Intended for healthcare professionals

Observations Austerity in Europe

“Troika” mandated austerity and the emerging healthcare crisis in Greece: an open letter to the Greek government

BMJ 2013; 346 doi: (Published 30 April 2013) Cite this as: BMJ 2013;346:f2807
  1. Thomais Kakouli, lecturer in biosciences1
  2. and co-signatories
  1. 1Department of Science and Health, Institute of Technology Carlow, Carlow, Ireland

Thomais Kakouli and more than 100 co-signatories of Greek scholars and physicians write to express their concern regarding the current dire state of healthcare services in Greece

To the prime minister of Greece and president of New Democracy Party, Antonis Samaras; the president of PASOK, Evangelos Venizelos; the president of the Democratic Left, Fotis Kouvelis; the minister of health, Andreas Lykouretzos.

Our country has fallen into a dismal state, and it is constantly challenged by extrinsic and intrinsic pressures, while the economic and social climate deteriorates further day by day. The Greek government, in total obedience to the irrational demands of the “Troika,” focuses on the obligations of the citizens towards the state and seems to forget or ignore its own obligations towards its citizens. The government has imposed a brutal and self defeating fiscal austerity: in a confiscatory manner, it tries to collect extra revenue from an already impoverished and afflicted populace, while it neglects its main role, as specified by the constitution—the protection of the rights and the welfare of the citizen body.

In three short years, governments comprised of the current coalition parties have managed to reduce the country’s gross domestic product (GDP) by 25%, leading Greece to the deepest and longest lasting economic depression in the history of the modern Western world. During the same period, the public debt expanded from 109% of GDP to 170% of GDP, unemployment rose from 8% to 27%, and youth unemployment now holds the world record at 58%. Incomes have been reduced by more than 40%, leading to a record number of families and individuals living below the poverty line. It is worth noting that the famous “haircut” (PSI), presented by the government as a notable achievement, ultimately increased the public debt while raiding the reserves of pension funds, reserves that were gathered painstakingly by the contributions of workers and pensioners.

One of the sectors that has been most hard hit is healthcare. The public health system in Greece is now collapsing on all fronts. Having signed a memorandum of understanding with the unelected and unaccountable Troika to reduce public health expenditures from 9.8% of GDP (pre-crisis) to 6% of GDP (the shrunken, post-crisis GDP), the Greek government has instituted measures which seriously undermine the health of the population. Removing health coverage from thousands of unemployed is guaranteed to increase mortality in this segment of the population.

This policy of subservience to the Τroika’s demands has led to the closure or downgrading of hospital units. For example, the hospital of the town of Kymi “Georgios Papanikolaou,” the hospital of the city of Thebes, and many others in the provinces and in metropolitan centres have seen their medical personnel reduced, the staff remained unpaid for long periods, their medical equipment in progressive deterioration, and laboratories with increasing shortages in all kinds of consumables (syringes, bandages, reagents, etc). Patients now have to pay for consumables, for medical tests, and for surgeries. This is all on top of what they already paid through their insurance funds. Those with chronic diseases, such as chronic obstructive pulmonary disease, are forced to pay a 25% deductible for the cost of their medication, whereas before the crisis this deductible stood at 5%. Cancer and kidney failure patients not only face the increased costs of specialised treatments but also the general rundown of these facilities, loss of key staff, and dramatic shortages in medications. Unable to receive treatment at home anymore, they have to travel long distances and wait in endless queues in the corridors of bureaucratic health insurance offices and hospital clinics. Patients in mental health units, such as Dromokaitio, face every day the alienation and indifference of a state that fails to support them. The staff and the resources in most psychiatric clinics are decreasing rapidly, while the number of patients is increasing (as this crisis is taking its toll). Psychiatric hospitals in Greece can no longer perform at the level required to provide even basic treatment to patients diagnosed with serious mental illnesses.

Furthermore, the establishment of a “standard rate” for surgeries is forcing patients to pay in advance about 20% of the value of materials and services. This standard rate makes emergency and elective surgeries virtually impossible for a broad segment of the population. For example, on the basis of the newly introduced pricing, the cost for a hip replacement surgery at a public hospital is about €1000 (£840, $1300); this cost is further increased by the remuneration of the surgeon, the anaesthetist, and other essential staff. Thus, this common surgery is unaffordable by an elderly patient with a basic pension of less than €600; such retirees would be unable to secure the funds, having to prioritise purchasing of basic foodstuffs, paying for rent and utilities, securing funds for heating, acquiring regular medication, and affording sundry living expenses (and often this small pension supports an additional family member).

