialized countries exert on the development, production, and distribution of vaccines at the expense of less-developed economies, can describe and explain in a more realistic way the observed inequalities during the pandemic. Our study proposes a circuit of vaccine imperialism that explains how economic imperialist exploitation takes place via transfers of value from less-developed economies (vaccine recipient countries) to imperialist economies (vaccine producing and patent holder countries) using four different channels: (a) protection of intellectual property (IP) rights (patents), (b) earnings from royalty payments for the use of vaccines (monopolistic prices and profits), (c) exercise of monopoly power on the production and distribution of vaccines (control over the quantity of vaccines supplied, exclusion of competitors through vaccine licensing), and (d) public debt servicing.
Objectives: Refugees and migrants (R&Ms) exhibited higher risk of COVID-19 infection, and higher ... more Objectives: Refugees and migrants (R&Ms) exhibited higher risk of COVID-19 infection, and higher mortality rates during the pandemic. Acknowledging these risks, R&Ms early in the pandemic were identified by WHO as a priority vaccination group in need of protection. The aim of this study was to assess the vaccination roll-out and uptake among R&Ms residing in Reception Identification Centers (RICs) and Reception Sites (RSs) in Greece, relative to the general population.
Study design: Nationwide observational study.
Methods: Retrospective analysis of national vaccination routine data and population census data, collected and triangulated from multiple official/governmental sources. Weekly vaccine roll-out and uptake were calculated for the general Greek population and the R&M population, through the first year of the vaccination programme in Greece (December 2020–December 2021).
Results: Vaccine roll-out among migrants in RICs/RSs started with a 22-week delay, compared to the general population. By the end of the first year of the vaccination programme in Greece in December 2021, the national vaccination uptake among registered R&Ms residing in official reception facilities was 27.3 % for 1st dose and 4.7 % for booster dose; considerably lower compared to the general population (69.5 % uptake for 1st dose, 64.7 % for 2nd dose, and 32.0 % for 3rd dose).
Conclusion: Delayed vaccine roll-out and low vaccine uptake among R&Ms in Greece are signs of low prioritisation and implementation failures in the R&M vaccination strategy. In face of future public health threats, lessons should be learned, and vaccine equity should be insured for all socially vulnerable and high-risk population groups.
Coverage of migrant and refugee data is incomplete and of insufficient quality in European health... more Coverage of migrant and refugee data is incomplete and of insufficient quality in European health information systems. This is not because we lack the knowledge or technology. Rather, it is due to various political factors at local, national and European levels, which hinder the implementation of existing knowledge and guidelines. This reflects the low political priority given to the topic, and also complex governance challenges associated with migration and displacement. We review recent evidence, guidelines, and policies to propose four approaches that will advance science, policy, and practice. First, we call for strategies that ensure that data is collected, analyzed and disseminated systematically. Second, we propose methods to safeguard privacy while combining data from multiple sources. Third, we set out how to enable survey methods that take account of the groups' diversity. Fourth, we emphasize the need to engage migrants and refugees in decisions about their own health data. Based on these approaches, we propose a change management approach that narrows the gap between knowledge and action to create healthcare policies and practices that are truly inclusive of migrants and refugees. We thereby offer an agenda that will better serve public health needs, including those of migrants and refugees and advance equity in European health systems.
Η επιδημική ετοιμότητα, η ικανότητα δηλαδή πρόληψης, ελέγχου και αντιμετώπισης των επιδημικών απε... more Η επιδημική ετοιμότητα, η ικανότητα δηλαδή πρόληψης, ελέγχου και αντιμετώπισης των επιδημικών απειλών, για πολλά έτη παρέμενε έννοια λησμονημένη και μη συνδεδεμένη με τον στρατηγικό σχεδιασμό και την άσκηση πολιτικής στον χώρο της υγείας. Ακρογωνιαίος λίθος της επιδημικής ετοιμότητας είναι η ετοιμότητα των υπηρεσιών δημόσιας υγείας, η οποία με τη σειρά της περιλαμβάνει την ικανότητα έγκαιρης προειδοποίησης και αποτελεσματικού ελέγχου της διασυνοριακής μετάδοσης των λοιμωδών νοσημάτων, την ικανότητα σχεδιασμού και υλοποίησης στοχευμένων, αναλογικών μη φαρμακευτικών παρεμβάσεων για τον έλεγχο της διασποράς των λοιμωδών νοσημάτων, την επιδημιολογική επιτήρηση, τη διαφανή διαχείριση των επιδημιολογικών δεδομένων, την επιστημονική συνέπεια και τη λογοδοσία των φορέων δημόσιας υγείας. Η πανδημία COVID-19 ανέδειξε, τόσο σε εθνικό όσο και σε υπερεθνικό επίπεδο, τα σοβαρά κενά και τις συστημικές ανεπάρκειες σε όλους τους παραπάνω κρίκους της επιδημικής ετοιμότητας. Οι σύγχρονες και μελλοντικές απειλές της δημόσιας υγείας δεν αφήνουν περιθώρια εφησυχασμού και επιβάλλουν τον ριζικό ανασχεδιασμό των υπηρεσιών δημόσιας υγείας με έμφαση στην οργανική διασύνδεσή τους με συστήματα ολοκληρωμένης πρωτοβάθμιας φροντίδας υγείας και την ενίσχυσή τους με όλους τους αναγκαίους δημόσιους χρηματοδοτικούς πόρους, τις υποδομές και το ανθρώπινο δυναμικό.
International Journal of Health Policy and Management, 2023
Decentralisation is a key element of any healthcare reform that aims to strengthen local healthca... more Decentralisation is a key element of any healthcare reform that aims to strengthen local healthcare systems and make them more responsive to local health and healthcare needs. In this sense the question in policy debate is not whether to decentralise in general or not, but what functions to decentralise and how. Under certain circumstances, decentralising administrative, political, and/or healthcare expenditure powers to subnational authorities can increase local effectiveness. On the contrary decentralising healthcare revenue powers to subnational localities entails too many risks and dangers as theory, pre-pandemic empirical evidence, and the COVID-19 experience in fiscally decentralised health systems actually suggest.
Even in capitalism, redistribution of income and wealth has historically been (under welfarism) and should remain a responsibility of the central, rather than the local, state. Centralised pooling of resources and centralised resource allocation to regions might not be sufficient (depending on tax progressivity and resource allocation equalizers) but are necessary conditions for any meaningful attempt to redistribute income and wealth among individuals and across jurisdictions. Accordingly, rejecting fiscal decentralisation might not be a sufficient option to heal inequities and healthcare deficiencies, but it is a necessary condition for any attempt towards that direction.
International Journal of Social Determinants of Health and Health Services, 2023
The COVID-19 pandemic necessitated the mobilization of all available health care resources, inclu... more The COVID-19 pandemic necessitated the mobilization of all available health care resources, including private, for-profit ones. The aim of this multiple methods study (combination of document and secondary data analysis) was to assess government regulations facilitating the private health sector's participation in the COVID-19 response in Greece.
During the pandemic, the government made three successive increases in private providers’ reimbursement fees, provided additional financial incentives to private providers, and allocated €280 million of emergency funding for the private sector's involvement in the national COVID-19 response. In response, private hospitals made available on average 2.2% of their total bed capacity per epidemic wave for the treatment of COVID-19 patients and 1.7% of their total bed capacity for the treatment of non-COVID-19 patients transferred from National Health System (NHS) hospitals. In 2020 the five largest health care corporate groups maintained their revenues, while in 2021 they increased them by 18.7%—a striking comparison with the 9% recession experienced by the Greek economy in 2020 and its 8.4% recovery in 2021.
In a time of an acute public health crisis, private health care providers responded to society's pressing health care needs by insulating their facilities from COVID-19 patients and NHS patient transfers, minimizing their social contribution and safeguarding their revenues and profits.
What has become increasingly apparent during this pandemic is the inverse care law defined by J T... more What has become increasingly apparent during this pandemic is the inverse care law defined by J T Hart in 1971 as the observation that “the availability of good medical care tends to be inversely associated with the need of it in the population served”. In other words, health and social systems in general tend to provide fewer services and of inferior quality to those who need them most, and more services and of superior quality to those who need them less. Enough evidence exists to suggest that refugees and asylum seekers were at increased risk of developing COVID-19 during the pandemic mainly due to their overcrowded living conditions both in camps and in the community. Moreover, they were disproportionately represented in reported COVID-19 deaths. Yet, despite their increased need for protection and increased risk of infection, refugees and asylum seekers in many countries were excluded from national vaccination plans, and if included they were not prioritized.
Data transparency has played a key role in this pandemic. The aim of this paper is to map COVID-1... more Data transparency has played a key role in this pandemic. The aim of this paper is to map COVID-19 data availability and accessibility, and to rate their transparency and credibility in selected countries, by the source of information. This is used to identify knowledge gaps, and to analyse policy implications. The availability of a number of COVID-19 metrics (incidence, mortality, number of people tested, test positive rate, number of patients hospitalised, number of patients discharged, the proportion of population who received at least one vaccine, the proportion of population fully vaccinated) was ascertained from selected countries for the full population, and for few of stratification variables (age, sex, ethnicity, socioeconomic status) and subgroups (residents in nursing homes, inmates, students, healthcare and social workers, and residents in refugee camps). Nine countries were included: Bangladesh, Indonesia, Iran, Nigeria, Turkey, Panama, Greece, the UK, and the Netherlands. All countries reported periodically most of COVID-19 metrics on the total population. Data were more frequently broken down by age, sex, and region than by ethnic group or socio-economic status. Data on COVID-19 is partially available for special groups. This exercise highlighted the importance of a transparent and detailed reporting of COVID-19 related variables. The more data is publicly available the more transparency, accountability, and democratisation of the research process is enabled, allowing a sound evidence-based analysis of the consequences of health policies.
International Journal of Health Policy and Management, 2022
Background: Fiscal decentralisation (FD) is a widely implemented decentralisation policy consisti... more Background: Fiscal decentralisation (FD) is a widely implemented decentralisation policy consisting of the allocation of pooling and spending responsibilities from the central government to lower levels of governance within a country. In 2001, The Italian National Health System (Servizio Sanitario Nazionale, SSN) has introduced a strong element of FD, making regions responsible for their own pooling of resources and for their budgets. Despite the relevance, only few studies exist on health sector-FD in Italy, mostly looking at the effects of FD on infant mortality. Methods: This study performs a fixed-effects panel data analysis of Italian Regions and Autonomous provinces between the years 2001 and 2017, to investigate the effects of health sector-FD on availability, accessibility, and utilisation of healthcare services in Italy. Results: FD decreases availability of staff and hospital beds, decreases utilisation of care, measured by hospitalisation rates, and increases interregional patients' mobility for healthcare purposes, a finding suggesting increased disparities in access to healthcare. These effects seem to be stronger for public-rather than private-services, and are more prominent in poorer areas. Conclusion: This evidence suggest that FD has created a fragmented and unequal healthcare system, in which levels of availability, utilisation of, and accessibility to resources-as well as the extent of public sector's retrenchment-coincide with the wealth of the area.
