Addressing informal payments in the Greek health system (2018)
The Greek health system is facing major demographic, epidemiological and economic challenges and performance problems due to organizational and operational weaknesses such as pervasive fragmentation in pooling, purchasing and service delivery. Focusing on recommendations for action, this report addresses informal payments (IPs, known as fakel(l)aki/ϕακελακι) on the basis of a literature review; analysis of policy documents; and interviews with 13 key informants. The phenomenon is analysed in the so-called inxit framework (Gaál & McKee, 2004) which understands IPs as a product of health-system failures. The available evidence shows consistently that the bulk of IPs in the Greek health system can be considered informal fees for service, hence policy focus should be shifted from the public sector corruption approach to reform of those health-system characteristics which induce and maintain fee-type IPs. These can be addressed successfully only if reforms aim to eliminate their root causes.
The strategy to address IPs should mix long-term and large-scale health-system reforms which focus on efficiency improvements and reallocate savings to shortage areas – particularly remuneration of health workers – and short-term measures which address the phenomenon directly. Among quick-fix policies, the only viable option appears to be formalization of IPs: removing choice of physician from the publicly financed patient pathway and introducing user charges for those who want to retain this choice. While this may be seen to create a barrier to access, in fact it aims to eliminate the access barrier that IPs create. The political risks of the quick-fix policy should be weighed against the detrimental impact of letting IPs persist, but such risks can be decreased by the application of change management and large-scale system transformation techniques and skills which appear to be critical success factors in driving change in the Greek health system.