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CHRYSSA VELISSARIOU

SONGSOPTOK THE WRITERS BLOG | 4/15/2016 |





SONGSOPTOK
 INTERVIEW WITH CHRYSSA
HEALTHCARE – A RIGHT OR A PRIVILEGE?

SONGSOPTOK: Do you consider primary healthcare to be a fundamental right? Is it deemed as such in the society you live in? Please explain your answer with a few examples if possible.

CHRYSSA VELISSARIOU Regardless of our age, gender, socio-economic or ethnic background, we consider our health to be our most basic and essential asset. When we talk about well-being, health is often what we have in mind. The right to health is a fundamental part of our human rights and of our understanding of a life in dignity. The right to the enjoyment of the highest attainable standard of physical and mental health, to give it its full name, is not new. Internationally, it was first articulated in the 1946 Constitution of the World Health Organization (WHO), whose preamble defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”. The preamble further states that “the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition.” The 1948 Universal Declaration of Human Rights also mentioned health as part of the right to an adequate standard of living (art. 25). The right to health was again recognized as a human right in the 1966 International Covenant on Economic, Social and Cultural Rights. Since then, other international human rights treaties have recognized or referred to the right to health or to elements of it, such as the right to medical care. The right to health is relevant to all districts of Greece: every district has ratified at least one international human rights treaty recognizing the right to health. Moreover, my country has committed itself to protecting this right through international declarations, domestic legislation and policies, and at international conferences. In recent years, increasing attention has been paid to the right to the highest attainable standard of health, for instance by human rights treaty monitoring bodies, by WHO and by the Commission on Human Rights (now replaced by the Human Rights Council), which in 2002 created the mandate of Special Rapporteur on the right of everyone to the highest attainable standard of physical and mental health. These initiatives have helped clarify the nature of the right to health and how it can be achieved.


SONGSOPTOK: What is the system of healthcare in the country and the society you live in? Is it a just and equitable system in the sense that all citizens enjoy the same benefits across economic and social classes?

CHRYSSA VELISSARIOU: The economic crisis in Greece may offer an opportunity for the reorganisation of the health system, and although primary healthcare reform is high on the political agenda, questions remain about the direction of restructuring. THE POLITICS OF PRIMARY HEALTH CARE IN GREECE. Weaknesses in the Greek health system include poor continuity of care, excessive use of curative services, lack of preventive measures, low levels of satisfaction, high rates of out-of pocket payments, and significant inequalities in the range and quality of health services. In the past a plethora of occupational funds had offered different packages of primary healthcare coverage. In some cases they used their own infrastructure (GP-led health clinics) and/or contracted private physicians and laboratories, situated mainly in urban and semi-urban areas. In 1953 the state established the first public medical posts in rural areas a few years later, obliging medical graduates to offer their services to local populations as fully employed civil servants. In 1983 the Greek National Health System (Ethniko Systima Ygeias [ESY]) was founded following the Alma Ata Declaration's emphasis on primary care. It foresaw the replacement of the existing primary healthcare infrastructure with ESY urban and rural health centres and the unification of social health insurance schemes. In the next decade 176 health centres and 19 small hospitals were established in rural areas offering health services accessible to all, comprehensive and free at the point of use. Unfortunately, the 220 urban health centres envisaged by the ESY implementation plan, were never established. The sickness funds' primary care infrastructure and variable benefits remained untouched, due to opposition from physicians engaged in private practice, and social groups who received enhanced healthcare benefits. The 1983 reforms missed a unique opportunity to overhaul the fragmented system of social health insurance and to create a universal, integrated primary healthcare system. From 1994 to 2009 numerous primary healthcare reform plans sought to promote users' freedom of choice, to introduce the family/personal physician as the cornerstone of primary care system's structure, and to unify primary care services. A purchaser–provider split, selective contractual arrangements with existing providers, gate keeping, and capitation payments for family doctors were endorsed by all of these plans, but ultimately none were implemented. Their failure was partly due to the Greek state's administration but mainly to obstruction by those with vested interests, such as private physicians, part-time social security doctors, and wealthy insurance funds. In March 2011 the government passed yet another bill for the unification of primary care, introducing the capitated ‘personal doctor’ as the referral point within the healthcare system. It also left intact all existing primary healthcare providers, created incentives for entrepreneurs to invest in primary care facilities, and tried to integrate these providers through selective contracting with a single social health insurance purchaser. One year later this crisis-led ‘reform’ is partly implemented, facing mainly the opposition of the Greek Medical Association based on the reasonable fear that single private surgeries will soon be absorbed by primary healthcare corporate. 

