Characteristics of included articles
The database search returned 391 documents. After duplicates were removed, the titles of 347 documents, and where necessary their abstracts, were screened for inclusion along with 19 documents that were identified through other sources, including 4 legislative documents. Out of the 366 records screened, 8 were not accessible in full text and 287 were excluded with reasons. The remaining 71 full-text documents were assessed for eligibility and 27 were excluded. In total, 44 documents were included in this scoping review (see Fig.1 for the detailed selection process).
Out of the final 44 documents, 38 were research-based: 33 were based on qualitative design, 2 on quantitative, and 3 on a mixed design. We also included 2 documents classified as grey literature and 4 parliamentary laws. Laws aside, the majority of the documents included (27 out of 39) were published in the second half of the decade and 10 in 2019. For the full list of reviewed documents please see supplementary material B. All included documents (apart from the laws) were critically appraised. No articles were excluded upon screening process. The Mixed Methods Appraisal Tool (MMAT) [26] was used for published literature and the AACODS [27] checklist for grey literature (see supplementary materials C, D, E, and F).
Narrative synthesis
Population coverage
While prior to the reforms a part of the rural population could access health centers and practices, in urban areas PHC was delivered mainly by ambulatory clinics and private specialists rather than GPs, of which a small percentage contracted with the SHI schemes [28]. Even though overall satisfaction for PHC services was relatively high and users understood the important role of a primary care physician, doctors, at least in rural areas, identified significant gaps in the provision of PHC, among which notably the lack of community nurses [29,30,31]. However, the evidence suggests there is a conflicting perception of what PHC entails, with further divergence regarding its effectiveness, especially between users and providers [31].
Until the completion of the SHI merge under EOPYY in 2014, population coverage and access to care were reduced significantly, especially in urban areas, for three main reasons: loss of insurance entitlements due to increased unemployment (up to 27.4%) [32], excessive reduction of human resources due to doctors moving to private sector or abroad and reduction of services [33]. Shrinking public health expenditure caused a reduction of human resources, supplies, and services [34] further burdening the already limited resources [29], thus reducing population coverage and leading service users towards the private sector. One consequence and strong indication of the ensuing gaps in service provision, especially in urban areas, was the establishment of solidarity PHC clinics by citizens as a response to the health system inefficiency. These clinics provided basic primary and emergency care, mostly to people with no health insurance, including refuges and migrants. A survey among 92 solidarity clinics, reported a 10% or more increase in the number of patients attending from 2013 to 2014 [35].
At the peak of unemployment followed by a steady increase of unmet healthcare needs [36], law 4238/2014 attempted to reorganize PHC. Although it attempted to resolve structural distortions, significant difficulties were met during implementation [37] mainly because it was rather fiscal-driven within the overall mindset of economic reforms. While the integration of the former SHI polyclinics into the newly-established PEDY network under the ESY aimed at defragmenting services, instead it led to an association of PHC with ambulatory specialist care. Furthermore, it was met with resistance from the contracted doctors who were working in the SHI polyclinics while having their private practices at the same time. These doctors were called to decide whether to work for the public or for the private sector, leading many to opt-out from their public-sector contracts, thus affecting population coverage [33]. Moreover, the integration of services did not address the issue of the unequal distribution of health professionals between urban and rural areas and failed to introduce the family physician as a mandatory first point of contact [3, 33]. Later studies revealed that the number of specialty doctors and their relative distribution among specialties remained almost unchanged between 2010 and 2015 [34, 38].
In 2015, 1 year after the second reform, overall satisfaction in PHC was relatively low (48.6%) and most participants reiterated the need for a new approach, whereas the majority of the participants (81.8%) reported a preference for a family physician that would guide them to specialist services [39]. The latter is supported by other studies too, which report that service users, and especially those with low health literacy, expect to be guided by doctors [40].
Furthermore, the increasing arrival of refugees and migrants from that year onward, caused additional pressure to the health system and increased the burden of disease among marginalized groups. Stigmatization, exclusion, and powerlessness have been identified as the main barriers for poor access to healthcare for this population [41]. Administrative and structural barriers especially with the asylum process caused further exclusion [37]. Recent evidence indicates that migrants face significantly more barriers in accessing health services than non-migrants [42], especially those with chronic diseases and in need for medicines [43].
In 2016, law 4368/2016 [44] granted access to public healthcare services to the uninsured population,, and the following year, law 4486/2017 [22] introduced a new PHC model [45]. This aimed to steer care back to the community, with a focus on prevention, health promotion, and integrated care [46], also providing care for free to those with no insurance. The initial phase of the new reform included the planned roll-out of 239 multidisciplinary units, the TOMYs, within a timeframe of 2 years, but as of June 2019 the roll-out had paused at approximately half of the original target, with 127 TOMYs [47,48,49,50,51,52,53,54,55]. In addition to that, the potential registration capacity of the TOMYs based on their staffing at the end of 2019 was 650,250 citizens; however, at that time there were just about over 400,000 registered citizens [55]. On the upside, there existed an increasing trend to register with family doctors and health care teams, in contrast with the previous state of no registrations at all, which is a slight improvement in population coverage in terms of actual PHC services [55]. Unavailability of GPs and inadequate premises are largely considered to be the main reasons that not all planned TOMYs started to operate [5, 55]. The evidence reveal that there was only a slight increase in GPs amidst the reform, from 3.4 per 10,000 inhabitants in 2017 to 3.6 in 2018, which is still the lowest in Europe [56]. This might be partly attributed to dissatisfaction with their level of income [57], especially in rural and remote areas.
