A questionable future


Now that we are starting to slowly establish that Greece is going to become the poorest nation within one generation, it is also time to look to the future. Greece has recently focused entirely on the financial shortcomings of the economic crisis and the wider, internationally influenced, political agenda impacting on public spending. The case for health, however, is increasingly becoming the product in a can of worms that no one wants to open.

The escalating financial crisis in Greece is not only economic, but also about health and social care. Public healthcare provision is overstretched: there have been about 50% cuts in hospital budgets, secondary and tertiary care centres are understaffed, shortages of medical supplies have been reported, and the day-to-day running of healthcare services remains non-transparent and bureaucratic. In this environment, public health and prevention are taking the highest toll; public health spending has shrunk to 4% of GDP, whilst health promotion activities are by large left to underfunded non-governmental organisations.

Take vaccination for example. Greece faces low vaccine confidence, troubled health policies with mixed priorities and lacks focus on long term public health goals. There are two key factors that extend the significant public health impact of the economic crisis to population vaccination programmes.

A vaccination crisis
(I) Drug Supply: There is an existent structural problem in Europe with how pharmaceutical products are distributed and sold, and Greece’s financial restrictions have only made matters worse. According to official statistics, the government owes pharmacies €0.5 billion. In the Greek healthcare system, people that are insured only pay a percentage of their prescription costs, but out-of-pocket payments have increased and salaries have decreased leading to reduced uptake of vaccines. As a result, Greece had 688 meningitis cases (mostly preventable) in 2013 with deaths of unvaccinated infants recorded. In addition, the public insurance schemes neither cover the costs for certain vaccines (e.g. the new meningitis B vaccine costed at €116), resulting in virtually zero uptake, nor have enough funds to cover drug expenses any longer. This, in combination with pharmaceutical companies seeking secure profits in other countries, has led to shortage of pharmaceutical products. In 2015 on occasion several vaccines that are included in the national vaccination programme were in short supply.

(II) Public Confidence: Greece ranks second from bottom among European Union countries in adherence to vaccines. Under normal circumstances this would call for health promotion campaigns. However, the Hellenic Centre for Disease Control and Prevention (HCDC) announced in 2014 that, due to the recession, it lacked the necessary funding to plan and execute a campaign to inform the public. Further, for a few months in 2013-14, the service of the last National Committee on Vaccines had ended with no new members appointed due to economic and bureaucratic issues. Thus, there are substantial periods of time with no one working on vaccine confidence in Greece. These are further aggravated by a wider mistrust in the government.

The evidence
There is a wealth of evidence on the value of vaccination in public health and most professionals, as well as the public, would agree that it is one of the most important public health practices. Vaccination is a collective activity, meaning that the result of immunising individuals can lead to the protection of groups of people and can cross boundaries between countries and continents resulting in global impact. The impact of national routine vaccination programmes on the incidence of communicable diseases like smallpox, poliomyelitis, and measles has been immense.

Further, there is an increasing body of evidence about how national spending on childhood vaccination programmes also adds economic benefits. Even though it is hard to estimate the economic value of vaccines, there are various direct or indirect ways through which vaccination impacts indices of economic growth. These vary from simple observations (vaccination improves or retains health and allows individuals to contribute to economic growth), to cost calculations (vaccination is indeed one of the most cost-effective, even cost-saving, interventions that contribute to healthcare system efficiency), and to intangible gains often ignored by traditional economic analyses (including outcome-related productivity gains and community externalities).

Why not?
Despite the unambiguous messages derived from research evidence, Greece is lagging behind in implementation and confidence. There are numerous barriers to improved implementation of vaccination programmes in Greece.
First, Greek political and social life is in a state of flux, following multiple recent election rounds and increasing international involvement with internal affairs. Constant change of administrations impedes research-based decision-making as it breaks existing communication channels. Therefore, in this political environment, vaccination programme does not seem like a priority. One could argue that, given that politicians are interested in quick wins, advocating for better implementation of preventative public health measures could be a good story for the newly elected government. Recent vaccine policy research in the United States looking into the determinants that impact where government allocates attention showed that key factors include problem severity (disease incidence or the cost of a problem) and interest group activity.