Objectives: Refugees, asylum seekers, and undocumented migrants globally have been disproportiona... more Objectives: Refugees, asylum seekers, and undocumented migrants globally have been disproportionally impacted by COVID-19. Vaccination has been a major tool to reduce disease impact, yet concerns exist regarding equitable allocation and uptake. Methods: A rapid literature review was conducted based on PRISMA guidelines to determine COVID-19 vaccination acceptance rates and level of access for these population groups globally. Results: Relatively high COVID-19 vaccine acceptance levels were commonly reported in these populations, although, trust in host governments was a frequently expressed concern, especially for undocumented migrants. Outreach efforts and access to comprehensive information from a trusted source and in appropriate language were found to be major determinants of COVID-19 vaccine acceptance. COVID-19 vaccination access and policies varied considerably across host countries despite urgings by international organizations to include migrants and refugees. While most governments endorsed inclusive policies, evidence of successful program implementation was frequently lacking, creating difficulty to better tailor and implement COVID-19 outreach programs. Conclusion: This review identifies impactful improvements to be implemented to ensure equitable COVID-19 vaccinations and to reduce disease burden on refugees, asylum seekers, and undocumented migrants.
Comparison of COVID-19 trends in space and over time is essential to monitor the pandemic and to ... more Comparison of COVID-19 trends in space and over time is essential to monitor the pandemic and to indirectly evaluate non-pharmacological policies aimed at reducing the burden of disease. Given the specific age-and sex-distribution of COVID-19 mortality, the underlying sex-and age-distribution of populations need to be accounted for. The aim of this paper is to present a method for monitoring trends of COVID-19 using adjusted mortality trend ratios (AMTRs). Age-and sex-mortality distribution of a reference European population (N = 14,086) was used to calculate age-and sex-specific mortality rates. These were applied to each country to calculate the expected deaths. Adjusted Mortality Trend Ratios (AMTRs) with 95% confidence intervals (C.I.) were calculated for selected European countries on a daily basis from 17th March 2020 to 29th April 2021 by dividing observed cumulative mortality, by expected mortality, times the crude mortality of the reference population. These estimated the sex-and age-adjusted mortality for COVID-19 per million population in each country. United Kingdom experienced the highest number of COVID-19 related death in Europe. Crude mortality rates were highest Hungary, Czech Republic, and Luxembourg. Accounting for the age-and sex-distribution of the underlying populations with AMTRs for each European country, four different patterns were identified: countries which experienced a two-wave pandemic, countries with almost undetectable first wave, but with either a fast or a slow increase of mortality during the second wave; countries with consistently low rates throughout the period. AMTRs were highest in Eastern European countries (Hungary, Czech Republic, Slovakia, and Poland). Our methods allow a fair comparison of mortality in space and over time. These might be of use to indirectly estimating the efficacy of nonpharmacological health policies. The authors urge the World Health Organisation, given the absence of age and sex-specific mortality data for direct standardisation, to adopt this method to estimate the comparative mortality from COVID-19 pandemic worldwide.
Ο εξευρωπαϊσμός, η διαδικασία δηλαδή διαμόρφωσης και μεταφοράς πολιτικών της Ευρωπαϊκής Ένωσης (Ε... more Ο εξευρωπαϊσμός, η διαδικασία δηλαδή διαμόρφωσης και μεταφοράς πολιτικών της Ευρωπαϊκής Ένωσης (ΕΕ) στα κράτη μέλη, είναι έννοια επίκαιρη, αφορώντας ολοένα και περισσότερα πεδία άσκησης πολιτικής. Σκοπός του άρθρου είναι η διερεύνηση της έκτασης και έντασης του εξευρωπαϊσμού στο πεδίο της πολιτικής υγείας και η δημιουργία ενός θεωρητικού, ταξινομητικού πλαισίου των μηχανισμών μέσω των οποίων αυτός συντελείται. Τα αποτελέσματα της μελέτης δείχνουν, πρώτον, ότι ο εξευρωπαϊσμός στο πεδίο της πολιτικής υγείας ως θεσμική πρακτική υφίσταται και συνεχώς διευρύνεται και, δεύτερον, ότι, ενώ πριν την εκδήλωση της οικονομικής κρίσης επιλέγονταν κύρια οριζόντιοι μη υποχρεωτικοί μηχανισμοί εξευρωπαϊσμού, κατά την περίοδο της κρίσης παρατηρείται μετακίνηση σε κάθετους υποχρεωτικούς μηχανισμούς, που αυξάνουν την ένταση των παρεμβάσεων της ΕΕ στο χώρο της υγείας.
Objectives: Ensuring access to care for all patients - especially those with life threatening and... more Objectives: Ensuring access to care for all patients - especially those with life threatening and chronic conditions - during a pandemic is a challenge for all healthcare systems. During the COVID-19 pandemic many countries faced excess mortality partly attributed to disruptions in essential healthcare services provision. This study aimed to estimate the utilization of public primary care and hospital services during the COVID-19 epidemic in Greece and its potential association with excess non-COVID-19 mortality in the country.
Study design: Observational study
Methods: Retrospective analysis of national secondary utilization and mortality data from multiple official sources, covering the first nine months of the COVID-19 epidemic in Greece (February 26th to November 30th, 2020).
Results: Utilization rates of all public healthcare services during the first nine months of the epidemic dropped significantly compared to the average utilization rates of the 2017-19 control period; hospital admissions, hospital surgical procedures and primary care visits dropped by 17.3% (95% CI: 6.6%-28.0%), 23.1% (95% CI: 7.3%-38.9%), and 24.8% (95% CI: 13.3%-36.3%) respectively. This underutilization of essential public services – mainly due to supply restrictions such as suspension of outpatient care and cancelation of elective surgeries - is most probably related to the 3,778 excess non-COVID-19 deaths (representing 62% of all-cause excess deaths) that have been reported during the first 9 months of the epidemic in the country.
Conclusions: Greece’s healthcare system, deeply wounded by the 2008-18 recession and austerity, was ill resourced to cope with the challenge of the COVID-19 epidemic. Early and prolonged lockdowns have kept COVID-19 infections and deaths at relative low levels. However, this “success” seems to have been accomplished at the expense of non-COVID-19 patients. It is important to acknowledge the “hidden epidemic” of unmet non-COVID-19 needs and increased non-COVID-19 deaths in the country and urgently strengthen public healthcare services to address it.
Greece recently faced a severe second COVID-19 wave. Despite having enough time to prepare due to... more Greece recently faced a severe second COVID-19 wave. Despite having enough time to prepare due to the few cases until June, and ignoring early calls for urgent investment on epidemiological surveillance and transparency, the system is still failing to collect adequate data and even report minimum indicators. These serious data gaps are not unique in Europe and are mostly related to the lack of prioritization and under-investment in local public health surveillance systems. Given the time needed in order to achieve herd immunity through vaccination, immediate investment in comprehensive epidemiological surveillance is the only way to maintain reduced levels of transmission and avoid resurgences.
Background: Migrants globally, including refugees and asylum seekers, have experienced adverse cl... more Background: Migrants globally, including refugees and asylum seekers, have experienced adverse clinical and socioeconomic impacts of the COVID-19 pandemic. For approximately 56,000 refugees and asylum seekers in Reception and Identification Centers (RICs) and Reception Sites (RS) in Greece, living in severely substandard living conditions, prevention measures have been impossible with limited provision in terms of routine testing, surveillance, and access to healthcare. These migrant populations have experienced prolonged lockdowns and restricted movement since the pandemic began. We aimed to assess the impact of COVID-19 on refugees and asylum seekers in reception facilities in Greece and explore implications for policy and practice. Methods: A retrospective analysis of policy documents and national surveillance data was conducted to identify COVID-19 outbreaks and estimate incidence among asylum seekers and refugees residing in these camps during the first 9 months of the epidemic in Greece (26th February À 15th November 2020). Incidence proportion (IP) of COVID-19 confirmed cases was calculated for three population groups (refugees and asylum seekers in RICs, refugees and asylum seekers in RSs, and the general population in Greece) during three time periods (first wave, second wave, and overall across the 9-month period). Findings: Twenty-five COVID-19 outbreaks were identified in refugee and asylum seeker reception facilities, with 6 (85.7%) of 7 RICs and 18 (56.3%) of 32 RSs reporting at least one outbreak during the study period. The overall 9-month COVID-19 IP among refugee and asylum seeker populations residing in RSs on the Greek mainland was 1758 cases per 100,000 population; in RICs the incidence was 2052 cases per 100,000 population. Compared to the general population the risk of COVID-19 infection among refugees and asylum seekers in reception facilities was 2.5 to 3 times higher (p-value<0.001). The risk of acquiring COVID-19 infection was higher among refugee and asylum seeker populations in RSs on the Greek mainland (IP ratio: 2.45; 95% CI: 2.25À2.68) but higher still among refugee and asylum seeker populations in RICs in the Greek islands and the land border with Turkey (IP ratio: 2.86; 95% CI: 2.64À3.10), where living conditions are particularly poor. Interpretation: We identified high levels of COVID-19 transmission among refugees and asylum seekers in reception facilities in Greece. The risk of COVID-19 infection among these enclosed population groups has been significantly higher than the general population of Greece, and risk increases as living conditions deteriorate. These data have immediate implications for policy and practice. Strategies are now needed to ensure refugee and asylum seeker populations are included in national response plans to reduce transmission in atrisk groups for COVID-19, alongside inclusion in plans for COVID-19 vaccine roll out.