PRO-CRISIS PROVISION OF PRIMARY CARE  SERVICES IN GREECE

Primary health care in Greece is fragmented, tripartite, and based on a complex public/private mix of the ESY, social health security, and the private health sector. The ESY consists of 201 rural health centres, 1478 rural medical posts/surgeries, three urban health centres, and the outpatient clinics of 140 public hospitals. Health centres are considered as decentralised units of the ESY regional hospitals and rural medical posts are considered as satellite units geographically attached to health centres. All health centres are tax-financed, receiving budgets on a retrospective basis in accordance to last fiscal year's payroll and overhead costs but not weighted for local healthcare needs. ESY health centres and medical posts are staffed with 1787 full-time salaried medical doctors (mainly GPs, pediatricians, dentists, and specialists in internal medicine) and approximately 2414 other health professionals, most of them enjoying permanent tenure. ESY centres and their satellite surgeries offer 24-hours a day, free at the point of use, preventive, curative, emergency, and rehabilitation services to their rural populations of 10–30 000 citizens. Outpatient clinics of ESY hospitals offer specialist and diagnostic services to urban and semi-urban populations, free of charge with minimal co-payments during working hours, and on a fixed fee-for-service basis during evening hours. No referral system exists, and users can bypass primary care to seek specialist services. Although ESY health centres represent a major breakthrough, their weaknesses include shortages in personnel and equipment, lack of medical record documentation, low technical and scale efficiencies compared with social security's primary care units, and low users' satisfaction rates, a fact that causes a constant flow of patients from rural to urban areas in search of better care. Social health security consists of 36 occupational sickness funds that offer different packages of primary healthcare coverage to almost 95% of the population. Some funds have their own primary care infrastructure, while others purchase services from contracted private physicians and laboratories. Their health units are staffed by full-time salaried medical doctors (mostly specialists) and part-time salaried doctors who are also free to do private practice. Within this complex regime, users have free access, during working hours, to a range of mainly curative and diagnostic services at their insurance fund's primary healthcare units and/or access, on a co-payment basis to contracted private physicians and laboratories. No referral system exists and social security beneficiaries can directly seek hospitalization at public or private hospitals. Although this primary care infrastructure substitutes to some extent for the absence of public primary healthcare services in urban areas, it still suffers from many weaknesses including surprisingly low users' satisfaction rates, excessive use of curative and diagnostic services, and unethical practices; social security doctors often use their posts to attract patients to their private offices. The resent legislation regarding PHC has been inadequately promoted. Primary Health Care in Greece is provided by a heterogeneous network comprised of services of the National Healthcare System (“Ethnikon Systima Ygeias”, ESY), Social Insurance Organizations (SIOs), regional authorities (municipalities, perfectures) and private practitioners. The main characteristics of the present PHC network are fragmentation, ineffective central coordination and inconsistency in the availability, accessibility and quality of PHC services between urban and rural areas. Health promotion services are inadequate. Recent legislation reforms target unification of the health sector of the SIOs to form a new organisation which will be responsible for the PHC network in Greece. In addition, the legislation on decentralisation confers the responsibility for local PHC policies on the regional authorities. Effective enforcement the new legislation is expected to have a favourable effect on the Greek PHC system. It is crucial that quality assessment and management systems are developed to monitor the changes.


SONGSOPTOK: Do you think that free healthcare cannot be a right, but it can be a privilege and a shared burden of sacrifice for the sake of the social contract?

CHRYSSA VELISSARIOU No it is a right . WHAT IS THE RIGHT TO HEALTH? A. Key aspects of the right to health  • The right to health is an inclusive right. We frequently associate the right to health with access to health care and the building of hospitals. This is correct, but the right to health extends further. It includes a wide range of factors that can help us lead a healthy life. The Committee on Economic, Social and Cultural Rights, the body responsible for monitoring the International Covenant on Economic, Social and Cultural Rights, calls these the “underlying determinants of health”. They include: Safe drinking water and adequate sanitation; Safe food; Adequate nutrition and housing; Healthy working and environmental conditions; Health-related education and information; Gender equality.  • The right to health contains freedoms. These freedoms include the right to be free from non-consensual medical treatment, such as medical experiments and research or forced sterilization, and to be free from torture and other cruel, inhuman or degrading treatment or punishment. • The right to health contains entitlements. These entitlements include:  The right to a system of health protection providing equality of opportunity for everyone to enjoy the highest attainable level of health;   The right to prevention, treatment and control of diseases;   Access to essential medicines; Many of these and other important characteristics of the right to health are clarified in general comment N° 14 (2000) on the right to health, adopted by the Committee on Economic, Social and Cultural Rights.  The Covenant was adopted by the United Nations General Assembly in its resolution 2200A (XXI) of 16 December 1966. It entered into force in 1976 and by 1 December 2007 had been ratified by 157 States.  Maternal, child and reproductive health;   Equal and timely access to basic health services;   The provision of health-related education and information;  Participation of the population in health-related decision making   at the national and community levels. • Health services, goods and facilities must be provided to all without any discrimination. Non-discrimination is a key principle in human rights and is crucial to the enjoyment of the right to the highest attainable standard of health (see section on non-discrimination below). • All services, goods and facilities must be available, accessible, acceptable and of good quality.  Functioning public health and health-care facilities, goods and services must be available in sufficient quantity within a State. They must be accessible physically (in safe reach for all sections   of the population, including children, adolescents, older persons, persons with disabilities and other vulnerable groups) as well as financially and on the basis of non-discrimination. Accessibility also implies the right to seek, receive and impart health-related information in an accessible format (for all, including persons with disabilities), but does not impair the right to have personal health data treated confidentially.  The facilities, goods and services should also respect medical   ethics, and be gender-sensitive and culturally appropriate. In other words, they should be medically and culturally acceptable.  Finally, they must be scientifically and medically appropriate and of good quality. This requires, in particular, trained health professionals, scientifically approved and unexpired drugs and hospital equipment, adequate sanitation and safe drinking water. Human rights are interdependent, indivisible and interrelated. This means that violating the right to health may often impair the enjoyment of other human rights, such as the rights to education or work, and vice versa. The importance given to the “underlying determinants of health”, that is, the factors and conditions which protect and promote the right to health beyond health services, goods and facilities, shows that the right to health is dependent on, and contributes to, the realization of many other human rights. These include the rights to food, to water, to an adequate standard of living, to adequate housing, to freedom from discrimination, to privacy, to access to information, to participation, and the right to benefit from scientific progress and its applications. It is easy to see interdependence of rights in the context of poverty. For people living in poverty, their health may be the only asset on which they can draw for the exercise of other economic and social rights, such as the right to work or the right to education. Physical health and mental health enable adults to work and children to learn, whereas ill health is a liability to the individuals themselves and to those who must care for them. Conversely, individuals’ right to health cannot be realized without realizing their other rights, the violations of which are at the root of poverty, such as the rights to work, food, housing and education, and the principle of non-discrimination.


SONGSOPTOK: What, in your opinion, should be the role of the government for ensuring equal healthcare to all citizens? What role is played by the government of the country you live in?