Second, Greece has a decision-making political culture that is based on experience and immediate pressures, and not necessarily evidence-based. On this point, utilising international support for research and lobbying to prioritise the issue of vaccinations as a public health priority could help change the agenda. Indicatively, promoting and strengthening the role of vaccines is in line with documents recently published by the Council of the European Union, calling member states to develop comprehensive and coordinated approaches to vaccination programmes and to encourage use of vaccines.

Third, Greece lacks particular stakeholder groups driving change on this topic. Mass media have remained relatively uninterested in the topic of vaccinations in recent years, so it would take a perspective shift to achieve communication of the right messages. Industry is losing interest in the Greek market. The power of the Ministry of Health politicians to influence change has diminished in recent years because of increasing involvement of international actors. Arm’s-length bodies cannot exercise considerable power on their own. Academics in Greece can only influence the agenda-setting through partnerships and providing the evidence base.

Lastly, but perhaps most importantly, Greece lacks the economic resources to implement changes requiring even minor investment in healthcare, and long term public health objectives are rarely part of the agenda. This is a barrier with deep roots in the current Greek political temperament and the most creative strategy to overcome it is to explore ways to present the vaccination agenda item as linked to an urgent need for problem-solving. Greece is currently further tested with the refugee crisis with over 250,000 asylum seekers and migrants crossing the Mediterranean over to Greece in 2015. The epidemiological profile of the population arriving in Greece can be considerably different to that of the permanent residents of the country with outbreak-prone diseases a threat to conflict-affected populations. Tighter national control of routine vaccination programmes would help control communicable diseases and safeguard both Greek permanent residents and arriving refugees, thus bringing short-term benefits to a potential public health crisis.

Driving change

The vaccination problem is only one of the public health issues Greece is facing. Solutions can only be implemented through national co-ordinated approaches. These require research (surveillance, scientific studies), evidence from economic analyses, strategic planning for implementation, and close collaboration with the international industry and stakeholders. Advocacy coalitions have worked well in other settings. Ensuring that a case for change will be heard is also important.

Above all, achieving effective and sustainable change requires – for once – careful planning, in the short- and long- term. This would take into account multiple resources, like personnel, skills, access to policy makers, and costs. Further, convergence of the problem, its proposals and the politics around it (i.e. appropriate routes for implementation) needs to be planned at the critical time when policy windows are open. It seems to me that this should be happening… well, now.


PS. Sources and further reading:

  • Kentikelenis A et al. Health effects of financial crisis:omens of a Greek tragedy. Lancet. 2011;378(9801):1457-8.
  • Karamanoli E. 5 years of austerity takes its toll on Greek health care. Lancet. 2015;386(10010):2239-40.
  • Burki TK. Maintaining drug supply to Greece in an uncertain future. Lancet Oncol. 2015;16(8):e382.
  • Kingdon JW. Agendas, alternatives, and public policies. New York:Longman, 1995.
  • Ehreth J. The global value of vaccination. Vaccine. 2003;21:596-600.
  • Bloom DE. The value of vaccination. Adv Exp Med Biol. 2011;697:1-8.
  • Deogaonkar R et al. Systematic review of studies evaluating the broader economic impact of vaccination in low and middle income countries. BMC Public Health. 2012;12:878.
  • Barnighausen T et al. Rethinking the benefits and costs of childhood vaccination:The example of the Haemophilus influenzae type b vaccine. Vaccine. 2011;29(13):2371–80.
  • Papaevangelou V. Determinants of vaccination coverage and adherence to the Greek national immunization program among infants aged 2-24 months at the beginning of the economic crisis (2009-2011). BMC Public Health. 2014;14:1192.
  • Council of the EuropeanUnion. Council conclusions on vaccinations as an effective tool in public health. Brussels, 2014.
  • Abbasi K et al. Europe’s refugee crisis:an urgent call for moral leadership. BMJ;205:351:h4833.
  • Abu Sa’Da C, Serafini M. Humanitarian and medical challenges of assisting new refugees in Lebanon and Iraq. FMR. 2013;44:70-73.
  • Gilson L et al. Using stakeholder analysis to support moves towards universal coverage: lessons from the SHIELD project. Health Policy Plan. 2012;27:i64-76.
  • Salisbury DM et al. Vaccine programmes and policies. Br Med Bull. 2002;62(1):201-11.