Economic crises carry a substantial impact on population health and health systems, but little is... more Economic crises carry a substantial impact on population health and health systems, but little is known on how these transmit to health workers (HWs). Addressing such a gap is timely as HWs are pivotal resources, particularly during pandemics or the ensuing recessions. Drawing from the empirical literature, we aimed to provide a framework for understanding the impact of recessions on HWs and their reactions. We use a systematic review and best-fit framework synthesis approach to identify the relevant qualitative, quantitative and mixed-methods evidence, and refine an a priori, theory-based conceptual framework. Eight relevant databases were searched, and four reviewers employed to independently review full texts, extract data and appraise the quality of the evidence retrieved. A total of 57 peer reviewed publications were included, referring to six economic recessions. The 2010–15 Great Recession in Europe was the subject of most (52%) of the papers. Our consolidated framework suggests that recessions transmit to HWs through three channels: (1) an increase in the demand for services; (2) the impacts of austerity measures; and (3) changes in the health labour market. Some of the evidence appeared specific to the context of crises; demand for health services and employment increased during economic recessions in North America and Oceania, but stagnated or declined in Europe in connection with the austerity measures adopted. Burn-out, lay-offs, migration and multiple jobholding were the reactions observed in Europe, but job opportunities never dwindled for physicians during recessions in North America, with nurses re-entering labour markets during such crises. Loss of motivation, absenteeism and abuse of health systems were documented during recessions in low-income countries. Although the impacts of recessions may vary across economic events, health systems, labour markets and policy responses, our review and framework provide an evidence base for policies to mitigate the effects on HWs.
Early introduction of social distancing/isolation measures has successfully controlled the first ... more Early introduction of social distancing/isolation measures has successfully controlled the first wave of Covid-19 epidemic in Greece. Immediate decongestion of refugee camps, full integration of refugee care in the national healthcare plan, and effective epidemiological surveillance and contact tracing systems for the entire population are public-health prerequisites for sustaining this success.
Introduction: Fiscal federalism and fiscal decentralization are distinct policy options in public... more Introduction: Fiscal federalism and fiscal decentralization are distinct policy options in public services in general and healthcare in particular, with possibly opposed effects on equity, effectiveness, and efficiency. However, the pertinent discourse often reflects confusion between the concepts or conflation thereof. Methods: This paper performs a narrative review of theoretical literature on decentralization. The study offers clear definitions of the concepts of fiscal federalism and fiscal decentralization and provides an overview of the potential implications of each policy for healthcare systems. Results: The interpretation of the literature identified three different dimensions of decentralization: political, administrative, economic. Economic decentralization can be further implemented through two different policy options: fiscal federalism and fiscal decentralization. Fiscal federalism is the transfer of spending authority of a centrally pooled public health budget to local governments or authorities. Countries like the UK, Cuba, Denmark, and Brazil mostly rely on fiscal federalism mechanisms for healthcare financing. Fiscal decentralization consists of transferring both pooling and spending responsibilities from the central government to local authorities. Contrarily to fiscal federalism, the implementation of fiscal decentralization requires as a precondition the fragmentation of the national pool into many local pools. The restructuring of the pooling system may limit the cross-subsidization effect between high-and low-income groups and areas that a central pool guarantees; thus, severely affecting local equality and equity. With the limited availability of local public resources in poorer regions, the quality of services drops, increasing the disparity gap between areas. Evidence from Italy, Spain, China, and Ivory Coast-countries with a strong fiscal decentralization element in their healthcare services-suggests that fiscal decentralization has positive effects on the infant mortality rate. However, it decreases healthcare resources as well as access to services, fostering spatial inequities. Conclusion: If public resources are and remain adequate, allocation follows equitable criteria, and local communities are involved in the decision-making debate, fiscal federalism-rather than fiscal decentralization-appear to be an adequate policy option to improve the healthcare services and population's health nationwide and achieve health sector economic decentralization. HIPPOKRATIA 2020, 24(3): 107-113.
Introduction During economic recessions, health professionals face reduced income and labour oppo... more Introduction During economic recessions, health professionals face reduced income and labour opportunities, hard conditions often exacerbated by governments’ policy responses to crises. Growing evidence points to non-negligible effects on national health workforces and health systems—decrease in motivation, burnout, migration—arising from the combination of crisis-related factors. However, no theoretical conceptualisation currently exists framing the impacts recessions have on human resources for health (HRH), or on their reactions. Methods and analysis This paper lays out a protocol for a systematic review of the existing qualitative, quantitative and mixed-method evidence on the economic recessions and HRH; results from the review will be used to develop a conceptual framework linking existing theories on recessions, austerity measures, health systems and population health, with a view of informing future health policies. Eight relevant databases within the health, health systems, multidisciplinary and economic literature will be searched, complemented by secondary searches and experts’ input. Eligible studies will present primary quantitative or qualitative evidence on HRH impacts, or original secondary analyses. We will cover the 1970–2019 period—the modern age of global economic recessions— and full texts in English, Spanish, Italian, French, Portuguese or Greek. Two reviewers will independently assess, perform data extraction and conduct quality appraisal of the texts identified. A ‘best-fit’ framework synthesis will be applied to summarise the findings, using an a priori, theoretically driven framework. That preliminary framework was built by the research team to inform the searches, and will be appraised by external experts.
The General Agreement on Trade in Services (GATS), established in 1994, has been a key element of... more The General Agreement on Trade in Services (GATS), established in 1994, has been a key element of market liberalization of health care services. Brazil had the provision of health care services partially protected from international competition until 2015, when a constitutional change opened the national health care market to international provision. We performed a retrospective and prospective policy analysis based on a systematic policy document review, general literature review, and secondary data analysis mapping, describing and analyzing the international trade agreements signed by Brazil with the World Trade Organization (WTO) and the available legislation relevant to health care services. The provision of health care services was not included in the WTO commitments signed by Brazil during the analyzed period (1994-2018). Financing of private health insurance was part of the agreement since 1994. There was a mild liberalization of the private health insurance sector, while provision of health care services was forbidden to foreign investors until 2015. The mode 3 of GATS presents the greatest potential impact as it exposes health care provision to international competition. The international liberalization of the provision of health care services in Brazil
Η ανεργία, η εργασιακή επισφάλεια, η εντατικοποίηση της εργασίας με την τηλεργασία, η φτώχεια, η ... more Η ανεργία, η εργασιακή επισφάλεια, η εντατικοποίηση της εργασίας με την τηλεργασία, η φτώχεια, η οικιστική ανασφάλεια που έχει προκαλέσει η πανδημία διευρύνουν με δραματικό ρυθμό τις κοινωνικές ανισότητες, οι οποίες με τη σειρά τους προσδιορίζουν και τη διεύρυνση των ανισοτήτων στην υγεία. Αυτός ο φαύλος κύκλος κατασπατάλησης της υγείας των χαμηλότερων κοινωνικών τάξεων, του μεγαλύτερου δηλαδή μέρους του πληθυσμού, δεν πρόκειται να σταματήσει από μόνος του. Αντιθέτως, η αδηφάγα κερδοσκοπία χρησιμοποιεί ως ευκαιριακό εργαλείο την πανδημία, με στόχο την περαιτέρω απορρύθμιση της εργασίας και την αποδιάρθρωση δημόσιων δομών φροντίδας της υγείας και κοινωνικής πρόνοιας. Η πραγματικότητα αυτή καταδεικνύει την αναγκαιότητα να ενδυναμωθεί και αναπτυχθεί περαιτέρω η έρευνα στο πεδίο των ανισοτήτων στην υγεία κατά την περίοδο της πανδημίας COVID-19.
Our analysis indicates that health care system in Greece shows many crisis symptoms, such as: (a)... more Our analysis indicates that health care system in Greece shows many crisis symptoms, such as: (a) poor satisfaction rates with the overall performance of health care services in the country, due mainly to access and accommodation problems of public services (b) rising health care inequalities due to high rates of indirect taxes, out of pocket payments and unequal social security contributions and benefits (c) and a flourishing private for – profit health care market with high profit rates. Surprisingly, many of these symptoms fit to the recently identified, in the case of developing countries, “mixed health systems syndrome”. A situation where health systems of public/private mix show poor performance, as indicated from their poor responsiveness, failure to achieve fairness in financing and inability to achieve equity in outcomes. The Greek experience shows that, at least in the case of a developed country with a semi – dependent role within the international economic environment, such symptoms of severe malfunction that compose the “mixed health system syndrome”, can occur when an underdeveloped public health sector is pushed towards privatization and marketization, while at the same time private for – profit providers are left unregulated.
International Association of Health Policy Europe (IAHPE), 2007
This analysis of the development characteristics of the PFP health providers indicates that p... more This analysis of the development characteristics of the PFP health providers indicates that private sector in Greece was literally sponsored by the governments policies. The legislative oversight and facilitation, the absence of state control on the type, quantity and quality of health care services provided by the private sector, the contracting policy of public sickness funds which offers a guaranteed income to the sectors enterprises, indicate the attachment of both social-democratic and conservative governments to the ensuring and promoting of corporate interests in the health care sector in Greece. Additionally, the policies of underfunding the public sector, the fragmentation of social insurance and public health services, the lack of an organized public primary health care, policies of understaffing (especially with nurses), the informal payments and the shortage of medical equipment and accommodation in public hospitals (aspects not thoroughly discussed in this paper, as they exceed the scope and limits of our analysis) created an environment of imposed failings and dissatisfaction for the public health sector, leading to an increased demand for private health services.
Our analysis shows that privatisation of health care in Greece was and still is a deliberate policy choice rather than a spontaneous reaction of the private health industry to the inborn inabilities of the public health sector.
Στόχος της έκδοσης είναι, έναν χρόνο μετά την εμφάνιση της πανδημίας, να αποτελέσει μια πρώτη προ... more Στόχος της έκδοσης είναι, έναν χρόνο μετά την εμφάνιση της πανδημίας, να αποτελέσει μια πρώτη προσπάθεια αποτίμησης αυτής της σύγχρονης παγκόσμιας περιπέτειας. Η κριτική ανάλυση των αιτίων της πανδημίας, η επιδημιολογική αποτίμηση της εξέλιξής της, η περιγραφή της αντιμετώπισής της ως πρωταρχικού κινδύνου της δημόσιας υγείας, η πολιτική ελέγχου της διασποράς του ιού, η διαχείριση της νοσηρότητας και της περίθαλψης των κρουσμάτων και γενικά η πολιτική υγείας για την αντιμετώπισή της αποτελούν σημαντικά πεδία της έρευνας.