Beyond these specific destructive measures, one can easily recognise the impact on public health of the consecutive decreases in pensions and the confiscatory tax measures. Many pensioners have no choice but to forego basic lifesaving drugs and healthcare monitoring in order to afford food and heating (the government’s devastating policies in heating fuel are duly noted here). The pricing of basic goods has increased (not only by inflation but also by the drastic increases in tax on even basic items), while incomes have been drastically reduced. The imposed increase of 500% or more on deductibles for drugs and doctor visits are simply making it impossible for many pensioners to maintain their assigned treatments. The consequences are increased morbidity and mortality, especially for people with serious and chronic diseases.

This rapid decline in the quality of care administered is complemented by the haemorrhaging of highly trained individuals—more than 4000 Greek doctors have emigrated because of their frustration with the degradation of the system and the successive cuts in wages, overtime remuneration, and benefits. It is worth noting that the national health system (ESY) in our country has operated efficiently, provided exceptional services, and constituted an important achievement of our society before the crisis. It was the hard work of the doctors, nurses, pharmacists, laboratory scientists and technicians, administrators, and ancillary staff of ESY that advanced the status of the public health in the country. This system is now bereft of basic resources, besieged at every level, and plundered with your consent. Its members are fleeing in increasing numbers.

In this context, we call on the Greek government to keep and defend the value of health. There should be no cuts on funds required for the normal operation of the hospitals in Greece, both for those in major metropolitan centres and those in the islands and other remote areas of our country. We ask that you do not downgrade regional hospitals to just health centres. Such centres will provide limited services and result in the collapse of public health in the provinces. Do not let these regional and provincial hospitals remain understaffed, manned simply by general practitioners or pathologists, bereft of key specialised staff; your policies will degrade terminally what has been the key strength of these regional hospitals, a strength that contributed greatly to the improvement of public health in Greece in the past few decades. If your policies were fully enabled, key specialised staff would be found only in large, crowded hospital conglomerates in metropolitan centres. Such a policy would force Greeks who need special attention to travel farther from home in order to secure proper care, assuming that they can even afford it. The additional costs and the absence of timely specialised care would undoubtedly lead to increased morbidity and mortality in the provinces. A welfare state that respects its institutions and history, and cares about its continued existence in the future, should not contemplate such drastic cuts in public health. Such actions can be expected by foreign installed, occupation governments, not by a government of Greeks for Greeks.

Thus, we request the following actions by the Greek government:

  • 1. The proper staffing, maintenance, and modernisation of existing hospitals in the country, especially in the provinces and the islands

  • 2. The restoration of proper medical coverage of population groups, the collective health of which is especially under threat by the current economic crisis. These groups include the long term unemployed, the working poor, low income pensioners, and others. For these population groups, you must introduce a substantial rollback of the increases in the cost of healthcare that you have instituted

  • 3. The creation of policies and incentives that will assist in the proper geographical allocation of physicians and nursing staff of all specialties in order to avoid needless and counterproductive concentration of qualified staff (often unemployed) in metropolitan centres

  • 4. The proper remuneration of physicians, nurses, laboratory scientists, and technicians to avoid further depletion of these key staff through emigration. The drastic cuts in wages, salaries, and overtime pay must be rolled back. Otherwise, the exodus of qualified staff will turn into a stampede, with disastrous consequences for public health

  • 5. The introduction of policies that will assist in the ready availability of drugs, consumables, laboratory supplies, and devices. The government should forgo unconvincing public releases about primary surpluses and regularly pay suppliers and pharmaceutical companies the full amount owed.

As the government of Greece, you have the responsibility for our country’s survival and for the welfare of its citizens. You have no right to obtain credit by degrading the health of your compatriots and by sending to an early grave the most vulnerable among us. You are obliged to say “No” to the demands of the unelected members of the Troika, when obedience to these demands has devastating consequences for our country. If saying no to the Troika’s destructive demands means exiting the eurozone, then you must do so. Many of us believed in a united Europe, but the eurozone has proved to be only a means of exploitation of the weaker nations by the stronger ones. The consequences of our continued participation in the common currency have become obvious by now. Along with the impoverishment of our country, you have made us forget not only the meaning of “pride” but also the meaning of “dignity.” Despite the ongoing crisis, record unemployment, the rapid decline in GDP, the dramatic increase in poverty and hunger, the deteriorating health of the population, the sharp decline in birth rates, the wave of suicides, and total loss of hope, you cling tenaciously to your policies of supplication and subjugation while continuing to sell off public property and public companies at rock bottom prices.