CHRYSSA VELISSARIOU:  The right to health is NOT only a programmatic goal to be attained in the long term. The fact that the right to health should be a tangible programmatic goal does not mean that no immediate obligations on States arise from it. In fact, States must make every possible effort, within available resources, to realize the right to health and to take steps in that direction without delay. Notwithstanding resource constraints, some obligations have an immediate effect, such as the undertaking to guarantee the right to health in a non-discriminatory manner, to develop specific legislation and plans of action, or other similar steps towards the full realization of this right, as is the case with any other human right. States also have to ensure a minimum level of access to the essential material components of the right to health, such as the provision of essential drugs and maternal and child health services. Accountability compels a State to explain what it is doing and why and how it is moving, as expeditiously and effectively as possible, towards the realization of the right to health for all. International human rights law does not prescribe an exact formula for domestic mechanisms of accountability and redress, so the right to health can be realized and monitored through various mechanisms. At a minimum, all accountability mechanisms must be accessible, transparent and effective. States have the primary obligation to respect, protect and promote the human rights of the people living in their territory. So seeking the implementation of the right to health at the domestic level is particularly important. Where domestic mechanisms exist and function, they are often quicker and easier to access than regional or international mechanisms .  Administrative and political mechanisms are complementary or parallel means to judicial mechanisms of accountability. For instance, the development of a national health policy or strategy, linked to work plans and participatory budgets, plays an important role in ensuring accountability of the Government. Some of the most crucial measures related to domestic enforcement are the provision of judicial mechanisms for rights considered justiciable in accordance with the national legal system. Such mechanisms should provide remedies to individuals if their right to health is violated. The incorporation into domestic laws of international instruments recognizing the right to health can significantly strengthen the scope and effectiveness of remedial measures. It enables courts to adjudicate violations of the right to health by direct reference to the International Covenant on Economic, Social and Cultural Rights. Domestic courts, including supreme courts, have increasingly heard cases relating to the right to health. For instance, the courts in Argentina have ordered the State to ensure an uninterrupted supply of antiretroviral drugs to persons with HIV/AIDS, to ensure the manufacturing of a vaccine against an endemic disease, and to ensure the continued provision free of charge of a drug against bone disease. Another issue examined by the courts has been the exclusion from and termination of health coverage, particularly by private health insurance. In some cases the courts referred to Argentina’s ratification of the International Covenant on Economic, Social and Cultural Rights and other treaties to reaffirm the constitutional status of the right to health.


SONGSOPTOK: According to the data published by World Health Organization (WHO), nearly 16 000 children under the age of 5 die every day in the world (5.9 million in 2015) from infectious, neonatal or nutritional conditions. Is this a reality in the country you live in? If so, what would your suggestions of improvement be?