Η διεπιστημονική προσέγγιση που επιχειρείται σε αυτήν τη συλλογική εργασία φιλοδοξεί, με δεδομένους βέβαια τους περιορισμούς εξαιτίας της δυναμικής εξέλιξης της πραγματικότητας, να συμβάλει στην περαιτέρω ανάλυση και εμβάθυνση του ρόλου της πανδημίας στη διεύρυνση των κοινωνικοοικονομικών ανισοτήτων στην υγεία καθώς και στα αναγκαία μέτρα για την αντιμετώπισή τους υπέρ του κόσμου της εργασίας.
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Valentina Gallo, Howard Waitzkin, Απόστολος Βεΐζης, Δημήτρης Κιβωτίδης, Ηλίας Κονδύλης, Χρήστος Λάσκος, Έφη Μακρίδου, Σταύρος Μαυρουδέας, Αλέξης Μπένος, Δημήτρης Παπαμιχαήλ, Χριστίνα Παρασκευοπούλου, Μαρία Πετμεζίδου, Μιχάλης Πουλημάς, Στέργιος Σερέτης, Φίλιππος Ταραντίλης
ΚΕΠΥ - Κέντρο Έρευνας και Εκπαίδευσης στη Δημόσια Υγεία, την Πολιτική Υγείας και την Πρωτοβάθμια Φροντίδα Υγείας, 2024
Κατά τη χρονική περίοδο 2020-23 τα χαμένα χειρουργεία στα νοσοκομεία του ΕΣΥ, υπολογίζονται σε 36... more Κατά τη χρονική περίοδο 2020-23 τα χαμένα χειρουργεία στα νοσοκομεία του ΕΣΥ, υπολογίζονται σε 360.000 έως 540.000 χαμένες χειρουργικές επεμβάσεις ανάλογα με το μέτρο σύγκρισης, ανάλογα δηλαδή με το αν συγκρίνει κανείς με τα επίπεδα των χειρουργικών επεμβάσεων του 2019 προ πανδημίας ή τα επίπεδα χειρουργικών επεμβάσεων της πενταετίας 2014-19 επίσης προ πανδημίας. Η μειωμένη αυτή χειρουργική δραστηριότητα των τελευταίων τεσσάρων ετών στα νοσοκομεία του ΕΣΥ, πέραν των σημαντικών και αποδεδειγμένων αρνητικών επιπτώσεων στην υγεία του πληθυσμού, έχει οδηγήσει στη συσσώρευση πλήθους χειρουργικών περιστατικών στις λίστες αναμονής για χειρουργεία και στην εκτίναξη των χρόνων αναμονής για αναγκαίες χειρουργικές επεμβάσεις. Τα 34.000 «δωρεάν», χρηματοδοτούμενα από το Ταμείο Ανάκαμψης και Ανθεκτικότητας, απογευματινά χειρουργεία στα νοσοκομεία του ΕΣΥ και τις ιδιωτικές κλινικές το 2025, πέραν του ότι αποτελούν σταγόνα στο ωκεανό των εκατοντάδων χιλιάδων χαμένων χειρουργείων της τελευταίας 4ετίας, δεν έχουν επενδυτικό χαρακτήρα, δεν δημιουργούν δηλαδή τις αναγκαίες προϋποθέσεις σε υλικές υποδομές και ανθρώπινο δυναμικό για την μακρόπνοη αντιμετώπιση του χρόνιου προβλήματος των αναμονών για χειρουργικές επεμβάσεις στη χώρα μας.
ΚΕΠΥ - Κέντρο Έρευνας και Εκπαίδευσης στη Δημόσια Υγεία, την Πολιτική Υγείας και την Πρωτοβάθμια Φροντίδα Υγείας, 2024
Τα στοιχεία που παρουσιάζονται στο παρόν Συνοπτικό Στατιστικό Δελτίο (Data Brief) του ΚΕΠΥ περιγρ... more Τα στοιχεία που παρουσιάζονται στο παρόν Συνοπτικό Στατιστικό Δελτίο (Data Brief) του ΚΕΠΥ περιγράφουν την πορεία υποβάθμισης των υλικών όρων που εξασφαλίζουν την καλή λειτουργία και αναπαραγωγή της δημόσιας Ανώτατης Εκπαίδευσης, ώστε να διευκολυνθεί η ιδιωτικοποίησή της, αναδεικνύοντας τη χρόνια υποστελέχωση των δημόσιων πανεπιστημίων, την πολυετή χρηματοδοτική τους εγκατάλειψη, την μετακύλιση του βάρους της χρηματοδότησης της τριτοβάθμιας εκπαίδευσης στα νοικοκυριά -γεγονός που επιβαρύνει δυσανάλογα τις χαμηλές εισοδηματικές τάξεις- και την πολυετή προσπάθεια δημιουργίας μιας κερδοφόρας αγοράς, αρχικά, στον κλάδο της μεταλυκειακής και, τώρα, της ανώτατης εκπαίδευσης, η οποία θα λειτουργεί σε ένα ενιαίο πλαίσιο ανταγωνισμού με τα εμπορευματοποιημένα δημόσια πανεπιστήμια. Η παρούσα έκδοση του ΚΕΠΥ φιλοδοξεί να αναδείξει την επείγουσα ανάγκη για αντιστροφή αυτής της πορείας ιδιωτικοποίησης της ανώτατης εκπαίδευσης στην Ελλάδα, τόσο διά της εγκατάλειψης των όποιων σχεδιασμών για παράκαμψη/κατάργηση του άρθρου 16 του Συντάγματος όσο και διά της αποκατάστασης του κοινωνικού χαρακτήρα της ανώτατης εκπαίδευσης, μέσω της αποκατάστασης της δημοκρατικής λειτουργίας και του δωρεάν χαρακτήρα των δημόσιων ΑΕΙ και της ολόπλευρης ενίσχυσής τους σε ανθρώπινο δυναμικό και χρηματοδοτικούς πόρους.
Όπως αποδεικνύει η εν λόγω έκθεση, οι πολιτικές λιτότητας που επιβλήθηκαν την περίοδο της οικονομ... more Όπως αποδεικνύει η εν λόγω έκθεση, οι πολιτικές λιτότητας που επιβλήθηκαν την περίοδο της οικονομικής κρίσης είχαν μια καταστροφική επίδραση στη στελέχωση των νοσοκομειακών υπηρεσιών του ΕΣΥ με συνολική απώλεια της τάξης των 19.000 εργαζομένων. Είναι εξίσου εντυπωσιακό ότι παρά τη δημοσιονομική χαλάρωση και κυρίως την έλευση της πανδημίας το μεγαλύτερο μέρος αυτής της απώλειας είναι υπαρκτό και σήμερα, ενώ οι όποιες κινήσεις αποκατάστασης των κενών έγιναν με επικουρικό προσωπικό. Παράλληλα, η γήρανση των εργαζομένων με μόνιμη απασχόληση, χωρίς αυτόματη αναπλήρωση των αποχωρήσεων, οδηγεί με συνέπεια στην οριστική αποδιάρθρωση των νοσοκομειακών υπηρεσιών του ΕΣΥ. Για την άμεση ανακούφιση των νοσοκομείων του ΕΣΥ απαιτείται η πλήρης αποκατάσταση καταρχήν των απωλειών της οικονομικής κρίσης σε ανθρώπινο δυναμικό, με προσλήψεις τουλάχιστον 15.000 υγειονομικών, πέραν των ετήσιων προσλήψεων προς αντικατάσταση των αποχωρήσεων λόγω συνταξιοδότησης ή άλλων λόγων. Απαιτείται επίσης η μονιμοποίηση των 11.000 επικουρικών εργαζομένων στα νοσοκομεία του ΕΣΥ σήμερα και η αποκατάσταση της πλήρους και αποκλειστικής απασχόλησης στο σύνολο του προσωπικού.
Κέντρο Έρευνας και Εκπαίδευσης στη Δημόσια Υγεία, την Πολιτική Υγείας και την Πρωτοβάθμια Φροντίδα Υγείας - ΚΕΠΥ, 2022
Η παρακολούθηση της επιδημίας COVID-19 στα Ανώτατα Εκπαιδευτικά Ιδρύματα, ιδίως τους τελευταίους ... more Η παρακολούθηση της επιδημίας COVID-19 στα Ανώτατα Εκπαιδευτικά Ιδρύματα, ιδίως τους τελευταίους τρεις μήνες της επαναλειτουργίας τους με φυσική παρουσία διδασκόντων και διδασκομένων σε συνθήκες μάλιστα εκτεταμένης διασποράς του SARS-CoV2 στην κοινότητα, προσφέρει μία ευκαιρία για άντληση χρήσιμων διδαγμάτων σχετικά με τη διαχείριση της επιδημίας στη χώρα μας και τη χάραξη πολιτικών δημόσιας υγείας για το αμέσως προσεχές διάστημα. Προϋπόθεση βέβαια για μία τέτοια άσκηση αποτελούν η υψηλή προτεραιοποίηση της προστασίας της δημόσιας υγείας έναντι οικονομικών ή άλλων συμφερόντων, η επάρκεια, αξιοπιστία και διαφάνεια των επιδημιολογικών δεδομένων και η ειλικρινής διάθεση για διαρκή βελτίωση της επιδημικής ετοιμότητας και υγειονομικής θωράκισης της χώρας έναντι των τρεχόντων ή μελλοντικών απειλών δημόσιας υγείας, προϋποθέσεις οι οποίες δεν μοιάζει να συντρέχουν, τουλάχιστον σε επαρκή βαθμό, στη χώρα μας. Το παρόν συνοπτικό σημείωμα επιχειρεί να αναλύσει την εξέλιξη της επιδημίας COVID-19 στο Αριστοτέλειο Πανεπιστήμιο Θεσσαλονίκης (ΑΠΘ), το οποίο λόγω του μεγέθους του αποτελεί ικανό δείγμα για την μελέτη της δυναμικής της επιδημίας στα ΑΕΙ της Ελλάδας.
Κέντρο Έρευνας και Εκπαίδευσης στη Δημόσια Υγεία, την Πολιτική Υγείας και την Πρωτοβάθμια Φροντίδα Υγείας - ΚΕΠΥ, 2021
Η επαναφορά στη δια ζώσης λειτουργία των πανεπιστημίων σε συνθήκες αυξημένου συγχρωτισμού φοιτητώ... more Η επαναφορά στη δια ζώσης λειτουργία των πανεπιστημίων σε συνθήκες αυξημένου συγχρωτισμού φοιτητών και εργαζόμενων, ανεπαρκούς φυσικού αερισμού της συντριπτικής πλειοψηφίας των αιθουσών διδασκαλίας και απουσίας επιδημιολογικής επιτήρησης είχε έγκαιρα επισημανθεί ότι θα οδηγήσει σε έξαρση της επιδημίας στο campus του ΑΠΘ και αυξημένο κίνδυνο νόσησης ιδιαίτερα για τους εργαζόμενους στο ίδρυμα, οι οποίοι/ες έρχονται καθημερινά σε στενή επαφή με εκατοντάδες φοιτητές/τριες.