The disastrous policies that undermine even the basic health of the Greek population must come to an end. As Greeks, we are able to survive the crisis and rebuild. However, to do so, having our physical health is a prerequisite.


Cite this as: BMJ 2013;346:f2807


  • Co-signatories to the open letter: Medical and support staff of the Metropolitan Social Clinic of Elliniko, Greece; Alkis Akritas, professor, CS/KU, USA; Efrosini Albrecht-Piliouni, International Programs, Auburn University, Auburn, AL 36849, USA; Efstratia Almpoura, developmental psychologist, IED-Paris8, Vincennes-Saint Denis, Paris, and Harvard ES, Cambridge MA, Athens, Greece; Ioanna Anastassopoulou, professor, School of Chemical Engineering, Department of Material Science and Engineering, Athens, Greece; Antonios Andreatos, professor, Department of Computer Science, Department of Air Science, Air Force Academy, Athens, greece; Theodoros Antikas, Greece; Aggeliki Apostolaki, psychologist, AUTH Faculty of Philosophy, Department of Psychology, Thessaloniki, Greece; Ioannis Argyrokastritis, associate professor, Agricultural University of Athens, Greece; Giannis Argyropoulos, AT&T Labs; Vassiliki Aroniadou-Anderjaska, associate professor of neurosciences, Bethesda, Maryland, USA; Kimon Valaskakis, former ambassador of Canada, professor of economics (emeritus), University of Montreal, Canada; Evangelos Vallianatos, associate professor, Pitzer College, USA; Tasos Vartholomaios, registered consultant pathologist, member of the Faculty of Homeopathy, UK; Athina Vartholomaiou-McLean, professor, Sociology, Anthropology and Social Work, Central MI University USA; George Vichas, cardiologist, head of the medical team of the Greek Metropolitan Social Clinic of Elliniko, Greece; Jacques Vigot, artist-painter, educator in painting and drawing, Animation Center Les Halles-Le Marais, Paris, France; Alexander Vogiatzis, former associate professor, University of Macedonia, Greece; Angela R Burriel, professor, Veterinary Microbiology, University of Thessaly, Greece; Bucher Matthias, assistant professor, University of Crete, Chania, Greece; Lito Georgopoulou, educator, Greece; Efrosyni Giannaki, surgeon dentist, Dental School of the National and Kapodistrian University of Athens, Greece; Spiros Yannacopoulos, associate dean and director, School of Engineering, University of British Columbia, Okanagan Kelowna, Canada; Panagiotis Giannopoulos, associate professor, Department of Civil Engineering, University of Patras, Greece; Konstantinos Giannoukos, doctoral candidate, Faculty of Engineering, Division of Materials Mechanics and Structures, University of Nottingham, UK; Stamatios Giannoukos, research assistant and doctoral candidate, Department of Electrical Engineering and Electronics, University of Liverpool, UK; Nikos Giokaris, professor, Department of Physics, University of Athens, Greece; Nina Gatzoulis, Languages, Literature and Cultures, University of New Hampshire, USA; Stella S Dascalopoulos, assistant professor in medicine, director, Vascular Health Unit, Department of Medicine, Division of Internal Medicine, McGill University, Canada; Socrates Dokos, associate professor, Graduate School of Biomedical Engineering, University of New South Wales, Sydney, Australia; Margarita Dritsas, emeritus professor of economic history, Greek Open University (Hellenic Open University), Greece; George Savva Eleftheriades, ExarchOSETrAu, New South Wales, Australia; Evgenia Eleftheriades, Sydney, New South Wales, Australia; Christos C Evangeliou, professor of philosophy, honorary president of IAGP, Towson University, Towson MD, USA; Zavos Panayiotis, director and chief of andrology, Andrology Institute of America, president of ZDL, Lexington, KY, USA; Evgenia Zerva, doctoral candidate, Process and Environmental Engineering Research Division, University of Nottingham, UK; Vassiliki Zotou, Language and Linguistics in Education, University of Thessaly, Volos, Greece; Gregorios Zografopoulos, dentist, Dental School of the National and Kapodistrian University of Athens, Florina, Greece; Ifestos Panagiotis, professor, International Relations-Strategic