CHRYSSA VELISSARIOU:  The Greek Constitution contains a number of solemn proclamations affecting the status of children: that childhood shall be under the protection of the State; that families with a large number of children, war orphans, and everyone who suffers from incurable physical or mental illness have the right to special care by the State; and that the latter also have the right to enjoy measures that secure and facilitate their independence, their professional integration, and their participation in the financial, political, and social life of the country. It also states that the State cares for the health of its citizens and takes special measures for the protection of the children. Furthermore, it proclaims that housing for those in need is the responsibility of the State. Another guiding principle enshrined in the Greek Constitution and legislation that also has a bearing on children is the prohibition of discrimination based on race, gender, physical or mental disability, language, or social status.While the Constitution does not further elaborate on the scope and the extent of these general pronouncements, subsequent statutes and secondary legislation that have been enacted are based on the constitutional mandate to secure the rights of children and to prohibit discrimination. Furthermore, the various policies, services, and programs designed for children that are adopted and implemented by the State at a central or regional level and that are discussed below reflect to a large extent the country’s efforts to protect its children. Nevertheless, Greece still faces numerous challenges, especially in the areas of violence against women and children, trafficking of persons, and discrimination against Roma children.In Greece, children under the age of fifteen constitute about 15.5 percent of the overall population (11,000,000), which is below the average percentage in the European Union. Greece, as other European countries, has experienced in the last few years a high rate of influx of immigrants. As a result, a new multi-cultural and multi-ethnic society has emerged. There are approximately 130,000 immigrant students, mostly from Albania and other Balkan countries, that attend local schools and benefit from the services and programs offered by the Greek State. In Greece, there is no centralized agency designated to provide care and assistance and to supervise the various services provided by the State. Instead, a number of government agencies are responsible for providing social welfare and health services, as well as free education and child care. Generally speaking, the Ministry of Health and Welfare is responsible for health services, and the Ministry of Social Assistance is responsible for assistance to children who are vulnerable, that is orphans, the handicapped, and trafficked children. The Ministry of Health and Welfare and the Ministry of the Interior have joint responsibility at the national level for early childhood care. Local authorities are responsible for preschools and child care services; the Ministry of Education supervises the early childhood programs at the national level. The Ministry of Labor and Social Security handles the social insurance benefits and the family allowances for each child. The Social Insurance Institute (IKA) administers benefits through local offices. The general framework law on social care is Law 2646/1998 on Reorganization of the National System of Social Care and Other Provisions. Based on the constitutional mandate that social care is the responsibility of the state, the Law reaffirms the right of access to social care and welfare services provided by the National Health System to everyone who legally resides in Greece. Thus, the main objective is to ensure participation of all people in the services provided, in order to ensure that all people have an acceptable standard of living. Consequently, as long as foreign nationals and their children have proof of legal residence, they are eligible for the welfare services and programs offered, including daycare centers, infant care centers, state-run holiday camps, and others. The institution of foster parents was introduced in 1992. Minors under the age of eighteen who have no place to stay or who live in unhealthy family living conditions could in theory be placed with foster families until they attained the age of majority. Children with special needs could stay with foster families beyond that age. However, the Greek Ombudsman reported in 2005 that the foster parent program was not put into operation. Since 1973, the state-run orphanages have been converted into child care centers. Abandoned children or those with no place to stay, from the age of five to fifteen, are accepted free of charge. The decision to place a child in a child care center is made based on a report prepared by the social worker assigned to the case and upon verification that living with family or relatives is not feasible. Orphans who have lost one or both parents are given preference, followed by children whose single parent is blind, deaf-mute, handicapped from birth, mentally ill, or incarcerated. Children between the ages of three and six are accepted at state-run kindergartens. There are also state-run nurseries that cover the needs of children from the age of eight months until they are accepted at elementary schools. Since 1960, Law 4051 on Supporting Unprotected Children has offered financial benefits to children who meet certain qualifications. Eligible children are those below the age of fourteen (and in some instances up to sixteen) who live with their own families and are: orphans who have lost both parents; orphans without fathers; children whose fathers cannot support them for reasons of health; or children born outside marriage. Children who live in state-run institutions do not qualify for these allowances. Other state-run institutions also provide a small allowance to children of single parents, to those close to the poverty line, or to those children whose families experience medical or social hardships. The government also made monetary contributions of a lump-sum, at the beginning of each school year, to families with children up to sixteen years old who attend public schools and whose annual income is no more than €3,000 (about US$4,161, at the exchange rate of €1=US$1.39, effective Sept. 17, 2007). Another allowance was €1000 to families with children studying in cities other than the place of residence of their families. Other laws directly or indirectly assisted low-income families with children. An annual allowance of €15 to purchase school items was given to families of the unemployed and to single-parent families. Another example is Law 3227/2004, on Measures against Unemployment, which gave an incentive to employers to hire unemployed mothers of at least two children. The incentive consisted of a subsidy of an amount equal to the employer’s insurance contribution liability for providing insurance coverage for the employed mothers. The subsidy was equal to a year’s contribution for each child of the employed mother. Moreover, the same law exempted women farmers from contributing to the Farmers’ Fund (Agricultural Insurance Organization O.G.A.) for every child born after the first child. The government also provided pensions for low-income families in rural areas and financial incentives for children who attended school. Other government programs also provided a certain amount of money for families with three children. It should also be noted, that the National Center for Emergency Social Care, which operates as a legal entity, under the authority of the Ministry of Health and Welfare, has extended its services in almost all regions of Greece. Thus, separated children or victims of human trafficking may receive emergency assistance in such centers. But almost all the beneficial above  has changed after Crisis in 2009. Now more than 250,000 children in Greece do not have access to public healthcare and don’t do the necessary vaccinations, the Greek branch of Doctors of the World said during a press conference on Wednesday. Speaking to journalists, general secretary Liana Mailli noted that this number is an approximation, as Greece doesn’t provide data on inoculations to the European Union, as it is supposed to. She also said the number was valid two years ago, before the dramatic rise of the refugee and migrant flows to Greece. “To the old numbers, we must now add the children of refugees who we don’t know how many vaccinations they’ve had. All these issues create an explosive situation and there’s a real risk that diseases which had been eliminated, such as diphtheria, tetanus, pertussis, measles and polio, will reappear,” Mailli said. After the dismissal of a large number of doctors, she added, the state-run health insurer EOPYY and other health facilities “have been decimated and cannot serve the insured, let alone uninsured children.” Greek children now have some of the worst dental health in Europe. It is a measure of the country’s economic depression, and could be storing up more problems for the future. In few places are the wounds of Greece’s economic depression more evident than in the mouths of the nation’s children. By most indicators of dental health, Greece is one of the unhealthiest places in Europe. The number of Greeks 16 years or older reporting unmet dental care needs was 10.6 percent in 2013, according to Europe’s statistical agency Eurostat. That compares to a European Union average of 7.9 percent. Dental problems are particularly acute among children, according to a recent survey by the Hellenic Dental Federation, a supervisory body. And the financial crisis has made things worse. In the decade up to 2014, 60 percent of all dental problems in 15-year-olds were left untreated for at least a year, up from 44 percent in the previous decade. Almost all the five-year-olds surveyed – 86.8 percent – suffered dental problems that had not been treated, the survey found. “Teeth are unfortunately considered a luxury,” said Niki Diamanti, a dentist who works at Hatzikosta Hospital, one of two public hospitals in the northwestern town of Ioannina. “If, five years ago, people went to the dentist once a year, now they go every five years.” Anybody living legally in Greece has a right to health care. Therefore anybody who can prove his or her resident status can access health care. However, the health sector has been particularly badly hit by the crisis. Patients must pay a fixed price of 5€ for every hospital visit. Doctors frequently ask their patients to buy their own plasters, needles and bandages as the hospitals are out of stock. According to Médecins du Monde, the situation is worsening. The organisation has started distributing enriched nutritional products to some children; the most vulnerable families can no longer cope. People are even going directly to the NGO headquarters for free checkups and the situation is becoming difficult for the organisation to manage. According to the Hellenic Centre for Disease Control and Prevention (a public health organisation, financed by the Ministry of Health) the number of children with HIV/AIDs is low. However, mother-to-child transmissions have been diagnosed as a consequence of nationwide deficiencies in screening pregnant women. Systematic AIDs tests are now carried out on pregnant women to prevent mother-to-child transmission. This is one more article were an English journalist witnesses the situation of the healthcare in Greece after the crisis: “In October I visited Greece to see the impact of austerity on the Greek people, in particular on health and healthcare.I joined healthcare workers and the Greece Solidarity Campaign to visit hospitals, clinics and food markets. I spoke to healthcare staff, volunteers, politicians and local government officials. What I witnessed appalled me - and brought tears to my eyes. In Greece’s biggest hospital, the Evangelismos Hospital in Athens, conditions were worse than those I have seen in developing countries. The moment the hospital doors open on ‘emergency’ days, people flood in. The collapse in official primary and community health care services means everyone who needs healthcare comes to A+E - whether for a major accident, medication for a long term condition or to get their child immunized. Staff told me that serious trauma cases often have to wait hours for X-rays and treatment due to understaffing and that, if too many cases come in at the same time, people die before they can be treated. The ‘austerity’ conditions imposed on Greece by the Troika (European Commission, European Central Bank and IMF) as the price of its debt bailout have closed many hospitals (including three psychiatric hospitals) and primary care clinics. Those that remained face drastic staff cuts. Thousands of health workers have been sacked. 30% of the Greek population is living in poverty, with no access to affordable healthcare. Healthcare is funded through insurance paid by employers and when people lost their jobs they lost their health insurance. The Government claimed to have reinstated health care for the neediest but doctors and nurses told me it was a sham. The promised tribunals to assess and means test the claims of those who can’t afford health care have yet to be established. At Evangelismos I saw 50 psychiatric patients crammed into a 25 bed ward, sharing two toilets and just one psychiatric nurse. Psychiatric patients of all ages and both sexes lay apathetically on trolleys on both sides of the long corridor. I turned a corner and saw another corridor similarly lined. These narrow uncomfortable beds, crammed together, were all the personal space patients had. Nurses and doctors told me it was impossible to do any therapeutic work. Despite the overcrowded conditions, the ward was eerily quiet. I got the impression most patients were sedated, or perhaps had just given up in despair. ‘Austerity’ and cuts have led to a sharp rise in depression. Suicide is up 45%. The patients in Evangelismos were the lucky ones - many others who need beds have been abandoned on the streets, with no community based support. As we were leaving a doctor appealed to me to tell people in the UK what I had seen and heard. He said they wanted “solidarity, not charity”. People are organizing to resist and defend their communities against the worst impacts of austerity. One expression of this is the mushrooming of community based “solidarity” structures to help people who lack food or healthcare. Social solidarity health clinics have been set up all around Greece staffed by volunteers who try to provide basic care for those with no access to healthcare.  Doctors, nurses and pharmacists volunteer in these clinics, but not nearly enough to meet the needs. I visited the Social Solidarity Clinic in Peristeri, a district of Athens with a population of about 400,000 people. The volunteer staff, doctors and nurses who worked there told me that most local state run health clinics had been shut. The government had closed all the polyclinics then reopened some recently but with only 30% of the doctors that they need. Whereas previously there had been 150 doctors providing services to the district, there were now only 50. A polyclinic for a population of 400,000 people had no gynecologists, no dermatologists, and only two cardiologists.   “We want our doctors back” – said one of the volunteers I spoke to. Thousands of doctors have left the country. Those that remain – including senior hospital doctors - earn about €12,000 a year. The Peristeri social solidarity clinic had been running for 1.5 years and had 60 volunteers including about 25 doctors who offered their services free. There was a simple consulting room and a small pharmacy with donated medicines. Clinic volunteers said that people with long term conditions like diabetes or with cancer had particular problems getting the treatment they needed. Uninsured cancer patients can’t afford chemotherapy. The solidarity organisations appeal to people on chemotherapy to donate one day’s worth of medication for patients who can’t afford to the drugs themselves. The Greek government passed a law in January allowing so that if people get into debt their property can be confiscated. Some people decline further treatment rather than accrue debt from healthcare costs that might lead to their family losing their home. Greek mothers are now charged €600 to have a baby and €1200 for a Caesarian or complications. It’s twice that for foreign nationals living in Greece. The mother has to pay the fee on leaving the hospital. When the charges were first introduced, if the mother couldn’t pay, the hospital kept the baby until the payment was made. International condemnation led to that practice being discontinued and now the money is reclaimed through extra tax - but if the family can’t afford that then their home or property can be confiscated.  And if she still can’t pay she can be imprisoned. An increasing number of newborn babies are abandoned in the hospital. One obstetrician I spoke to called it the “criminalization of childbirth.” Contraception is unaffordable for many – health insurance does not even cover it. There are many more abortions – 300,000 a year –and for the first time the death rate in Greece is outstripping the birth rate. People can’t afford to have babies. It’s hard enough to feed and care for existing children. A recent report compiled by Unicef and Athens University estimated that 34% of Greek children were at risk of poverty. An article in the Lancet (Greece’s Health Crisis: from Austerity to Denialism 22 Feb 2014) reported that the stillbirth rate had risen by 21% and the infant mortality rate by 40% between 2008 and 2011. Many families are living off the meager pensions of a grandparent– typically about 500 Euros a month.  The collapse in primary care systems means that thousands of children are not being immunized. It costs about 80 Euros for a course of childhood immunizations and many families cannot afford that. Collapse of the public healthcare systems has led to a doubling of TB rates, the reemergence of malaria after 40 years and a 700% increase in HIV infections. Food poverty is also worsening people’s  health. 1.7 million Greek people, nearly one in five of the population, do not have enough to eat, according to the OECD. We visited a food market in Athens organized by the social solidarity movement, which organizes the distribution of food direct from farmers to the population. The social solidarity food markets cut out the middleman so the food is cheaper than in the supermarkets while the farmers get a good price. In return the farmers donate a percentage of their product, which is distributed free to local families in need. Across the market a banner was strung saying “Putting hope into practice”. This, for me, epitomized the spirit I encountered everywhere I went – hope for change combined with a very practical approach to creating support structures. People I spoke to were clear these were not intended to be a substitute for state provision – they can’t be – but a means of sustaining life and resilience to prevent people sinking into destitution and despair.  They said that what was needed was action at government level. The success of the Syriza party is no surprise. We met Alexis Tsipras, Syriza’s leader, who said that rebuilding the healthcare system would be a priority for his government if elected. He did not kept his word though. Our European supervisors have no pity. The Greece Solidarity Campaign has launched an appeal for medical aid for Greece, prioritizing the purchase of immunisations for children. I myself I wrote a most popular poem inspire by all this situation. It is about people with cancer during crisis especially kids and I wrote it to raise awareness:

THE BALD SAINTS

There are some living Saints
with bowed bald heads'
Some holy beings
some aetherial acrobats
they're balancing on a tightrope at nights
amongst pain and life '
who just want to depart in peace
but they feel they have a duty to complete
therefore to still exist
for the sake of whatever they had been engaged to serve '
for the sake of whatever they shouldn't anyway leave behind alone'
to serve Love for as long they can bear it,
to do not give up hope for what will future bring ...
Potentially our overt or covert idols in deed ...
They often have a beautiful adolescent's or infant's form ...
Unspeakable the pain, severe heart's shame!
Ah! For some laudanum they just beg to withstand existance'
we, as despicable traitors or in a deep sleep resting
we dare to deprive the Gladiators of Courage
even from the opportunity to fight with a simple sword ...

Dedicated to my friends or unknown cancer patients or other severely ill patients , especially to the Young Heroes among them, who often in the merciless greek society of the financial crisis are seeking even painkillers to find or are humiliated to resort to the charity, which fortunately is offered by some of us.
Please donate painkillers for cancer patients in Greece . They can no longer afford  them so they can not cope with their pains.
Community clinics all over Greece fight voluntarily to provide FREE medical assistance to the UNEMPLOYED and POOR civilians with NO SOCIAL SECURITY or with very little income.
http://mki-ellinikou.blogspot.gr/
http://mkie-foreign.blogspot.gr/
http://www.kiathess.gr/index.php/2012-09-24-23-48-18
http://koinwnikoiatreiolarisas.blogspot.gr/p/blog-page_4.html


SONGSOPTOK: “Free access to healthcare is a fundamental human right. Access to free healthcare is not” – do you agree with this statement? Please explain your choice.