Στην περίπτωση του ΑΠΘ η ανάλυση των πρώτων στοιχείων κρουσμάτων για τα ακαδημαϊκό έτος 2021-22 που δόθηκαν στη δημοσιότητα (η αξιοπιστία και ακρίβεια των οποίων είναι προς επιβεβαίωση) δείχνει ότι οι εργαζόμενοι στο ΑΠΘ (μέλη ΔΕΠ, ερευνητικό προσωπικό και κυρίως οι διοικητικοί υπάλληλοι των Τμημάτων) έχουν αυξημένο κίνδυνο έκθεσης στον SARS-CoV2 σε σχέση με το γενικό πληθυσμό, λόγω αυξημένου συγχρωτισμού στους χώρους εκπαίδευσης του ιδρύματος.
Επιτακτική είναι η ανάγκη συνδυασμού των εμβολίων με όλα τα αναγκαία μέτρα δημόσιας υγείας (χρήση μάσκας, τήρηση αποστάσεων, αποφυγή συνωστισμού, επαρκή αερισμό κλειστών χώρων, επιδημιολογική επιτήρηση) για τον διαρκή έλεγχο της εξάπλωσης του SARS-CoV2 και την αποφυγή νόσησης από την COVID-19 σε όλο τον πληθυσμό, εντός και εκτός πανεπιστημίων.
Κέντρο Έρευνας και Εκπαίδευσης στη Δημόσια Υγεία, την Πολιτική Υγείας και την Πρωτοβάθμια Φροντίδα Υγείας - ΚΕΠΥ, 2021
Η συζήτηση περί υποχρεωτικότητας των εμβολιασμών ξεκίνησε και εκτυλίσσεται στο έδαφος της αδυναμί... more Η συζήτηση περί υποχρεωτικότητας των εμβολιασμών ξεκίνησε και εκτυλίσσεται στο έδαφος της αδυναμίας συγκράτησης της πανδημίας σε παγκόσμιο επίπεδο. Η άρνηση των κυβερνήσεων και των διεθνών οργανισμών να καταργήσουν τα Ιδιοκτησιακά Πνευματικά Δικαιώματα (IPRs – πατέντες) των εμβολίων ακόμη και την ύστατη στιγμή της ανάγκης προστασίας της δημόσιας υγείας, συνέβαλε καθοριστικά στον πολλαπλασιασμό των μεταλλάξεων του ιού και την ενδυνάμωση της διασποράς του παγκοσμίως.
Η αρχική άρνηση ισχυρών κυβερνήσεων (πχ σε ΗΠΑ, Αγγλία) να αναγνωρίσουν την ύπαρξη της τρέχουσας πανδημικής απειλής, η ολιγωρία και η υποτίμηση της δυναμικής της διασποράς της επιδημίας από το σύστημα διεθνούς διακυβέρνησης της υγείας, η παταγώδης αποτυχία των αποδιαρθρωμένων και ιδιωτικοποιημένων συστημάτων υγείας να προστατεύσουν αποτελεσματικά την υγεία των πολιτών και τα αντιφατικά πρωτόκολλα διαχείρισης της επιδημίας, έχουν ήδη κλονίσει την εμπιστοσύνη των πολιτών στις κυβερνήσεις και τα μέτρα δημόσιας υγείας που αυτές λαμβάνουν.
Η επιβολή της υποχρεωτικότητας και του εμβολιαστικού καταναγκασμού σε αυτό το πλαίσιο, κινδυνεύει να βαθύνει ακόμη περισσότερο το ρήγμα εμπιστοσύνης ανάμεσα στην πολιτεία και τους πολίτες, αυξάνοντας τον ανορθολογισμό και τελικά τα ποσοστά εμβολιαστικής άρνησης.
Ο στόχος της καθολικής εμβολιαστικής κάλυψης μπορεί να επιτευχθεί μόνο δια της πειθούς και της διατήρησης του εθελοντικού χαρακτήρα του εμβολιασμού. Η εμβολιαστική διστακτικότητα μπορεί να αντιμετωπισθεί δια της εμπέδωσης κλίματος εμπιστοσύνης, την επένδυση στην ενημέρωση και τη διευκόλυνση της πρόσβασης των πολιτών στα εμβόλια.
Κέντρο Έρευνας και Εκπαίδευσης στη Δημόσια Υγεία, την Πολιτική Υγείας και την Πρωτοβάθμια Φροντίδα Υγείας - ΚΕΠΥ, 2021
Η παρούσα έκθεση υπενθυμίζει ότι η Διακήρυξη της Doha του Παγκόσμιου Οργανισμού Εμπορίου (μέλη το... more Η παρούσα έκθεση υπενθυμίζει ότι η Διακήρυξη της Doha του Παγκόσμιου Οργανισμού Εμπορίου (μέλη του οποίου αποτελούν το σύνολο των χωρών της Ευρώπης, συμπεριλαμβανομένης και της Ελλάδας) από το 2001 και μετά επιτρέπει στα κράτη μέλη του Π.Ο.Ε. σε συνθήκες απειλής της δημόσιας υγείας να άρουν τους όποιους προστατευτισμούς στα πνευματικά ιδιοκτησιακά δικαιώματα ιατροφαρμακευτικών προϊόντων, η χρήση των οποίων μπορεί να βοηθήσει στην αντιμετώπιση του κινδύνου δημόσιας υγείας που διατρέχουν. Ανεξάρτητα και πέραν της ενεργοποίησης των συγκεκριμένων εξαιρέσεων της Doha για τη διευκόλυνση της ταχείας και σε επαρκείς ποσότητες παραγωγής και διακίνησης διαγνωστικών τέστ και εμβολίων για το νέο κορωναϊό, η πανδημία του COVID-19 ανέδειξε για ακόμη μία φορά τα αδιέξοδα της προσέγγισης του φαρμάκου ως καταναλωτικού αγαθού και της εκχώρησης της ευθύνης έρευνας, παραγωγής και διακίνησής του στις ιδιωτικές κερδοσκοπικές πολυεθνικές φαρμακοβιομηχανίες.
Κέντρο Έρευνας και Εκπαίδευσης στη Δημόσια Υγεία, την Πολιτική Υγείας και την Πρωτοβάθμια Φροντίδα Υγείας - ΚΕΠΥ, 2020
Η επιδημία της νόσου του νέου κορωναϊού (Covid-19) αποκαλύπτει με τον πλέον οδυνηρό τρόπο την έλλ... more Η επιδημία της νόσου του νέου κορωναϊού (Covid-19) αποκαλύπτει με τον πλέον οδυνηρό τρόπο την έλλειψη επιδημικής ετοιμότητας στις υπηρεσίες δημόσιας υγείας και τις χρόνιες ευαλωτότητες του εθνικού συστήματος υγείας στην Ελλάδα, προϊόντα αμφότερα της χρόνιας υποχρηματοδότησης και αποδιάρθωσής τους.
Η επιτυχής επιβράδυνση του 1ου επιδημικού κύματος covid-19, έδωσε χρόνο ο οποίος όφειλε να είχε χρησιμοποιηθεί για τη θωράκιση και ενίσχυση των παραπάνω υπηρεσιών.
Δεδομένων των κατά πάσα πιθανότητα χαμηλών ποσοστών ανοσίας του γενικού πληθυσμού, ως αποτελέσμα των οριζόντιων περιοριστικών μέτρων, υψηλός είναι ο κίνδυνος τοπικών αναζοπυρώσεων ή και άλλων επιδημικών κυμάτων, μετά την άρση του lockdown και εντός των επόμενων μηνών ή και έτους.
Με βάσει τα παραπάνω γίνεται ξεκάθαρο ότι η επιδημία covid-19 δεν μπορεί να αντιμετωπίζεται ως μία έκτακτη κατάσταση ολίγων εβδομάδων, αντιθέτως απαιτεί μακρόπνοο σχεδιασμό, επαρκή χρηματοδότηση και οργάνωση.
Η σύσταση μόνιμου μηχανισμού επιδημιολογικής επιτήρησης και δειγματοληπτικής παρακολούθησης της επιδημίας σε πραγματικό χρόνο, η επάρκεια ανθρώπινου δυναμικού και διαγνωστικών μέσων στις υπηρεσίες δημόσιας υγείας και η ολόπλευρη θωράκιση της Πρωτοβάθμιας Φροντίδας Υγείας και των νοσοκομειακών υποδομών του ΕΣΥ αποτελούν αναγκαίες προϋποθέσεις για την αντιμετώπιση της επιδημικής κρίσης την επόμενη περίοδο.
Κέντρο Έρευνας και Εκπαίδευσης στη Δημόσια Υγεία, την Πολιτική Υγείας και την Πρωτοβάθμια Φροντίδα Υγείας - ΚΕΠΥ, 2020
Η υγεία των πληθυσμών είναι ιδιαίτερα σημαντική και ευάλωτη για να την εμπιστευτεί κανείς, ιδιαίτ... more Η υγεία των πληθυσμών είναι ιδιαίτερα σημαντική και ευάλωτη για να την εμπιστευτεί κανείς, ιδιαίτερα σε συνθήκες μίας παγκόσμιας απειλής δημόσιας υγείας, στις διαθέσεις φιλανθρωκαπιταλιστών σε επίπεδο Π.Ο.Υ, στις αποδόσεις κερδοσκοπικών πανδημικών ομολόγων σε διεθνές επίπεδο ή στα προσδοκόμενα οφέλη των ΣΔΙΤ στην υγεία σε εθνικό επίπεδο, η αναποτελεσματικότητα των οποίων, ειρίστω εν παρόδω, έχει ήδη κριθεί από 10ετίας στην Ευρώπη. Η συνέχιση και επέκταση των αναγκαίων μέτρων που έχουν παρθεί για τον έλεγχο και καθυστέρηση της εξάπλωσης της νόσου του νέου κορωναϊού είναι κατεπείγουσα ανάγκη να συνοδευτεί από μία παράλληλη καθολική ενίσχυση του ΕΣΥ, με έμφαση στην ολόπλευρη στήριξη του υπάρχοντος υγειονομικού προσωπικού, στην πρόσληψη του αναγκαίου μόνιμου προσωπικού και στην εξασφάλιση του απαραίτητου δημοσιονομικού χώρου με γενναία αύξηση της κρατικής χρηματοδότησης, για την απρόσκοπτη λειτουργία του συστήματος υγείας σε συνθήκες σταδιακά αυξανόμενης υγειονομικής ανάγκης και χρήσης.
