Personal responsibility and public healthcare: Greece on a wing and a prayer
Apart from coronavirus and pandemic, the words on everyone’s lips in Greece over the past few days have been “personal responsibility.” This is what Prime Minister Kyriakos Mitsotakis called for in his first televised address about Covid-19 as he revealed the first batch of measures the government had taken to combat the virus.
“No measure can replace personal responsibility,” he said last Wednesday, after closing schools and universities. His observation is perfectly accurate. In western societies, where paternalistic behaviour from the state is shunned and individual freedoms often overpower collective interests, imposing any top-down solutions is going to be a big challenge. This was underscored in a recent Wall Street Journal article on the different approaches to the virus in Italy and South Korea.
Of course, if he was truly expecting Greeks to show personal responsibility in the absence of a clear and immediate threat, the prime minister apparently does not know the country he leads very well. After all, this is where the smoking ban was flouted for years, crash helmets are used to protect motorcycle riders elbows rather than heads, wheelchair ramps are considered perfect places to park cars, a political leader sells on TV a balm he claims protects users from coronavirus and MPs from the ruling party advertise the fact they have participated in Holy Communion amid possibly the greatest public health crisis the world has faced in a century.
Furthermore, an opinion poll published last week indicated that roughly 30 percent of respondents believe the coronavirus was lab-developed and released to create global instability, would not want the vaccine when it is developed and feel Holy Communion is not dangerous in the current circumstances. If the survey is accurate, the concept of personal responsibility is unlikely to have any relevance for around a third of the population (assuming that the same people gave these three anwers).
If Mitsotakis did truly place his faith in Greeks to show maturity as the number of confirmed coronavirus cases grew steadily and the first deaths from the disease were announced, he was betrayed swiftly. The site of packed cafes, shopping malls and playgrounds in the days after schools closed led to him ordering them, along with theatres and cinemas, to be shut down on Friday.
Maybe the picture posted on social media a day earlier of a group of young New Democracy MPs having a night out together at a taverna was what tipped the balance. If the prime minister could not encourage personal responsibility in his own party, what chance did he have convincing Greeks to behave conscientiously?
Perhaps, the prime minister had not stated the seriousness of the situation strongly enough when he spoke to the public. Only a few weeks earlier, on January 31, the man that his government put in charge of the National Public Health Organization (EODY), which is responsible for surveillance and control of infectious diseases in Greece, told journalists that the coronavirus was like a “heavy flu,” which was not highly infectious and carried a low mortality rate. Maybe Greeks needed to be jolted out of this false sense of security by their premier.
Mitsotakis deservedly earned plaudits for becoming a first mover by adopting restrictive measures earlier than other leaders after heeding the multiple warnings coming from neighbouring Italy. But he partly undermined his own message by taking a laissez-faire approach to the Church of Greece’s insistence on continuing to hold services and Holy Communion. Just as the premier prepared to shut down schools last Monday (after avoiding calls for worshippers to be prevented from sharing the same spoon at communion), the church’s Holy Synod insisted that its Sunday services could not contribute to spreading the highly contagious virus, even though many of the faithful are in the age groups with the highest mortality rates for Covid-19.
Development Minister Adonis Georgiadis reacted to the persistent criticism of the failure to clampdown on church services by claiming that it was just born of spitefulness among those who always have it in for religion.
Mitsotakis had a chance to address this issue directly in his televised address on Wednesday, but rather than deliver a clear message, he treaded on eggshells. Mitsotakis told millions of viewers that he felt the need to call on his faith but that “the faith needed now is that we will be able to overcome the crisis.”
“As prime minister, I have to listen to the scientists with expertise,” he said. “Whatever applies to public gatherings, applies to churches.”
Mitsotakis received plaudits from some commentators for tackling this issue and delivering a measured, sober speech. However, you sense that some of those clapping from the sidelines would applaud a cardboard cut-out of the prime minister while claiming it had shown remarkable stoicism.
Let’s be clear: The New Democracy leader passed up the opportunity to highlight the gravity of the situation by essentially leaving the church to regulate itself. As a result, many Greeks who listened to the speech took away the message that there was no imminent danger for the public and that they, like the priests, could go about their normal business.
Proof of this came just a few days later, on Saturday, when parks, squares and beaches filled up with people of all ages who came out to take advantage of the fine weather. By Saturday night, Mitsotakis had to issue a new banning order, closing ski centres and organised beaches.
And yet, church services and Holy Communion went ahead as normal on Sunday. Reports suggested that Mitsotakis later spoke to Archbishop Ieronymos and asked him for churches to only be open for personal worshipping and christenings, weddings and funerals rather than for public services. It is now up to the head of the Church of Greece to show responsibility because, on this issue at least, the government does not seem prepared to display any.
While we are focussing on responsibility, we should also consider it within the context of policy making.
