1 Available online at Health Policy 88 (2008) Private health expenditure in the Greek health care system: Where truth ends and the myth begins Olga Siskou a,, Daphne Kaitelidou a,b, Vasiliki Papakonstantinou a, Lycourgos Liaropoulos a a Center for Health Services Management and Evaluation, Faculty of Nursing, University of Athens, 123 Papadiamantopoulou Street, Athens, Greece b Open University of Cyprus, Greece Abstract Greece today has the most privatized health care system among EU countries. Given the country s universal coverage by a public system this may be called the Greek paradox. The Objective of this paper is to analyze private health payments by provider and type of service in order to bring to light the reasons for and the nature of the extraordinary private expenditure in Greece. Methods: We used a randomized countrywide sample of 1616 households. Regression analysis was used to determine the extent to which social and economic household characteristics influence the frequency of use of certain health services and the size of household payments for such services. In all statistical analyses we used the p < 0.05 level of significance. Results: Out of the total private household health expenditure (D 6141 million), 66% is for outpatient services, with the largest share for dental services, absorbing 31.1% (D 1912 million or 1.5% of GDP) of the total out-of-pocket health expenditure. Rural dwellers seek private outpatient care more often, because of the understaffed public primary facilities. The hospital sector absorbs less than 15% (or D 884 million) of household private health expenditure. A significant part (20%) of hospital care financed privately concerns informal payments within public hospitals, an amount almost equal with formal payments in the form of cost sharing. Admissions to private hospitals are only 16% of total admissions. Our results indicate that this is a result of the political emphasis in public hospitals and of the considerably high cost of private hospital care. Conclusions: The rise in private health expenditure and the development of the private sector during the last 20 years in Greece is associated with public under financing. The gap was filled by the private sector through increased investment, mostly in upgraded amenities and new technology. Today, the complementary nature of private care in Greece is no longer disputed, but is a matter of serious concern, as it undermines the constitutionally guaranteed free access and equitable distribution of health resources Elsevier Ireland Ltd. All rights reserved. Keywords: Private health expenditure; Out-of-pocket payments; Informal payments; Greece 1. Introduction Corresponding author. Tel.: ; fax: address: (O. Siskou). In 1983 Greece instituted a national health system in which Government must, under the Constitution, guarantee that all citizens enjoy the benefits of a /$ see front matter 2008 Elsevier Ireland Ltd. All rights reserved. doi: /j.healthpol
2 O. Siskou et al. / Health Policy 88 (2008) Table 1 Private health expenditure as % of total health expenditure in 2004, in EU-19 Austria 24.4 Belgium 26.2 Czech Republic 10.8 Denmark 15.7 Finland 22.8 France 20.6 Germany 23.1 Hungary 29.5 Ireland 21.8 Italy 24.2 Luxembourg 9.4 Poland 31.4 Portugal 28.4 Slovak Republic 26.2 Spain 29.1 Sweden 15.4 United Kingdom 13.7 Netherlands n/a Average 22 Greece 47.2 a Source: OECD Health Data Base a Figure represents data before the 2006 GDP revision. complete range of services of high quality free at the point of service (The Greek Constitution, 1975). On the demand side, the country has universal mandatory coverage by a public insurance system and a low level of cost-sharing arrangements . Not surprisingly, it has been called the Greek paradox, that Greece has the most privatized health care system among EU countries. In 2004, 47.2% of total health expenditure was funded privately. By comparison, private expenditure in the other EU (19) countries (Table 1), was less than half for the same year . The rise in private health expenditure and the development of the private sector during the last 20 years in Greece took place at a time of public under financing. The gap was filled by private investment, which increased from D 33 million in 1998 to D 438 million in 2004 . At the same time, rising disposable incomes and the mobilization of private health insurance  led more households to look for privately paid services in order to meet unsatisfied demand . The Greek health system is characterized as a dual system. The supply side is largely organized along the Beveridge 1 lines, with state-provided hospital care and a network of rural health centers covering almost one third of the population. On the demand side, the system functions mainly along the Bismarck 2 lines with health insurance provided by 39 health funds covering the entire population. This, however, is a rather schematic description which does not portray the true picture. The lack of a credible public primary health care system, leads people to seek services in the private sector . With 4.9 doctors/1000 pop and 1.2 dentists/1000 pop, Greece has almost twice the number of medical practitioners compared with other EU countries (3.26/1000 pop and 0.68/1000 pop, respectively). On the supply side, the private sector covers an increasingly large part of the population health needs, but the increasing number of doctors in private practice leads to induced demand, for medical and pharmaceutical care [6,2]. Although accurate data do not exist (Greece has not yet adopted the OECD System of Health Accounts [7,8]), various estimates put private sector participation at nearly 30% of hospital care and close to 50% of medical services. On the demand side, recent estimates show roughly equal proportions of funding from public and private sources. This dependence on private financing is a major source of inequity in the system, and, as shown in a previous paper, it is also a source of corruption . In this paper we will investigate the exact nature of private health expenditure, its root causes, and its effects 1.1. Historical evolution When a democratic government returned to Greece in 1974, health care reform was the major social issue in the agenda leading to the establishment of a National Health System (NHS), in As a result of the political shift to the left in 1981, the government increased spending on health during the 1980s, in order to make up for under financing in previous decades. The increase 3 in public spending was financed 1 Modeled after Britain s NHS, care is provided by public hospitals and health centers funded by public funds. 2 The Bismarck model is based on mandatory Social Insurance funded by employer employee contributions. 3 In Table 2 we see that public expenditure increased sevenfold between 1980 and The nominal increase in later periods is considerably lower.