Κέντρο Έρευνας και Εκπαίδευσης στη Δημόσια Υγεία, την Πολιτική Υγείας και την Πρωτοβάθμια Φροντίδα Υγείας - ΚΕΠΥ, 2020
H ικανότητα και ο προγραμματισμός της απάντησης ενός συστήματος υγείας στις προκλήσεις μίας επιδη... more H ικανότητα και ο προγραμματισμός της απάντησης ενός συστήματος υγείας στις προκλήσεις μίας επιδημίας προϋποθέτει τη λεπτομερή και καθημερινή συλλογή επιδημιολογικών δεδομένων και την έγκυρη και με διαφάνεια επικοινωνία τους με την επιστημονική κοινότητα και τους πολίτες.
Ο βασικός αυτός κανόνας για τον έλεγχο και την αντιμετώπιση των συνεπειών των επιδημιών, μοιάζει να υποτιμάται στη χώρα μας.
Aligned to the Lancet Migration Global Statement to include migrants and refugees in countries' r... more Aligned to the Lancet Migration Global Statement to include migrants and refugees in countries' response to COVID-19 2 , this brief focuses on Greece's challenges and opportunities to build an inclusive response. Asylum seekers and refugees in Greece are currently placed by the Greek governments in Reception and Identification Centres (RICs), apartments, hotels and camps across the Greek islands and the mainland, along with a proportion who are homeless. Currently there are six RICs on the Greek islands: Vial on Chios island; Pyli on Kos island; Lepida on Leros island; Moria on Lesvos island; and Vathy on Samos, as well as an unofficial camp on Rhodes. In addition there are 18 camps in the northern mainland of Greece; 13 camps in the southern mainland of Greece and one in the southern peninsula (Peloponnese). Greek Islands 1.1 About 37,000 asylum seekers and migrants are currently living in Greece's Eastern Aegean islands, concentrated on the islands of Lesvos (19,503), Samos (6985) and Chios (5132), with smaller numbers on Leros, Kos and others. 3 1.2 Most live in overcrowded camps, known as Reception and Identification Centres (RICs) or 'hotspots', which only have the capacity to host 6095 people. 4 Others are housed in facilities run by UNHCR, or international organisations. Many are under administrative detention in police stations or so-called 'pre-departure centres', sometimes detained for the length of their asylum procedures. 5 As per Greek law, vulnerable individuals should be housed in suitable accommodation and given access to appropriate healthcare, but many remain in dire conditions in the RICs. 6 1.3 The Eastern Aegean islands constitute one of the two main migration routes into Greece from Turkey, the other being the Edirne land border. Between January-May 2020 there have been over 7600 sea arrivals from Turkey to the Aegean islands. 7 1.4 Most asylum seekers in the island RICs are from Afghanistan, Syria, Palestine and DRC. Children make up 33% of inhabitants of the RICs, and around 13% of children are unaccompanied. 8 1.5 As of 18 th May, there have been no confirmed cases of COVID-19 among the migrant population residing in the RICs on the Greek islands, but four cases have been identified among recent arrivals to Lesvos now held in a temporary quarantine facility. 9 There have been 9 reported local Greek population cases across all the Aegean islands where RICs are located. Greek Mainland 1.6 Approximately 76,000 refugees and migrants are currently living on the Greek mainland. 10 They are housed in open accommodation centres, the Filoxenia Program of accommodation run by the IOM, ESTIA accommodation provided by UNCHR, and shelters for unaccompanied minors run by the IOM and other NGOs; many are homeless or in detention. 1.7 From February 26 th until May 3 rd 212 cases of COVID-19 were reported among refugee and asylum seeker populations on the Greek mainland (Figure 1): • On the 2nd April, a woman living in the Ritsona camp north of Athens tested positive for COVID-19 after giving birth in Athens University Hospital; the camp was subsequently placed in quarantine. 11 Over a period of three weeks 41 more migrants and asylum seekers tested positive for COVID-19 in the Ritsona camp. • On the 5th April, a man living in the Malakasa camp north of Athens also tested positive for COVID-19, and the camp was quarantined. 12 Over a period of four weeks 23 more migrants tested positive for COVID-19 in the Malakasa camp.
Centre for Health and the Public Interest - CHPI, 2018
In a few days the NHS will reach the milestone of being 70 years old. As with all major birthdays... more In a few days the NHS will reach the milestone of being 70 years old. As with all major birthdays this has prompted introspection and comparisons with others. No wonder we're being deluged with a range of statistics and league tables which present a mixed and somewhat contradictory picture of the NHS, in which some commentators have focused on areas of the NHS's performance that seem below average, whether to stimulate debate or to promote alternative healthcare models. But too often forgotten in the ensuing exchanges is a key question: how can we measure how good a healthcare system is unless we define what 'goodness' means?
Centre for Primary Care and Public Health, Queen Mary, University of London, 2013
The major closures, redundancies, sell-offs and service reconfigurations that will follow the TSA... more The major closures, redundancies, sell-offs and service reconfigurations that will follow the TSA regime for the SLHT do not serve patients, whose needs have been, at best, down-played and at worst ignored. PFI is playing a major role in service closure. In the case of Lewisham hospital, there can be little doubt that the government is sacrificing a thriving local hospital in order to protect the interests of bankers, shareholders and corporate stakeholders. In the case of SLHT, the victims are being blamed for the consequences of government policies to promote PFI, deflate the national tariff, and require efficiency savings, all of which involve misallocation of funds originally ear-marked for NHS services in the area. The real victims here are the people of South East London and those who work in and use the health services there. If the Secretary of State implements the TSA recommendations, the public health consequences are likely to be catastrophic.
Τα ευρήματα της μελέτης δείχνουν ότι ο ιδιωτικός τομέας υγείας στην Ελλάδα αναπτύχθηκε σε καθεστώ... more Τα ευρήματα της μελέτης δείχνουν ότι ο ιδιωτικός τομέας υγείας στην Ελλάδα αναπτύχθηκε σε καθεστώς συνεχών νομοθετικών διευκολύνσεων και σε συνθήκες πλημμελούς ποιοτικού, διοικητικού και οικονομικού ελέγχου. Στηρίχτηκε χρηματοδοτικά στα ταμεία κοινωνικής ασφάλισης υγείας, αναπτύχθηκε δηλαδή υπό καθεστώς δημόσιας χρηματοδότησης, παρέχοντας υπερκοστολογημένες υπηρεσίες, αμφισβητούμενης ποιότητας σε πολλές περιπτώσεις. Τα παραπάνω ευρήματα, οδηγούν στο συμπέρασμα ότι ανεξάρτητα από την επίδραση και άλλων παραγόντων (τεχνητές ελλείψεις κύρια του δημόσιου τομέα σε υλικοτεχνική υποδομή και χρηματοδότηση), η ανάπτυξη του ιδιωτικού τομέα υγείας στην Ελλάδα υπήρξε μία συνειδητή, στρατηγική πολιτική επιλογή και όχι μία αυθόρμητη αντίδραση των δυνάμεων της αγοράς στις «εγγενείς» αδυναμίες του δημόσιου τομέα.
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Papers by Elias Kondilis
Study design: Nationwide observational study.
Methods: Retrospective analysis of national vaccination routine data and population census data, collected and triangulated from multiple official/governmental sources. Weekly vaccine roll-out and uptake were calculated for the general Greek population and the R&M population, through the first year of the vaccination programme in Greece (December 2020–December 2021).
Results: Vaccine roll-out among migrants in RICs/RSs started with a 22-week delay, compared to the general population. By the end of the first year of the vaccination programme in Greece in December 2021, the national vaccination uptake among registered R&Ms residing in official reception facilities was 27.3 % for 1st dose and 4.7 % for booster dose; considerably lower compared to the general population (69.5 % uptake for 1st dose, 64.7 % for 2nd dose, and 32.0 % for 3rd dose).
Conclusion: Delayed vaccine roll-out and low vaccine uptake among R&Ms in Greece are signs of low prioritisation and implementation failures in the R&M vaccination strategy. In face of future public health threats, lessons should be learned, and vaccine equity should be insured for all socially vulnerable and high-risk population groups.
Even in capitalism, redistribution of income and wealth has historically been (under welfarism) and should remain a responsibility of the central, rather than the local, state. Centralised pooling of resources and centralised resource allocation to regions might not be sufficient (depending on tax progressivity and resource allocation equalizers) but are necessary conditions for any meaningful attempt to redistribute income and wealth among individuals and across jurisdictions. Accordingly, rejecting fiscal decentralisation might not be a sufficient option to heal inequities and healthcare deficiencies, but it is a necessary condition for any attempt towards that direction.
During the pandemic, the government made three successive increases in private providers’ reimbursement fees, provided additional financial incentives to private providers, and allocated €280 million of emergency funding for the private sector's involvement in the national COVID-19 response. In response, private hospitals made available on average 2.2% of their total bed capacity per epidemic wave for the treatment of COVID-19 patients and 1.7% of their total bed capacity for the treatment of non-COVID-19 patients transferred from National Health System (NHS) hospitals. In 2020 the five largest health care corporate groups maintained their revenues, while in 2021 they increased them by 18.7%—a striking comparison with the 9% recession experienced by the Greek economy in 2020 and its 8.4% recovery in 2021.
In a time of an acute public health crisis, private health care providers responded to society's pressing health care needs by insulating their facilities from COVID-19 patients and NHS patient transfers, minimizing their social contribution and safeguarding their revenues and profits.
mortality, number of people tested, test positive rate, number of patients hospitalised, number of patients discharged, the proportion of population who received at least one vaccine, the proportion of population fully vaccinated) was ascertained from selected countries for the full population, and for few of stratification variables (age, sex, ethnicity, socioeconomic
status) and subgroups (residents in nursing homes, inmates, students, healthcare and social workers, and residents in refugee camps). Nine countries were included: Bangladesh, Indonesia, Iran, Nigeria, Turkey, Panama, Greece, the UK, and the Netherlands. All countries reported periodically most of COVID-19 metrics on the total population. Data were
more frequently broken down by age, sex, and region than by ethnic group or socio-economic status. Data on COVID-19 is partially available for special groups. This exercise highlighted the importance of a transparent and detailed reporting of COVID-19 related variables. The more data is publicly available the more transparency, accountability, and democratisation
of the research process is enabled, allowing a sound evidence-based analysis of the consequences of health policies.