The immediate hiring of 2,000 doctors and nurses was among the measures announced last week by the prime minister to prepare for what is likely to be an almighty effort to keep the public healthcare system from buckling under the pressure of Covid-19. The hirings are undoubtedly necessary and it is welcome that the government is making them while the situation is still manageable. But a few other aspects need to be considered.
As Greece emerged from its third bailout in 2018, the then SYRIZA government sought to adopt a new hiring ratio in the public sector, which would lead to one new employee being brought in for every departure. It had lined up the hiring of 1,000 doctors and 1,500 nurses in 2019 as part of this process.
SYRIZA’s policy drew instant criticism from New Democracy and much of the media, which spoke of an attempt by SYRIZA to “steal the keys to the state” (which implied that they had been in someone else’s possession beforehand) and to buy votes ahead of the European Parliament and local elections due in May 2019, seen as a pre-cursor to the national vote eventually held ahead of schedule in July last year.
There was good ground for this criticism given that numerous Greek governments had used public sector jobs as vote winners in the past and that SYRIZA could barely hide its glee at being in a position to increase the number of civil servants following the extensive reduction of the public sector payroll during the crisis years.
However, as was the case during the crisis when jobs had to be cut, recent arguments over hirings were not based on any clear concept of which parts of the public sector were in most need of personnel, nor of what dangers they faced, or how they could benefit. It was always a row over who would make the cuts or additions. Nothing more. Even when the troika of international lenders mandated reductions in public spending during the bailout year.
As Greece’s two leading parties were squabbling over appointments in late 2018, the Council of Europe’s Commission for Human Rights published a report detailing the dire state of the Greek health service.
The report argued that “large-scale austerity measures have both crippled the healthcare system’s capacity to respond to the medical needs of the general population, and at the same time increased these needs.” It pointed out the serious under-funding of the health system, with public health expenditure at approximately 5.2 percent of GDP compared to an EU average of 7.5 percent. Funding of public hospitals fell by more than half between 2009 to 2015, it pointed out. Treatment services, diagnostics, and disease prevention programmes were cut by 20 percent.
The report also highlighted that, according to the Health Ministry, some 18,000 doctors left the country during the economic crisis, while in 2018 the Panhellenic Medical Association estimated that public hospitals were short of 6,500 permanent staff.
There is another aspect to this story, though, which has to do with the considerable waste and corruption in the health sector before the crisis. During the 2000s, Greece’s health care spending outpaced the country’s growth rate, with total expenditure on health rising from 14.7 billion euros (8.6 percent of GDP) in 2003 to 22.5 billion euros (9.5 percent of GDP) in 2009, an increase of over 53 percent. Spending on pharmaceuticals per person shot up by an estimated 80 percent over the same period.
Both the absolute spending levels and the rate of increase were out of line with the rest of the European Union, where the average health care spend went from 8 percent to 8.9 percent of GDP, while spending on drugs went up by just 29 percent over the same time frame.
The wastefulness of the pre-crisis years, the austerity of the bailouts and the successive failed healthcare policies have left the Greek health system in a highly vulnerable state.
A study published by the Dianeosis think-tank in Greece a few weeks ago drew on the expertise of seven academics with extensive knowledge of the country’s public healthcare system. They concluded that the service’s key problems included an absence of organised primary health care, lack of modern units, limited use of new technology, an almost total absence of control and evaluation mechanisms and an aging workforce.
The study found that up to a third of emergency room cases are estimated to be for conditions that could be otherwise dealt with at primary care units, which are seriously lacking in the Greek system. Staffing was also an issue - while Greece has the highest number of doctors as a proportion of the population among OECD countries, it also has the lowest number of nurses. It is estimated that the system requires two to three nurses per doctor, and currently only has 1.3. This has led to a shortfall of around 20,000 nurses, the report indicated.
When New Democracy came to power last July, one of the first things it did was to push ahead with the health sector hirings that had not been completed under SYRIZA (apparently earlier concerns about the public sector being stuffed with party loyalists had disappeared). But it also announced the hiring of 1,500 motorcycle-riding policemen. even though Greece has 497 police officers per 100,000 inhabitants, the second-highest ratio in the EU and almost 50 pct above the EU average, raising questions about whether this was the most appropriate use of public resources.
Like their counterparts in Italy and Spain, Greeks are being called upon to go onto their balconies each evening and applaud their health service workers, who are undoubtedly deserving of our gratitude. But don’t let this mask the fact that, in Greece’s case at least, these people work in conditions that do not befit them and are unsuitable for tackling any crisis because of the systematic enfeebling of the public health system over many years.
In the coming days, when we are reminded about the importance of personal responsibility, we must act with the maturity these exceptional circumstances demand, but we should not forget the concept of political accountability.
When all this is over, we will have to rebuild from whatever is left. And to do so, we will need to be clear about where things went wrong. We should have no doubts that permitting exceptions to rules designed for the benefit of all undermines any concept of a collective effort. We will also have to agree that we need to invest in and nurture our vital public services rather than rely on desperate prayers to respond to challenges, whether they are the ones we face each day or those that will define our generation.