3 284 O. Siskou et al. / Health Policy 88 (2008) Table 2 Main sources of financing for health care in Greece (million D and % of total health expenditure), Million D % THE Million D % THE Million D % THE Million D % THE State Budget (taxation) Social insurance Total public Private insurance Out-of-pocket and other Total private THE: total health expenditure. Sources: OECD Health Data, 2006, Social Budgets of various years. Fig. 1. Total and private health expenditure as % of GDP, Greece and OECD countries. Source: OECD Health Data, out of income taxation and indirect taxes on goods and services (general and hypothecated), which represent the largest proportion (58.4% of total tax revenue) . In 1990 more than 60% of public financing came from tax revenues and less than 40% from social security, financed by compulsory employer and employee contributions . The composition of public health expenditure over the last 25 years is shown in Table 2. The dependence on tax revenues to finance public expenditure reflects large government subsidies to public hospitals. This is to keep administered prices low, in order to alleviate pressures on social security, control inflation, and discourage the private hospital sector. 4 4 The balance between taxation and social security contributions changed only in 1992, when official public hospital per diem charges [12,13]. Until today, periodic hospital debt settlements fill the gap between rates paid by Social Security and the actual cost of services 5 . Total health expenditure (THE) in Greece increased steadily during the last 15 years, from 7.4% of GDP in 1990 to almost 10% in 2004 . Between 1990 and 2000, Greece experienced a much larger increase in spending than other OECD European countries, where health care expenditure remained fairly stable. Public expenditure over the last 25 years was were almost doubled. As a result, social insurance financing in 1994 rose to 53%. 5 In 1997 the hospital deficit settled by tax revenues had reached D 578 million. Another debt settlement was made in 2001 when the deficit had exceeded D 939million. In 2007, the deficit is estimated at D 1.3 billion.
4 O. Siskou et al. / Health Policy 88 (2008) directed more at increasing employment and salaries and less at service quality and infrastructure development. As a consequence, satisfaction with the public health system has deteriorated [15 18] and, not surprisingly, private expenditure increased rapidly (Fig. 1) and is currently almost half of total health expenditure and the highest in Europe . Almost all private expenditure is out-of-pocket payments, as private health insurance accounts for only 2% of total health expenditure [2,3]. It includes formal cost-sharing arrangements, direct payments, and informal payments, with the latter two representing the highest proportion of out-of-pocket payments among EU countries. User charges for NHS services are low, limited mostly to pharmaceuticals, where copayments vary from 0-25% depending on the severity, the chronic nature of the disease and ability to pay [1,10] Objective of the paper The objective of this paper is to analyze the magnitude and the reasons for private payments in the health care sector in Greece. Private payments are generally attributed to shortfalls in the public sector . We, will, therefore, also attempt to shed light on the health needs that the public system does not meet qualitatively and/or quantitatively and on the geographical imbalances of services provision. These aspects are addressed by provisional results from the European Health Survey SHARE  and the National Statistical Service Household Budget Surveys (various years). Although both of these sources provide useful insight, our objective is to offer further information on aspects of private expenditure which have not been analyzed yet in Greece. 2. Materials and methods This paper draws from a study designed to analyze informal payments in the Greek health care sector , using a randomized countrywide sample of 1616 households. The survey methodology was that of interviews with a specially designed questionnaire developed by specialists in the areas of health systems and health economics. The questionnaire contained three main parts: (a) the frequency of use and the magnitude of net payments 6 for outpatient services (e.g. dental care, internal medicine, surgeons etc) for each member of the household during the last 12 months. (b) Questions on admission procedures and size of net payments (direct and informal) for in-hospital care in the last 12 months. (c) The demographic and socioeconomic characteristics of the household. Data recording was with the help of the SPSS statistical package. The descriptive statistics (and socioeconomic characteristics) of the sample households are shown in Table 3. We used the Student t-test to check whether mean values of continuous variables between two groups varied significantly, after the necessary checks for the normality of the distribution with the Kolmogorov Smirnov test. Where the normality assumption did not hold, we used the non-parametric Mann Whitney test. To test for the independence between two categorical variables we used the Pearson χ 2 test. We used linear regression analysis to determine the extent to which social and economic household characteristics had an influence on the frequency of use of certain health services and the size of household payments for such services. The hypotheses tested appear in Table 4. The influence of these characteristics in some choices (e.g. hospitalization in private hospital) was investigated with the use of logistic regression. In all statistical analyses we used the p < 0.05 level of significance. In the Tables 7 and 8 we show the final results of the linear or logistic regressions carried out Variations in service utilization and expenditure are often attributed to factors other than actual need . Such factors are (a) demographic, such as population aging [22,23], (b) socioeconomic and economic, such as the educational level and income [24,25], and (c) the organizational and structural characteristics of the health system. The manner in which such factors impact on utilization and expenditure are often analyzed with the help of models. For example, the behavioral model includes three types of variables: predisposing variables, such as demographic and social, enabling variables such as system organization and other economic factors, and health needs . 6 Net payments are the remaining amount of money paid after reimbursement by social and private insurance.