Service coverage
Ambulatory and PHC services in Greece are accessible for a wide range of preventive procedures including blood tests, early diagnosis of chronic conditions and immunization under a national immunization programme, but administration of booster doses is often delayed [3]. This might indicate discontinuation in services and difficulty to follow up, for a variety of reasons, like the lack of medical records. Despite the ability of PHC in performing preventive and public health interventions, Greece reports one the highest rates of chronic diseases among the EU-27, with cardiovascular diseases and lung cancer being the leading causes of death, while mortality from diabetes and chronic respiratory conditions have increased over the last two decades [58,59,60]. Chronic conditions are not addressed adequately and integrated care is in an embryonic stage [61]. Even though approximately 25% of deaths are attributed to behavioral and lifestyle risk factors (including tobacco use and obesity), which could be addressed at the primary care level [37], there is still a long way ahead towards actual integration and chronic disease management. Despite the reforms, levels of integration are still quite low [62] especially with public health services and significant gaps in health promotion and preventive services have been identified [63, 64].
Prior to 2011, social insurance schemes covered almost the entire population, but by 2016 25% of the population lost their right to use EOPYY-financed health services [3]. When insurance funds merged under EOPYY in 2011, the package of services was rationalized and standardized. However, instead of investing on equal access to primary care services and family doctors, a big portion of the fund’s expenditure was given retroactively to hospitals, diagnostic services, and pharmaceuticals [28, 58]. A 2015 survey showed that the most common reasons for utilizing PHC were acute problems, drug prescription, and routine checkups, with only half the participants reporting adequate consultation time with the doctor [39]. The majority of the consultations were done within 10 min, which is a very short timeframe to perform preventive medicine and address behavioral risk factors. In the same study, 25% of participants reported low quality of healthcare services [39]. Later evidence revealed services being reduced to the bare minimum, with inadequate consultation time and it was highlighted that health literacy and support for self-management could not be achieved with such short consultation times [40].
In populations where there is low access to healthcare and even more so among vulnerable groups like older people with multimorbidity, self-management seems to be the most relevant modality [64] and a core element of integrated models. Chronic and palliative care are often either provided by relatives or informal carers, when at the same time health literacy which could support carers or self-management is at a significantly underdeveloped stage [40]. Consultation time for people with multimorbidity is not adequate, older people find the system too complex, and the one-point contact that could be a family doctor or other professional, is often missing [40]. People-centredness and integration are re-emerging issues brought up by users themselves much before the onset of the crisis [31]. Vulnerable and marginalized groups did not usually receive prevention and health promotion services [64]. It is noteworthy that the most frequent requests among PHC users in the recent years was the increase in the number of public health units [65]. Service users report that family medicine is necessary [31], indicating that citizens are not against a central role of PHC.
In regards to the TOMYs, the more frequently provided services include promotion of population health, planned adult and child health care, elderly health care, multi-morbidity monitoring, development of interventions and actions to promote health in the community, whereas services that need further development include public health services (including vaccination services), home-based healthcare, post-hospital care and rehabilitation [55]. A survey among TOMY users, indicated relatively high satisfaction, especially regarding the quality of medical and nursing care [66]. It is noteworthy that the quality of nursing care had high mean scores, which could indicate the gradually increasing trust of people to nurses in PHC and an expansion of their responsibilities. Although there seems to be a reorientation towards preventive services and community outreach as depicted in the 2017 law [22], it still remains to be assessed whether the actual practice corresponds to the legal framework [5, 66]. The overall framework of the job description does not automatically allow implementation, as operational and clinical guidelines have to be developed and introduced [37, 67]. Surveys among the employees suggest though that healthcare teams are happy that they can use their flexibility and autonomy to formulate community outreach actions [55].
Considerable differences, however, were found between facilities in their orientation towards acute or chronic care, with the most efficient ones focusing on prevention and chronic disease management [68]. Overall, disease management appears ineffective and there is no community outreach, whereas only few people receive screening services [5]. Even though evidence shows that GPs agree on the importance of screening in improving care, GPs older than 50 years of age, those practicing for more than 15 years, and GPs working in private sector, are less likely to comply with screening recommendations [63]. In practice the situation is more complex, as few clinical guidelines are in place in most of the PHC units and medical records are being kept internally [69]. Almost 9 out of 10 family doctors in the TOMYs report that they use a package of 13 General Medicine Guidelines/13 PHC Protocols provided by the Ministry of Health, along with an operational guideline called “Handbook for the Operation of Local Health Groups” [55]. It appears though that care for chronic patients and frail people along with promotion of self-management, need to be improved as does disease management through recorded clinical governance and data analysis [70].