Σκοπός του άρθρου είναι η διερεύνηση της έκτασης και έντασης του εξευρωπαϊσμού στο πεδίο της πολιτικής υγείας και η δημιουργία ενός θεωρητικού, ταξινομητικού πλαισίου των μηχανισμών μέσω των οποίων αυτός συντελείται.
Τα αποτελέσματα της μελέτης δείχνουν, πρώτον, ότι ο εξευρωπαϊσμός στο πεδίο της πολιτικής υγείας ως θεσμική πρακτική υφίσταται και συνεχώς διευρύνεται και, δεύτερον, ότι, ενώ πριν την εκδήλωση της οικονομικής κρίσης επιλέγονταν κύρια οριζόντιοι μη υποχρεωτικοί μηχανισμοί εξευρωπαϊσμού, κατά την περίοδο της κρίσης παρατηρείται μετακίνηση σε κάθετους υποχρεωτικούς μηχανισμούς, που αυξάνουν την ένταση των παρεμβάσεων της ΕΕ στο χώρο της υγείας.
Study design: Observational study
Methods: Retrospective analysis of national secondary utilization and mortality data from multiple official sources, covering the first nine months of the COVID-19 epidemic in Greece (February 26th to November 30th, 2020).
Results: Utilization rates of all public healthcare services during the first nine months of the epidemic dropped significantly compared to the average utilization rates of the 2017-19 control period; hospital admissions, hospital surgical procedures and primary care visits dropped by 17.3% (95% CI: 6.6%-28.0%), 23.1% (95% CI: 7.3%-38.9%), and 24.8% (95% CI: 13.3%-36.3%) respectively. This underutilization of essential public services – mainly due to supply restrictions such as suspension of outpatient care and cancelation of elective surgeries - is most probably related to the 3,778 excess non-COVID-19 deaths (representing 62% of all-cause excess deaths) that have been reported during the first 9 months of the epidemic in the country.
Conclusions: Greece’s healthcare system, deeply wounded by the 2008-18 recession and austerity, was ill resourced to cope with the challenge of the COVID-19 epidemic. Early and prolonged lockdowns have kept COVID-19 infections and deaths at relative low levels. However, this “success” seems to have been accomplished at the expense of non-COVID-19 patients. It is important to acknowledge the “hidden epidemic” of unmet non-COVID-19 needs and increased non-COVID-19 deaths in the country and urgently strengthen public healthcare services to address it.
These serious data gaps are not unique in Europe and are mostly related to the lack of prioritization and under-investment in local public health surveillance systems. Given the time needed in order to achieve herd
immunity through vaccination, immediate investment in comprehensive epidemiological surveillance is the only way to maintain reduced levels of transmission and avoid resurgences.
increase in the demand for services; (2) the impacts of austerity measures; and (3) changes in the health labour market. Some of the evidence appeared specific to the context of crises; demand for health services and employment increased during economic recessions in North America and Oceania, but stagnated or declined in Europe in connection with the austerity measures adopted. Burn-out, lay-offs, migration and multiple jobholding were the reactions observed in Europe, but job opportunities never dwindled for physicians during recessions in North America, with nurses re-entering labour markets during such crises. Loss of motivation, absenteeism and abuse of health systems were documented during recessions in low-income countries. Although the impacts of recessions may vary across economic events, health systems, labour markets and policy responses, our review and framework provide an evidence base for policies to mitigate the effects on HWs.
Methods and analysis This paper lays out a protocol for a systematic review of the existing qualitative, quantitative and mixed-method evidence on the economic recessions and HRH; results from the review will be used to develop a conceptual framework linking existing theories on recessions, austerity measures, health systems and population health, with a view of informing future health policies. Eight relevant databases within the health, health systems, multidisciplinary and economic literature will be searched, complemented by secondary searches and experts’ input. Eligible studies will present primary quantitative or qualitative evidence on HRH impacts, or original secondary analyses. We will cover the 1970–2019 period—the modern age of global economic recessions— and full texts in English, Spanish, Italian, French,
Portuguese or Greek. Two reviewers will independently assess, perform data extraction and conduct quality appraisal of the texts identified. A ‘best-fit’ framework
synthesis will be applied to summarise the findings,
using an a priori, theoretically driven framework. That
preliminary framework was built by the research team
to inform the searches, and will be appraised by external
experts.
Study design: Nationwide observational study.
Methods: Retrospective analysis of national vaccination routine data and population census data, collected and triangulated from multiple official/governmental sources. Weekly vaccine roll-out and uptake were calculated for the general Greek population and the R&M population, through the first year of the vaccination programme in Greece (December 2020–December 2021).
Results: Vaccine roll-out among migrants in RICs/RSs started with a 22-week delay, compared to the general population. By the end of the first year of the vaccination programme in Greece in December 2021, the national vaccination uptake among registered R&Ms residing in official reception facilities was 27.3 % for 1st dose and 4.7 % for booster dose; considerably lower compared to the general population (69.5 % uptake for 1st dose, 64.7 % for 2nd dose, and 32.0 % for 3rd dose).
Conclusion: Delayed vaccine roll-out and low vaccine uptake among R&Ms in Greece are signs of low prioritisation and implementation failures in the R&M vaccination strategy. In face of future public health threats, lessons should be learned, and vaccine equity should be insured for all socially vulnerable and high-risk population groups.
Even in capitalism, redistribution of income and wealth has historically been (under welfarism) and should remain a responsibility of the central, rather than the local, state. Centralised pooling of resources and centralised resource allocation to regions might not be sufficient (depending on tax progressivity and resource allocation equalizers) but are necessary conditions for any meaningful attempt to redistribute income and wealth among individuals and across jurisdictions. Accordingly, rejecting fiscal decentralisation might not be a sufficient option to heal inequities and healthcare deficiencies, but it is a necessary condition for any attempt towards that direction.
During the pandemic, the government made three successive increases in private providers’ reimbursement fees, provided additional financial incentives to private providers, and allocated €280 million of emergency funding for the private sector's involvement in the national COVID-19 response. In response, private hospitals made available on average 2.2% of their total bed capacity per epidemic wave for the treatment of COVID-19 patients and 1.7% of their total bed capacity for the treatment of non-COVID-19 patients transferred from National Health System (NHS) hospitals. In 2020 the five largest health care corporate groups maintained their revenues, while in 2021 they increased them by 18.7%—a striking comparison with the 9% recession experienced by the Greek economy in 2020 and its 8.4% recovery in 2021.
In a time of an acute public health crisis, private health care providers responded to society's pressing health care needs by insulating their facilities from COVID-19 patients and NHS patient transfers, minimizing their social contribution and safeguarding their revenues and profits.
mortality, number of people tested, test positive rate, number of patients hospitalised, number of patients discharged, the proportion of population who received at least one vaccine, the proportion of population fully vaccinated) was ascertained from selected countries for the full population, and for few of stratification variables (age, sex, ethnicity, socioeconomic
status) and subgroups (residents in nursing homes, inmates, students, healthcare and social workers, and residents in refugee camps). Nine countries were included: Bangladesh, Indonesia, Iran, Nigeria, Turkey, Panama, Greece, the UK, and the Netherlands. All countries reported periodically most of COVID-19 metrics on the total population. Data were
more frequently broken down by age, sex, and region than by ethnic group or socio-economic status. Data on COVID-19 is partially available for special groups. This exercise highlighted the importance of a transparent and detailed reporting of COVID-19 related variables. The more data is publicly available the more transparency, accountability, and democratisation
of the research process is enabled, allowing a sound evidence-based analysis of the consequences of health policies.
Σκοπός του άρθρου είναι η διερεύνηση της έκτασης και έντασης του εξευρωπαϊσμού στο πεδίο της πολιτικής υγείας και η δημιουργία ενός θεωρητικού, ταξινομητικού πλαισίου των μηχανισμών μέσω των οποίων αυτός συντελείται.
Τα αποτελέσματα της μελέτης δείχνουν, πρώτον, ότι ο εξευρωπαϊσμός στο πεδίο της πολιτικής υγείας ως θεσμική πρακτική υφίσταται και συνεχώς διευρύνεται και, δεύτερον, ότι, ενώ πριν την εκδήλωση της οικονομικής κρίσης επιλέγονταν κύρια οριζόντιοι μη υποχρεωτικοί μηχανισμοί εξευρωπαϊσμού, κατά την περίοδο της κρίσης παρατηρείται μετακίνηση σε κάθετους υποχρεωτικούς μηχανισμούς, που αυξάνουν την ένταση των παρεμβάσεων της ΕΕ στο χώρο της υγείας.
Study design: Observational study
Methods: Retrospective analysis of national secondary utilization and mortality data from multiple official sources, covering the first nine months of the COVID-19 epidemic in Greece (February 26th to November 30th, 2020).
Results: Utilization rates of all public healthcare services during the first nine months of the epidemic dropped significantly compared to the average utilization rates of the 2017-19 control period; hospital admissions, hospital surgical procedures and primary care visits dropped by 17.3% (95% CI: 6.6%-28.0%), 23.1% (95% CI: 7.3%-38.9%), and 24.8% (95% CI: 13.3%-36.3%) respectively. This underutilization of essential public services – mainly due to supply restrictions such as suspension of outpatient care and cancelation of elective surgeries - is most probably related to the 3,778 excess non-COVID-19 deaths (representing 62% of all-cause excess deaths) that have been reported during the first 9 months of the epidemic in the country.
Conclusions: Greece’s healthcare system, deeply wounded by the 2008-18 recession and austerity, was ill resourced to cope with the challenge of the COVID-19 epidemic. Early and prolonged lockdowns have kept COVID-19 infections and deaths at relative low levels. However, this “success” seems to have been accomplished at the expense of non-COVID-19 patients. It is important to acknowledge the “hidden epidemic” of unmet non-COVID-19 needs and increased non-COVID-19 deaths in the country and urgently strengthen public healthcare services to address it.