CHRYSSA VELISSARIOU No I don’t agree. Vulnerable and marginalized groups in societies are often less likely to enjoy the right to health. Three of the world’s most fatal communicable diseases - malaria, HIV/AIDS and tuberculosis - disproportionately affect the world’s poorest populations, placing a tremendous burden on the economies of developing countries. Conversely the burden of non-communicable disease – most often perceived as affecting high-income countries is now increasing disproportionately among lower income countries and populations. Within countries – some populations – such as indigenous communities are exposed to greater rates of ill-health and face significant obstacles to accessing quality and affordable healthcare. This population has substantially higher mortality and morbidity rates, due to noncommunicable diseases such as cancer, cardiovascular and chronic respiratory diseases, than the general public. People who are particularly vulnerable to HIV infection – including young women, men who have sex with men, and injecting drug users – are often characterized by social and economic disadvantage and discrimination. These vulnerable populations may be the subject of laws and policies that further compound this marginalization and make it harder to access prevention and care services. Violations or lack of attention to human rights can have serious health consequences. Overt or implicit discrimination in the delivery of health services violates fundamental human rights. Many people with mental disorders are kept in mental institutions against their will, despite having the capacity to make decisions regarding their future. On the other hand, when there are shortages of hospital beds, it is often members of this population that are discharged prematurely, which can lead to high readmission rates and sometimes even death, and also constitutes a violation of their right to receive treatment. Similarly, women are frequently denied access to sexual and reproductive health care and services in developing and developed countries. This is a human rights violation that is deeply engrained in societal values about women’s sexuality. In addition to denial of care, women in certain societies are sometimes forced into procedures such as sterilization, abortions or virginity examinations. A human rights-based approach to health provides strategies and solutions to address and rectify inequalities, discriminatory practices and unjust power relations, which are often at the heart of inequitable health outcomes.The goal of a human rights-based approach is that all health policies, strategies and programmes are designed with the objective of progressively improving the enjoyment of all people to the right to health. Interventions to reach this objective adhere to rigorous principles and standards, including: Non-discrimination: The principle of non-discrimination seeks ‘…to guarantee that human rights are exercised without discrimination of any kind based on race, colour, sex, language, religion, political or other opinion, national or social origin, property, birth or other status such as disability, age, marital and family status, sexual orientation and gender identity, health status, place of residence, economic and social situation. Availability: A sufficient quantity of functioning public health and health care facilities, goods and services, as well as programmes. Accessibility: Health facilities, goods and services accessible to everyone. Accessibility has 4 overlapping dimensions: non-discrimination; physical accessibility; economical accessibility (affordability); information accessibility. Acceptability: All health facilities, goods and services must be respectful of medical ethics and culturally appropriate as well as sensitive to gender and life-cycle requirements. Quality: Health facilities, goods and services must be scientifically and medically appropriate and of good quality.

Accountability: States and other duty-bearers are answerable for the observance of human rights. Universality: Human rights are universal and inalienable. All people everywhere in the world are entitled to them. Policies and programmes are designed to be responsive to the needs of the population as a result of established accountability. A human rights based-approach identifies relationships in order to empower people to claim their rights and encourage policy makers and service providers to meet their obligations in creating more responsive health systems.


SONGSOPTOK: How important is the role of the private sector for providing healthcare and related facilities in your country? What it is your opinion about it?

CHRYSSA VELISSARIOU The private health sector infrastructure consists of approximately 25 000 private physicians, 12 000 dentists, 400–700 private laboratories, and the outpatient departments of the 167 operating private hospitals. Private physicians in Greece, most of them specialists, run their own surgeries, and may also work as part-time salaried employees at private hospitals, receiving bonus payments for hospital admission. Corporate-owned diagnostic centres control more than 70–80% of the country's total biomedical equipment. Private physicians and diagnostic centres receive users' payments, fee-for-service payments from contracted social health insurance funds, and fee-for-service or capitated payments from private health insurance schemes. The private primary care sector in Greece absorbs more than 65% of total private health expenditure and substantial profits are made by the private diagnostic centres. In my view there is an urgent need for the rationalisation and consolidation of Greece's fragmented primary care system. The most obvious obstacles seem to be the financial interests of diagnostic services and corporate and part-time social security doctors, as well as the justifiable fears in some population groups of losing part of their advanced healthcare benefits. For more than 16 years primary healthcare reform plans have sought to overcome these obstacles by suggesting the virtual, rather than the actual, integration of primary care services in the country. Existing providers and their micro-regimes of vested interests would have remained untouched. Now primary care users, once members of a geographically determined population, become members of an ‘enrolment list’ and under the guidance of their personal physician consume services in a mixed healthcare market. With these proposals the Alma Ata Declaration's principles of a free, universal, integrated, and community-oriented primary care system have been abandoned. Despite their problems, the Greek ESY's primary healthcare centres represent the only organisational structure able to offer holistic services to clearly defined local populations. In a country like Greece with 27 years of experience of community-based health centres, it seems irrational to imitate once again controversial policies based on quasi-market mechanisms. The plan in the original Greek ESY Foundation Act for complete replacement of the existing primary care infrastructure, with public, community-based, urban, and rural health centres free at the point of use, seems to me to be the only realistic way to move forward.


SONGSOPTOK: Are charitable and Non-Governmental Organizations (NGO) active in the domain of public health? If yes, then in what spheres? Do you think that the civil society, either independently or through these organizations, should become the prime actor for ensuring healthcare for all?