Studies, University of Piraeus, Department of International European Studies, Greece; Anthony Theocharopoulos, lecturer in dental technology, Cork University Dental School and Hospital, Wilton, Cork, Ireland; Ioannou Petros, Electrical Engineering, University of Southern California, Los Angeles, CA, USA; Polyxeni Kaimara, Physical Medicine and Rehabilitation Center Florina, Greece; Theophilos Kakoullos, emeritus professor, University of Athens, Greece; Lambros Kamperidis, Concordia University, Montreal Classics, Modern Languages and Linguistics, Canada; Anastassios Carayannis, professor, Department of Applied Human Sciences, Concordia University, Montreal, Canada; Irini Caranastassi, assistant professor, Department of Greenhouse Crops and Floriculture, School of Agricultural Technology, TEI of Messolonghi, Greece; Panayiotis Karanis, professor of parasitology and anatomy, Medical School, University of Cologne, Cologne, Germany; Costas Katsifarakis, professor, Department of Civil Engineering, Aristotle University, Thessaloniki, Greece; Panagiotis Kelandrias, associate professor, Department of Translation and Interpreting, Ionian University, Greece; Luce Keromnes, retired senior manager of health, (CCI) School of Nurses-Managers of Pitié -Salpêtrière, Paris, France; John Kontos, professor emeritus, NKUA, Greece; Stamatina Kopatou, professor of French, French Institute of Athens (INFA), Greece, University of Languages and Literature Grenoble, Athens, Greece; Constantine Koudounas, Graduate Department of Physics UoA, Gold Coast, QLD, Australia; Mairi Koutselini, professor, University of Cyprus, Cyprus; Maria Kranidioti, associate professor, School of Law, University of Athens, Greece; Fenia Kriara, Aegean University, Greece; George Kyriakou, professor, Demokrition University of Thraki, Greece; Theophilus M Koletis, professor of cardiology, University of Ioannina, Greece; Petros Comodromos, lecturer, Department of Civil & Environmental Engineering School of Engineering, University of Cyprus, Cyprus; Demosthenes Kostantatos, Greenwich CT, USA; Dimitrios I Konstantelos, emeritus professor of Byzantine history and theology, Stockton College of New Jersey, Galloway, New Jersey, USA; Antigone Kostas, doctor of psychiatry, Greenwich CT, USA; Christina Lazaridis, retired from Dupont Company, Wilmington DE, USA (and Heraklion, Crete, Greece); Anastasios Lazaridis, professor emeritus, Widener University, Chester PA, USA (and Heraklion, Crete, Greece); Venetta Lampropoulou, professor of special-deaf education, president of the International Congress on the Education of the Deaf, Deaf Studies Unit, Department of Primary Education, University of Patras, Greece; P Lekanidou, emeritus professor, UoA, Greece; Abraham Loutridis, PhD candidate, Antenna and High Frequency Research Centre, Dublin Institute of Technology, Dublin, Ireland; Ioannis Μanios, surgeon dentist, National and Kapodistrian University of Athens, Faculty of Dental Surgery, Athens, Greece; Kostas Melakopides, associate professor of international relations (retired), University of Cyprus, Nicosia, Cyprus; George Michalakopoulos, assistant professor, Department of Translation and Interpreting of the Ionian University, Greece; Aristidis Moshakis, Concordia University, Montreal, Canada; Costas Moulopoulos, associate professor, Department of Physics, University of Cyprus, Nicosia, Cyprus; John E Batzakas, lecturer, University of the Aegean, Greece; Naoum Bacalis, Institute of Theoretical and Physical Chemistry, National Research Institute, Athens, Greece; George Baloglou, associate professor emeritus (SUNY Oswego), Thessaloniki, Greece; Victor Balopoulos, assistant professor Department of Civil Engineering, Democritus University of Thrace, Greece; Κ George Blytas, research consultant Royal Dutch Shell (retired), president GCB Separations Consulting, Texas, USA; Ioannis Bougas, professor of statistics, Montreal, Canada; Eleni Briasouli, professor, Department of Geography, University of the Aegean, Mytilene, Lesvos, Greece; L Nicholas Moraitis, professor of international relations-comparative politics, University of California, Berkeley, USA; Maria