Other limitations at achieving operational integration include absence of an organized referral system that could support the handling of emergencies [71], patient pathways, and an established social and community care system [37, 72, 73]. Electronic health and telemedicine have not been developed, despite the geographical dispersion of islands and remote areas and the high concentration of refugees especially on the islands of the North-Eastern Aegean, with limited provision of healthcare services [42, 43]. Consequently, the majority of the refugee population seek care at the emergency departments of hospitals and specialist care and not in PHC, whereas preventive services, with a few exceptions for certain communicable diseases and vaccinations, are not provided almost at all [43].
Apart from TOMYs, which have social workers in their teams, evidence suggest that PHC rarely supports mental health services, at least not in a coordinated manner. The number of people visiting PHC during the financial crisis of 2008–2018 due to mental health concerns increased [74], exacerbating already severe gaps in mental health service provision [75]. Communication and collaboration between primary care and mental health services is rather ineffective and professionals on both ends are rarely trained to refer people on to other services [76]. It has been suggested that the inclusion of psychiatrists in PHC might decrease the social stigma around mental health, increase population access to mental health services, and improve the detection and management through multidisciplinary involvement [77]. Overall, evidence indicates that service users are not involved in health decision making, stakeholders are not trained adequately to understand and promote integrated care, and the coordination of care is absent [67].
Financial protection
The case of Greece shows that linking healthcare entitlements with employment and contributions can significantly increase OOP for healthcare during an economic crisis. By 2016, approximately 25% of the population was uninsured thus not having access to healthcare services [28] and although law 4368/2016 [44] granted access to public services, the uninsured still had no access to services financed by EOPYY, including the EOPYY contracted physicians. In 2010, OOP was 28.6% of the health spending whereas in 2018 increased to 36.44% [4]. Catastrophic health spending appeared to decrease, but unmet needs increased. Evidence shows that 7.2% of households in Greece had experienced catastrophic health spending in 2010, a percentage that increased to 10.5% in 2015 and slightly dropped to 9.7% in 2016. The average OOP is much higher than expected, while catastrophic health expenditure increased particularly in the poorest quintiles of the population [78].
In 2014, EOPYY contracted doctors on a fee-for-service basis with a limit of 200 visits per month, paying the doctor 10€ per visit [33]. The limit was reached within few days and after that people had to pay using OOP [3, 5, 28]. Sometimes service users paid informally to avoid searching for a doctor who had not reached their visits and prescription limits [5]. This supply-induced demand for specialist services rather than preventive medicine, increased private expenditure and OOP, both through co-payments and informal payments. Until 2016, 44% of OOP among households who experienced catastrophic health spending were for medicines particularly among the poorest quintiles [78]. Furthermore, in regards to PHC services, outsourcing the appointment system for the contracted physicians, passed on the cost to the caller/patient, with prices ranging from €0.95 to €1.65 per minute [5].
Medicines and pharmaceuticals – with few exceptions – are not provided at PHC facilities. Patients receive the prescription and pick up the medicines at private pharmacies. An e-prescription system was initiated in 2010 and 2 years later prescription guidelines were also introduced. Most prescription medicines in Greece are dispensed with a fixed co-payment which varies between 0% for people exempted (uninsured, vulnerable etc) and 25% [5]. Service users also have to pay the difference between the price reimbursed by EOPYY and the retail price [5, 58], which might explain the reason why the share of OOP for pharmaceuticals is the largest [58], despite the significant pharmaceutical expenditure of the organization [33]. The amount people have to pay OOP therefore varies depending on the medicine purchased [3]. The negative effect of this co-payment policy is magnified when medicine prices are relatively high (e.g. due to inadequate regulation) and when doctors and pharmacists are not required or do not have incentives to prescribe and dispense cheaper alternatives. Overall, the household expenditure for pharmaceuticals and the average proportion of co-payments per month has increased from 9% in 2009 to 30% in 2016 [5, 28].
In addition to co-payments for prescribed medicines, OOP for medicines may arise through the purchase of over-the-counter medicines [3]. It is worth mentioning that the profit margin for pharmacies for over-the-counter medicines and non-reimbursed prescribed pharmaceuticals is around 35% [3]. Evidence also suggests that in order to avoid paying both for the doctor visit and the medicine, service users sometimes prefer to obtain prescription medicines over the counter, which means they have to pay the full cost [5]. This is facilitated by weak enforcement of regulation governing the dispensing of medicines [78] and by the availability of 216 out of 1582 (in 2016) over-the-counter medicines in stores other than pharmacies [3].
Disadvantaged and vulnerable groups, like migrants and unemployed people, reported financial barriers mostly for pharmaceuticals, which indicates barriers in access to PHC, exclusion from benefits, and unprescribed over-the-counter self-medication [42, 43]. In response to this, citizens organized PHC clinics in the form of solidarity outpatient clinics providing preventive, chronic and emergency healthcare to, mostly, uninsured people and migrants [35]. It is worth noting that even though disadvantaged groups like the uninsured, chronic patients, pensioners, and migrants find that healthcare is too expensive, they tend to prefer, where possible, the private sector over the free public one, with the perception of superior quality and timely access [40, 79].