CHRYSSA VELISSARIOU:  Human rights-based indicators support the effective monitoring of key health outcomes and some of the processes to achieve them. Reviews of policy, budgets or public expenditure, and governmental monitoring mechanisms (for example, health and labour inspectors assigned to inspect health and safety regulations in businesses and in the public health system) are important administrative mechanisms to hold the Government to account in relation to its obligations towards the right to health. Some health services have established systems, either internal or independent, which can receive complaints or suggestions and offer redress. Furthermore, assessments of various kinds, such as impact assessments, offer a way for policymakers to anticipate the likely impact of a projected policy and later to review the actual impact of policies on the enjoyment of the right to health. Political mechanisms, such as democratic processes, and the monitoring and advocacy performed by NGOs also contribute to accountability. Civil society organizations are increasingly using monitoring methods based on indicators, benchmarks, impact assessments and budgetary analysis to hold Governments accountable in relation to the right to health. The Treatment Action Campaign in South Africa illustrates how an NGO effectively used social mobilization, advocacy and resort to litigation jointly to ensure equal access to HIV/AIDS treatment. The Treatment Action Campaign in South Africa: ensuring equitable access to treatment for persons living with HIV/AIDS Making medicines available where they are most needed and using its resources adequately are two concrete examples of ways in which the Government can fulfill its obligations in relation to the right to health and be made accountable.

Minister of Health v. Treatment Action Campaign: The South African Government had chosen not to roll out a national programme to reduce the risk of mother-to-child transmission of HIV. Instead, it identified two research sites per province that alone were authorized to distribute the drug nevirapine, thus restricting the availability of the drug, although its efficacy had already been well established. This meant that HIV-positive mothers who could not afford private health care and did not have access to the research sites could not receive nevirapine. In August 2001, the Treatment Action Campaign, a network of organizations and individuals campaigning for equitable and affordable access to HIV/AIDS treatment, filed a claim against the Government before the Pretoria High Court, demanding that the Government distribute the drug to pregnant women in all public hospitals, on the grounds that the governmental policy was unconstitutional and failed to respect its human rights obligations. The South African Constitution recognizes the right of everyone to have access to public health-care services and the right of children to special protection. Decisions: In December 2001 the High Court decided in favour of the Treatment Action Campaign and held that the Government’s restrictions were unreasonable. In its decision upon appeal, in July 2002, the Constitutional Court upheld the Pretoria ruling and decided that the Government’s policy “had not met its constitutional obligations to provide people with access to healthcare services in a manner that is reasonable and takes account of pressing social needs”. The Court confirmed that the policy discriminated against poor people who could not afford to pay for services. The Government was required to remove restrictions on the availability of nevirapine at public hospitals and clinics that are not research sites, and to devise and implement within its available resources a comprehensive and coordinated programme to progressively realize the rights of pregnant women and their newborn children to have access to health services to combat mother-to-child transmission of HIV. These decisions led to the establishment of one of the largest programmes in Africa to reduce mother-to-child transmission. National human rights institutions (NHRIs) are important domestic mechanisms promoting and protecting human rights. Their functions in this respect include advising the Government and recommending policy or legislative changes, handling complaints, carrying out investigations, ensuring the ratification and implementation of international human rights treaties, and providing training and public education. NHRIs often have quasi-judicial functions and a mandate allowing them to contribute to the development of legislation. Most institutions may be categorized as commissions or ombudsmen. Some countries have specific health ombudsmen. While most NHRIs have traditionally focused their work on civil and political rights, they are increasingly focusing on economic, social and cultural rights. They can provide another avenue for the protection of the right to health. Selected national human rights commissions and the right to health The mandate of the National Human Rights Commission of India (http://nhrc.nic.in) is to protect and promote rights guaranteed by India’s Constitution and international treaties. The Commission has been very active with respect to the right to health. It has, for instance, advocated upgrading health-care facilities in the country and allocating medical staff to rural populations. It has also made several recommendations to the Government to ensure policies in favour of the right to health. For instance, it recommended that facilities be created in villages; that a proper mechanism be established to ensure essential drugs are available at primary health centres; that publicprivate partnerships be set up to maximize the benefits of health-care facilities; and that immunization programmes of the Health Department be organized regularly so that childhood diseases are contained at the earliest opportunity. In a report published in February 2007 the Commission also denounced the lack of safe drinking water in many areas of the country.  The Commission has also worked for a ban on manual scavenging, which has a very negative impact on health. It recommended that the Government should rehabilitate and reintegrate freed manual scavengers, that banks should facilitate loans at a favourable rate of interest for them and that schooling should be provided for their children. The Parliamentary Ombudsman in Finland (http://www.oikeusasiamies.fi) increasingly deals with right-to-health complaints, in particular with respect to patients’ rights and the right to health care (guaranteed under the Constitution). In 2005, the Ombudsman examined several complaints related to the unavailability of adequate health services, access to quality treatment and the manner in which patients were treated. The Ombudsman consulted the National Board of Medico-legal Affairs to reach a decision on these cases. The National Human Rights Commission in Mexico (www.cndh.org.mx) has been dealing increasingly with right-to-health complaints, in particular the refusal to provide or the inadequate provision of public health services, and medical negligence. In 2004, the Commission issued a general recommendation directed to relevant national and district ministers on the human rights of persons with psychosocial disabilities who had been institutionalized in reclusion  centres. The recommendation was based on an inquiry and visits made to such centres throughout the country to examine their compliance with human rights standards.


SONGSOPTOK: Do you think that multinational pharmaceutical and healthcare companies are responsible, to a certain extent, for the widely variable quality of healthcare in different countries? Can you please illustrate your reply with some examples?