5 286 O. Siskou et al. / Health Policy 88 (2008) Table 3 Socioeconomic profile of respondents No. of families % Cumulative total % Urbanization of place of residence a Rural area Rurban area Urban area without University Hospital Urban area with University Hospital Thessalonica Athens Number of family members member members members members Sum 4738 Net monthly family income (D ) Less than More than Educational status of the family head b Lower Middle Higher a Rural area: population <2000 residents; rurban area: population ,000 residents; urban area: population >10,000 residents. b Lower: none primary school (0 6 years); middle: high school, senior high or technical institutes (9 14 years); higher: university or colleges (>14 years). The problems of memory recall in dealing with past expenditure are a major drawback of telephone surveys [27,28]. It is, therefore, dangerous to extrapolate our findings to the whole population. In order to arrive at a satisfactory approximation, we made the assumption that memory recall does not vary among the various health service and health professional categories studied. In other words, we assume that memory lapse is the same in each expenditure category, i.e. between payments to medical doctors and surgeons. Under this assumption, we were able to utilize the results of the Household Budget Survey (2005) for the broad categories (Pharmaceutical & Therapeutic Appliance, Medical Care, Dental Care, Paramedical Services and Inpatient Care). The 2005 Household Budget Survey included a countrywide sample of 6555 households, which were previously asked to record all medical expenditures, eliminating thus the problem of memory recall. We therefore can use the national sample to apply the percentage distribution resulting from our questionnaire to arrive at detailed expenditure breakdown estimates by service and professional specialty, included in our questionnaire. 3. Results 3.1. The distribution of household expenditure by type of care The distribution of private health expenditure is shown in Table 5. Out of the total household health expenditure, approximately 66% (the sum of dental, medical, and paramedical services shown in Table 5) is for outpatient services, with the largest share for dental services, absorbing 31.1% of total household health expenditure (D 1912 million or 0.96% of GDP 7 ). This percentage is considerably larger than in the 23 7 The GDP, after the second revision that took place in 2008, was estimated to 198,609 million euros for the year 2005.
6 O. Siskou et al. / Health Policy 88 (2008) Table 4 Multivariate analyses that were performed Dependent variables Independent variables Hypotheses investigated: dependent/independent variables (1) Frequency of visiting private doctors (for outpatient (a) Urbanization of place of residence rural 1/a, b, c, e services) by major specialty area (reference category) Internal medicine Urban area specialties/obstetricians gynecologists/other surgical specialties/dentists orthodontists (2) Size of payment for private outpatient care by major Urban area without University Hospital 2/a, b, c, e specialty Internal medicine specialties/obstetricians gynecologists/other surgical specialties/dentists orthodontists (3) Probability of hospitalization in private hospital Urban area with University Hospital 3/a, b, c, d, e Thessalonica Athens (4) Total gross a amount paid annually by family for 4/a, b, c, d, e healthcare (b) Net monthly family income (D ) Less than 1000(reference category) More than 4000 (c) Educational status of the family head Lower (reference category) Middle Higher (d) Coverage from private health insurance (0 = no, 1 = yes) (e) Number of family members 1 member (reference category) 2 members 3 members 4 members+ a Gross payment is the amount paid as a whole before reimbursement by social and private insurance. OECD Europe countries with available data (0.34% of GDP for 2005). Even in the US, with a system considerably more privatized, and with 50 million uninsured, the corresponding percentage is only 0.7% of GDP. Private household health expenditure for other medical services was estimated at 23% (D 1430 million), or 0.72% of GDP. This percentage is larger than in other OECD (Europe 23) countries (0.31% of GDP for 2005), but much smaller than in the US (2.2%) . Concerning the distribution of payments by medical specialty (Table 5), we note that payments to gynecologists obstetricians exceed that of other surgical specialties. Household expenditure for pharmaceuticals and hospital care is much more in line with other OECD countries, amounting to 0.54% and 0.44% of GDP respectively, or 17.5% and 14.4% of total household health expenditure (Table 5). In money terms, household expenditure for inpatient care is D 884 million. It is remarkable that 20% of the amount going to hospital care concerns informal payments 8 within public hospitals (Table 5). This amount is almost equal to formal 8 As informal payments we defined all payments (extra fees and gratuities) to doctors for services which are theoretically provided free-of-charge.