These serious data gaps are not unique in Europe and are mostly related to the lack of prioritization and under-investment in local public health surveillance systems. Given the time needed in order to achieve herd
immunity through vaccination, immediate investment in comprehensive epidemiological surveillance is the only way to maintain reduced levels of transmission and avoid resurgences.
increase in the demand for services; (2) the impacts of austerity measures; and (3) changes in the health labour market. Some of the evidence appeared specific to the context of crises; demand for health services and employment increased during economic recessions in North America and Oceania, but stagnated or declined in Europe in connection with the austerity measures adopted. Burn-out, lay-offs, migration and multiple jobholding were the reactions observed in Europe, but job opportunities never dwindled for physicians during recessions in North America, with nurses re-entering labour markets during such crises. Loss of motivation, absenteeism and abuse of health systems were documented during recessions in low-income countries. Although the impacts of recessions may vary across economic events, health systems, labour markets and policy responses, our review and framework provide an evidence base for policies to mitigate the effects on HWs.
Methods and analysis This paper lays out a protocol for a systematic review of the existing qualitative, quantitative and mixed-method evidence on the economic recessions and HRH; results from the review will be used to develop a conceptual framework linking existing theories on recessions, austerity measures, health systems and population health, with a view of informing future health policies. Eight relevant databases within the health, health systems, multidisciplinary and economic literature will be searched, complemented by secondary searches and experts’ input. Eligible studies will present primary quantitative or qualitative evidence on HRH impacts, or original secondary analyses. We will cover the 1970–2019 period—the modern age of global economic recessions— and full texts in English, Spanish, Italian, French,
Portuguese or Greek. Two reviewers will independently assess, perform data extraction and conduct quality appraisal of the texts identified. A ‘best-fit’ framework
synthesis will be applied to summarise the findings,
using an a priori, theoretically driven framework. That
preliminary framework was built by the research team
to inform the searches, and will be appraised by external
experts.
COVID-19.
Surprisingly, many of these symptoms fit to the recently identified, in the case of developing countries, “mixed health systems syndrome”. A situation where health systems of public/private mix show poor performance, as indicated from their poor responsiveness, failure to achieve fairness in financing and inability to achieve equity in outcomes.
The Greek experience shows that, at least in the case of a developed country with a semi – dependent role within the international economic environment, such symptoms of severe malfunction that compose the “mixed health system syndrome”, can occur when an underdeveloped public health sector is pushed towards privatization and marketization, while at the same time private for – profit providers are left unregulated.
Our analysis shows that privatisation of health care in Greece was and still is a deliberate policy choice rather than a spontaneous reaction of the private health industry to the inborn inabilities of the public health sector.
Η διεπιστημονική προσέγγιση που επιχειρείται σε αυτήν τη συλλογική εργασία φιλοδοξεί, με δεδομένους βέβαια τους περιορισμούς εξαιτίας της δυναμικής εξέλιξης της πραγματικότητας, να συμβάλει στην περαιτέρω ανάλυση και εμβάθυνση του ρόλου της πανδημίας στη διεύρυνση των κοινωνικοοικονομικών ανισοτήτων στην υγεία καθώς και στα αναγκαία μέτρα για την αντιμετώπισή τους υπέρ του κόσμου της εργασίας.
Γράφουν οι:
Valentina Gallo, Howard Waitzkin, Απόστολος Βεΐζης, Δημήτρης Κιβωτίδης, Ηλίας Κονδύλης, Χρήστος Λάσκος, Έφη Μακρίδου, Σταύρος Μαυρουδέας, Αλέξης Μπένος, Δημήτρης Παπαμιχαήλ, Χριστίνα Παρασκευοπούλου, Μαρία Πετμεζίδου, Μιχάλης Πουλημάς, Στέργιος Σερέτης, Φίλιππος Ταραντίλης
Στην περίπτωση του ΑΠΘ η ανάλυση των πρώτων στοιχείων κρουσμάτων για τα ακαδημαϊκό έτος 2021-22 που δόθηκαν στη δημοσιότητα (η αξιοπιστία και ακρίβεια των οποίων είναι προς επιβεβαίωση) δείχνει ότι οι εργαζόμενοι στο ΑΠΘ (μέλη ΔΕΠ, ερευνητικό προσωπικό και κυρίως οι διοικητικοί υπάλληλοι των Τμημάτων) έχουν αυξημένο κίνδυνο έκθεσης στον SARS-CoV2 σε σχέση με το γενικό πληθυσμό, λόγω αυξημένου συγχρωτισμού στους χώρους εκπαίδευσης του ιδρύματος.
Επιτακτική είναι η ανάγκη συνδυασμού των εμβολίων με όλα τα αναγκαία μέτρα δημόσιας υγείας (χρήση μάσκας, τήρηση αποστάσεων, αποφυγή συνωστισμού, επαρκή αερισμό κλειστών χώρων, επιδημιολογική επιτήρηση) για τον διαρκή έλεγχο της εξάπλωσης του SARS-CoV2 και την αποφυγή νόσησης από την COVID-19 σε όλο τον πληθυσμό, εντός και εκτός πανεπιστημίων.
Η αρχική άρνηση ισχυρών κυβερνήσεων (πχ σε ΗΠΑ, Αγγλία) να αναγνωρίσουν την ύπαρξη της τρέχουσας πανδημικής απειλής, η ολιγωρία και η υποτίμηση της δυναμικής της διασποράς της επιδημίας από το σύστημα διεθνούς διακυβέρνησης της υγείας, η παταγώδης αποτυχία των αποδιαρθρωμένων και ιδιωτικοποιημένων συστημάτων υγείας να προστατεύσουν αποτελεσματικά την υγεία των πολιτών και τα αντιφατικά πρωτόκολλα διαχείρισης της επιδημίας, έχουν ήδη κλονίσει την εμπιστοσύνη των πολιτών στις κυβερνήσεις και τα μέτρα δημόσιας υγείας που αυτές λαμβάνουν.
Η επιβολή της υποχρεωτικότητας και του εμβολιαστικού καταναγκασμού σε αυτό το πλαίσιο, κινδυνεύει να βαθύνει ακόμη περισσότερο το ρήγμα εμπιστοσύνης ανάμεσα στην πολιτεία και τους πολίτες, αυξάνοντας τον ανορθολογισμό και τελικά τα ποσοστά εμβολιαστικής άρνησης.
Ο στόχος της καθολικής εμβολιαστικής κάλυψης μπορεί να επιτευχθεί μόνο δια της πειθούς και της διατήρησης του εθελοντικού χαρακτήρα του εμβολιασμού. Η εμβολιαστική διστακτικότητα μπορεί να αντιμετωπισθεί δια της εμπέδωσης κλίματος εμπιστοσύνης, την επένδυση στην ενημέρωση και τη διευκόλυνση της πρόσβασης των πολιτών στα εμβόλια.
Ανεξάρτητα και πέραν της ενεργοποίησης των συγκεκριμένων εξαιρέσεων της Doha για τη διευκόλυνση της ταχείας και σε επαρκείς ποσότητες παραγωγής και διακίνησης διαγνωστικών τέστ και εμβολίων για το νέο κορωναϊό, η πανδημία του COVID-19 ανέδειξε για ακόμη μία φορά τα αδιέξοδα της προσέγγισης του φαρμάκου ως καταναλωτικού αγαθού και της εκχώρησης της ευθύνης έρευνας, παραγωγής και διακίνησής του στις ιδιωτικές κερδοσκοπικές πολυεθνικές φαρμακοβιομηχανίες.
Η επιτυχής επιβράδυνση του 1ου επιδημικού κύματος covid-19, έδωσε χρόνο ο οποίος όφειλε να είχε χρησιμοποιηθεί για τη θωράκιση και ενίσχυση των παραπάνω υπηρεσιών.
Δεδομένων των κατά πάσα πιθανότητα χαμηλών ποσοστών ανοσίας του γενικού πληθυσμού, ως αποτελέσμα των οριζόντιων περιοριστικών μέτρων, υψηλός είναι ο κίνδυνος τοπικών αναζοπυρώσεων ή και άλλων επιδημικών κυμάτων, μετά την άρση του lockdown και εντός των επόμενων μηνών ή και έτους.
Με βάσει τα παραπάνω γίνεται ξεκάθαρο ότι η επιδημία covid-19 δεν μπορεί να αντιμετωπίζεται ως μία έκτακτη κατάσταση ολίγων εβδομάδων, αντιθέτως απαιτεί μακρόπνοο σχεδιασμό, επαρκή χρηματοδότηση και οργάνωση.
Η σύσταση μόνιμου μηχανισμού επιδημιολογικής επιτήρησης και δειγματοληπτικής παρακολούθησης της επιδημίας σε πραγματικό χρόνο, η επάρκεια ανθρώπινου δυναμικού και διαγνωστικών μέσων στις υπηρεσίες δημόσιας υγείας και η ολόπλευρη θωράκιση της Πρωτοβάθμιας Φροντίδας Υγείας και των νοσοκομειακών υποδομών του ΕΣΥ αποτελούν αναγκαίες προϋποθέσεις για την αντιμετώπιση της επιδημικής κρίσης την επόμενη περίοδο.
Η συνέχιση και επέκταση των αναγκαίων μέτρων που έχουν παρθεί για τον έλεγχο και καθυστέρηση της εξάπλωσης της νόσου του νέου κορωναϊού είναι κατεπείγουσα ανάγκη να συνοδευτεί από μία παράλληλη καθολική ενίσχυση του ΕΣΥ, με έμφαση στην ολόπλευρη στήριξη του υπάρχοντος υγειονομικού προσωπικού, στην πρόσληψη του αναγκαίου μόνιμου προσωπικού και στην εξασφάλιση του απαραίτητου δημοσιονομικού χώρου με γενναία αύξηση της κρατικής χρηματοδότησης, για την απρόσκοπτη λειτουργία του συστήματος υγείας σε συνθήκες σταδιακά αυξανόμενης υγειονομικής ανάγκης και χρήσης.
Ο βασικός αυτός κανόνας για τον έλεγχο και την αντιμετώπιση των συνεπειών των επιδημιών, μοιάζει να υποτιμάται στη χώρα μας.
Τα παραπάνω ευρήματα, οδηγούν στο συμπέρασμα ότι ανεξάρτητα από την επίδραση και άλλων παραγόντων (τεχνητές ελλείψεις κύρια του δημόσιου τομέα σε υλικοτεχνική υποδομή και χρηματοδότηση), η ανάπτυξη του ιδιωτικού τομέα υγείας στην Ελλάδα υπήρξε μία συνειδητή, στρατηγική πολιτική επιλογή και όχι μία αυθόρμητη αντίδραση των δυνάμεων της αγοράς στις «εγγενείς» αδυναμίες του δημόσιου τομέα.