CHRYSSA VELISSARIOU  Rational prescribing decisions should be enhanced by the quality of interactions between healthcare providers and the companies that research and develop medicines. The medicines that research-based companies produce and the scientific information they provide to physicians are important components of quality healthcare for patients. With the ever increasing number of treatment options available to patients, healthcare providers need to be kept up to date with the scientific advancements of new medicines. Likewise, providing patients with information relating to medicines may encourage healthcare providers to explore various treatment options in order to best match patient needs. It is important therefore that the information provided by companies is scientifically accurate and fair. Interactions between pharmaceutical companies and healthcare professionals should always be appropriate and support good patient care. With the aim of further supporting these important goals, the global pharmaceutical industry has made significant changes in recent years in the worldwide controls on companies’ interactions with healthcare professionals. Interactions and communication between companies that research and manufacturer medicines and the healthcare professionals that prescribe them are important in contributing to the appropriate and effective use of prescription medicines. These relationships are covered by pharmaceutical advertising codes and legislation. Additionally, national bribery and corruption legislation, such as the US Foreign Corrupt Practices Act (FCPA) and the UK Bribery Act, could have potential application to activities in any country for many companies. Ensuring compliance with the IFPMA Code and the affiliated national codes is likely to help ensure compatibility with relevant sections of anti-bribery legislation. Essentially, the code requirements are designed to prohibit inappropriate personal benefit being offered to healthcare professionals and often go beyond the requirements of anti-bribery legislation. One issue covered by most national codes is whether companies are able to support healthcare professional attendance at medical conferences. While codes in many countries deem it acceptable to sponsor attendance of healthcare professionals at scientific meetings, and cover associated costs such as reasonable travel, accommodation and meals, they also include a number of caveats. In particular, the main purpose of the meeting must be scientific and professional in nature and any refreshments provided must be incidental to that purpose. The venue must be conducive to the scientific or educational purpose, and international travel must be justified by the international nature of the meeting or other logistical or security reasons. Company sponsorship of healthcare professionals to attend meetings nevertheless remains a topic of debate. Some countries (e.g. the United States and Norway) do not permit direct sponsorship of attendance at scientific meetings (except for medical students in the US), while others (e.g. France) require review of the arrangements by an independent body. Some countries have put other measures in place such as co-payment of expenses. International companies may also impose on themselves policies relating to sponsorship of healthcare professionals that go beyond external rules. This highlights sensitivity over the perception of companies funding attendance at international educational meetings. However, ceasing sponsorship could deny healthcare professionals without access to sufficient funding the opportunity to hear and interact with world leaders in their chosen field, unless alternative funding arrangements are developed or digitally-based specialist educational services are expanded and are feasible in their country. This is particularly important for healthcare professionals from developing counties, where alternative sources of funding may not be available. Providing low-value branded promotional aids (pens, pads, tongue depressors, antiseptic wipes etc.) has long been a tradition of pharmaceutical, and other, advertising. International rules still permit inexpensive promotional aids, provided they are relevant to the practice of the healthcare professional. However, there is a trend to ban promotional aids altogether and within the past five years the US  and UK , amongst others, have prohibited branded promotional aids. At least one global company has ceased their distribution worldwide. The rationale for a ban is not that such promotional aids represent a gift that will affect a healthcare professional’s prescribing or purchasing decisions but rather that such items are not conducive to a new relationship built on mutual professional respect. In addition, industry leaders seek to base relationships with healthcare professionals on sharing educational information rather than on provision of items that could be perceived as gifts. In most parts of the world, it is permissible to provide samples of medicines to healthcare professionals and such samples may improve patient care. However, the situation varies considerably between countries according to local factors. In a number of countries, samples are not permitted at all, while several countries’ industry codes restrict their number, frequency, and the period after launch during which they can be provided. The attention and resources devoted to regulatory compliance regarding communication about prescription only medicines is probably at an all-time high. However, no set of rules is beyond improvement and changes in health systems, as well as advances in communication technology, will mean that codes, regulations, and laws will continue to evolve if they are to support optimal use of medicines to benefit patients. Continuing experience with the operation of existing codes will help inform future developments particularly in rapidly developing countries where international pharmaceutical company activities are expanding yet local manufacturers may not be subject to established codes of practice. Future developments in these countries should strive for international harmonization embracing all healthcare sectors but also take into account national differences. and simultaneously encourage broader participation and endorsement of codes across the industry operating in these countries. The IFPMA Code was extensively revised in 2006 and again in 2012 It is now well-established as an international model for effective local codes. Continued assessment of national industry codes of practice is appropriate to ensure that companies continue to meet the needs of patients and prescribers. Additionally individual companies will continue to pioneer additional standards, approaches, and initiatives. Areas that are being addressed at national and company level include a focus on increased transparency of the relationships between companies and both individual healthcare professionals and healthcare organizations. Low cost promotional aids are being increasingly restricted or banned altogether by companies and national or regional codes. Laws and regulations may change more slowly, but, in countries where there are perceived gaps, we can expect clarification in the form of new regulations and guidance. The pharmaceutical industry must continue to serve as a trusted partner in healthcare provision. Industry codes of practice can form the foundation for governing companies’ interactions and communications and therefore play an important part in the relationship between companies and other stakeholders in healthcare provision. Laws and regulations will remain important and legal action will be applied when needed. Nevertheless it will be important to avoid a “box-ticking” approach where the only question is “Is it legal to do that?” but rather to also encompass a code-based evaluation that goes beyond legal requirements. International companies have established global internal standards but they represent only a small share in the healthcare market in many developing countries, and it would be appropriate for unified self-regulatory codes to cover all sectors of the pharmaceutical market. We have already seen such developments in Mexico and South Africa, and such a model has also been proposed in India. A model of cooperation between industry codes and legislation already works well in some countries, particularly in Europe and Australia. Such a model could be equally successful in developing nations.


SONGSOPTOK: Do you think that adopting the Social Security model implemented in a lot of countries in Europe which ensures primary health coverage to all citizens and is financed by the totality of the working population can be relevant and efficient in all countries?

CHRYSSA VELISSARIOU: Yes I think so. A country’s difficult financial situation does NOT absolve it from having to take action to realize the right to health. It is often argued that States that cannot afford it are not obliged to take steps to realize this right or may delay their obligations indefinitely. When considering the level of implementation of this right in a particular State, the availability of resources at that time and the development context are taken into account. Nonetheless, no State can justify a failure to respect its obligations because of a lack of resources. States must guarantee the right to health to the maximum of their available resources, even if these are tight. While steps may depend on the specific context, all States must move towards meeting their obligations to respect, protect and fulfill.

References:
10.                       http://velissariou11.blogspot.gr/2013/01/blog-post_8898.html




CHRYSSA VELISSARIOU: Professor of Physics, specialized in Space Physics, candidate Doctor in Education.  Prized by the Ministry of Education in Greece. Elected in the Municipality of her hometown. Published in Greek and English in over 20 Anthologies, internet magazines and two personal books. Activist for Peace. World Poetry Canada and International Ambassador to Greece 2014-2016 for Peace. 100TPC events organizer. More than 3000 poems on her blogs. She also writes in French and German




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Aparajita Sen

(Editor: Songsoptok)

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