Many Greek households are at financial risk due to the large sums they pay out, either because they have chronic illnesses or their income is so low that most of it goes toward healthcare expenses. Kyriopoulos says the WHO survey was conducted so as to evaluate that risk. The risk is high in Greece, where socially and economically disadvantaged groups pay disproportionately high amounts. Households pay taxes and social insurance contributions to fund the health system, but they often have to resort to private payments as well. These private payments amount to 1.7 trillion drachmas a year. The study shows the health system’s problems arise from lack of funding and inadequate insurance coverage. A 20-year economic crisis and high inflation is reflected in the health system, keeping subsidies low. But there is a crisis in social insurance too, explains Kyriopoulos. Unemployment and under-employment deprive insurance funds of money, which means they cannot purchase services from hospitals and doctors at real prices. The effect is to negate the basis of social welfare, as the WHO study shows. It would not be accurate to say that the health system is not effective as such. Studies by the WHO and Greek researchers indicate the converse is true. But the funding and insurance problems have serious side effects on services offered by hospitals, health centers and clinics, which the insured perceive as being time-consuming and of poor quality. The study, which used 40 years of data from the Social Insurance Foundation (IKA), showed that when disposable income rises, so does private expenditure, while the use of public health services decreases. This can be observed in other funds. And it is due to the fact that service is poor and not very accessible. When households can afford it, they reduce the time and inconvenience by paying directly for private sector healthcare. Kyriopoulos points out that the price of public system healthcare is very low, which has side effects on health professionals: When prices fall, so does supply, availability, productiveness, and motivation among doctors, nurses and other health professionals. I’ve never seen better proof of this in the 25 years that I have been working than in the Greek health system. How much does an IKA doctor earn? Around 300,000 drachmas. What does that mean in real market terms? Two hours’ work. How much are National Health Service physicians paid? Around 600,000 drachmas, which, in real terms, is two and a half hours’ work. That is how much most of them work. I wonder why we don’t realize it. Of private medical expenditure, 90 percent represents direct payments by people without any supplementary payment by insurance funds, says Kyriopoulos, who believes alternative solutions must be found. The way in which these payments are made directly, without the intercession of any public or private insurance agency, minimizes the consumer’s sovereignty and puts households in an even more difficult position. Survey statistics The research was based on statistics from the budgets of 7,000 households in a random sample that was representative of the overall Greek population. In calculating how fairly the economic burden of funding health services was distributed, the research team took into account households’ income and expenditures, information from the Finance Ministry concerning income tax, property tax, owner-residents tax, VAT, and IKA data and other social insurance funds. The survey used a method where an indicator ranging from zero to one shows how fairly the burden of health services funding is distributed. The closer the indicator is to the round number one, the fairer the distribution of the burden. In Greece the figure is 0.924 – very low compared to other European countries. Luxembourg, for example is 0.98, Germany 0.978 and Spain 0.971. Greece is at 41st position, with 0.963, in the list of all WHO countries. The figures for developed countries in the OECD and the EU is 0.970 and upward. The WHO indicator, says a member of the research team, refers to the percentage of total household income spent on health services in relation to income minus food expenses. The expenditure includes direct payments, taxes, contributions to social or private insurance, doctors’ visits, medical treatment. The distribution of the burden would be even if this figure were the same for all households. It is not, thus the burden is unevenly spread.