Negreponti-Delivani, former rector and professor, University of Macedonia, Greece; Julia Notopoulou, developmental psychologist, Athens, Greece; Anne-Pascale Octeau, artist-painter, educator in painting and drawing, Paris, France; Basil P Panoskaltsis, Greece; Joanna Papavasileiou-Alexiou, assistant professor of counselling and guidance, University of Macedonia, Department of Educational and Social Policy, Thessaloniki, Greece; Gregorios Papagiannis, Byzantine Philology, Demokrition University, Thraki, Greece; Nikos T Papadopoulos, emeritus professor of medicine, Aristotle University, Thessaloniki, Greece; Maria Papadopoulou, civil engineer, Larissa, Greece; Maro Papathanasiou, professor, Department of Mathematics, University of Athens, Greece; P Stavros Papamarinopoulos, professor, University of Patras, Greece; Nikolaos Paparodopoulos, former lecturer, University of Aegean, Greece; P George Paul, associate professor, Department of Electrical and Computer Engineering, Polytechnic School of Xanthi, Xanthi, Greece; Sandrine Péré-Pasturel, nursing-nurse manager, Creche au Pont, Rhône-Alpes, France; Leonidas Petrakis, chairman and senior scientist (retired), Department of Applied Science, Brookhaven National Laboratory, USA; George Pirgiotakis, former associate professor, Greece; Anastassios Retzios, president, Bay Clinical R&D Services, San Ramon, California, USA; Aikaterini Riga, director of nematology laboratory and senior scientist, Verdesian Life Sciences, Pasco, WA, USA; Peter Roussos, assistant professor, Agricultural University of Athens, Greece; Veronique Sakatcheff, cognitive-behavioral psychologist, IED-Paris8, Vincennes-Saint Denis, Paris, Toulon, France; Maria Sarri, surgeon dentist UMFT Victor Babes, Athens, Greece; Elias Stamboliadis, professor, Department of Mineral Resources Engineering, Technical University of Crete, Greece; Niki Stavrakaki, professor of education, Ireland; George P Stavropoulos, cytologist, University of Athens, Athens, Greece; Mika Stavropoulou, Research Faculty, UoA, Greece; Georgia Stavropoulou, Los Angeles, CA, USA; Vasilis Stylianakis, University of Patras, Greece; Stavros-Dionisios Tzamtzis, psychologist, graduated from Aristotle University, Thessaloniki, Greece; George Tsobanoglou, president, International Sociological Association, Research Committee on Sociotechnics & Sociological Practice, associate professor, University of the Aegean, Department of Sociology, Mytilini, Greece; Anna Tsirka, paediatric cardiology, assistant professor, Tufts University School of Medicine, USA; A M Tsoutsoulopoulou, School of Humanities, University of Thessaly, Greece; George P Flessas, professor, Department of Information & Communication Systems Engineering, Department of the Aegean, Karlovassi, Samow, Greece; Evangelia Floros, professor, Tel & GL Larissa, Department Decorators/Graphic Designers, School of Architecture, University of Thessaloniki, Larissa, Greece; Katerina T Franzi, associate professor of informatics, Department of Mediterranean Studies, University of the Aegean, Greece; Stavros Fridas, professor of parasitology immunology, Thessaloniki, Greece; Pantelis Halamantaris, professor emeritus, Brandon University, deputy director, University of Manitoba Centre for Hellenic Civilization, Brandon, Manitoba, Canada; I Apostolos Hamilos, surgeon dentist, Dental School, Athens, Greece; A Ioannou Hamilou, surgeon dentist, Univerzita Karlova v Praze-Charles Univeristy, Prague, Athens, Greece; Aristotelis Hatzis, dentist, School of Dentistry, Aristotle University of Thessaloniki, Athens, Greece; Labros Hatzis, fellow, St John’s College, Cambridge University, UK, lecturer, Royal College of Surgeons in Ireland, Dublin, Ireland; N Ioannis Hatzopoulos, professor, University of the Aegean, Department of the Environment, Mytilene, Greece; Nikoletta Christodoulou, lecturer, Curriculum and Teaching, School of Education, University Frederick, Nicosia, Cyprus; Theodore Christou, assistant professor, Queen’s University, Faculty of Education, Canada.

  • Competing interests: We have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.

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