7 288 O. Siskou et al. / Health Policy 88 (2008) Table 5 Distribution of household payments for health services million D, 2005 Total health expenditure (%) 1. Pharmaceuticals Therapeutic appliance Medical care Medical care expenditure (%) 3.1 Internal medicine specialists Gynecologists obstetricians Surgical specialists Others Paramedical services Dental care Inpatient care Inpatient care expenditure (%) 6.1 Informal payments in public hospitals Private nursing assistants Public hospitals charges Per diem fees in private hospitals Physician payments in private hospitals Cardiac surgeons Gynecologists obstetricians Other surgical specialists Internal medicine specialists Anesthesiologists Total Source: Household Budget Survey and authors estimations. payments in the form of cost sharing. According to our findings, 36% of those treated in public hospitals had at least one informal payment to a hospital doctor. However, although, informal payments are at the center of public discourse, they account for just 2.9% of total household health expenditure. Finally, we should note that 4% of hospital payments are to privately paid non-professional exclusive nurses. Unknown in most European countries, this term indicates a nurse employed by the patient to offer nursing care exclusively to him. As in the UK hospitals, where a number of RNs are employed by the patients to cover special health needs, there is always a consensus between the hospital nursing service and physicians . Although they fill a need in understaffed hospitals , one cannot overlook the fact that these nurses often lack formal training and operate outside normal nursing procedures. Moreover, it is remarkable that none of the socioeconomic characteristics were found to be related either with the probability or with the size of payments to exclusive nurses. In Table 5, we see that 55% of funds paid by households for hospital care are payments to private hospitals. These payments are almost equally divided between payments to hospital fees and to doctors working in private hospitals. Concerning the distribution of payments by medical specialty in private hospitals, we note that payments to cardiac surgeons exceed that of other surgical specialties. This is mainly due to the fact that the reimbursement of D 8804 by social security for public and private hospitals alike does not seem to cover the true cost charged for such operations. We found that patients paid an additional D 5000 for each surgery (N = 8, mean = D 5336 min = 875 max = 8000 median = 6000 S.D. = 2963 S.E. = 1120). 9 In the majority of these cases, these payments are informal, implying tax evasion by cardiac surgeons of 85% of total income. We should note, however, that informal complementary payments to surgeons also include additional payments to anesthetists, a fact which partly explains the low payments reported for anesthesia. 9 Despite the small number of heart operations, we observe that the number reported in our sample of 4,738 is remarkably close to the national rate for heart surgery (20,000 for a population of 11,100,000 people).
8 O. Siskou et al. / Health Policy 88 (2008) Table 6 Visits per family to private doctors dentists by major specialty Specialties N Mean Min Max S.D. Internal medicine Dentists orthodontists Obstetricians gynecologists Other surgical specialties The reasons behind private health expenditure Our study confirms previous research findings [30 33], which report a positive relationship between household private expenditure and private health insurance coverage (b = 283.4, p = 0.043) and net family monthly income (b = 135.7, p = 0.072). Our findings go further in investigating the factors responsible for the use of services from the private sector and the corresponding payments Outpatient care According to our results, 42% of the sample households (N = 677) reported visiting at least one health professional on a private basis during the last year. A previous study among 873 people insured with the Public Social Security Administration found that 40.4% of those asked had visited a private doctor at least once in the last 12 months . Table 6 shows the distribution of family visits per major specialty. Among our households reporting at least one medical visit in the public or private sector, the odds of visiting a doctor privately is 1.5 (OR = 1.5, CI = , p = 0.005) and 1.8 (OR = 1.8, CI = , p = 0.000) times greater for the families whose main earner is of higher or medium educational level 10 compared to the families headed by a person with elementary education. Concerning the frequency of visiting doctors privately by place of residence, Table 7 shows that rural dwellers tend to seek private care more often. Also, families headed by persons with lower education tend to visit doctors in surgical specialties privately more often. This is somewhat at odds with earlier findings [35,24,36], that families of low educational status use specialist doctors less frequently. Also, such families are less well informed and less likely to seek care by 10 Educational level is somewhat related to family income (Pearson χ 2 = 288, p = 0,000). Table 7 Variables associated with frequency of private doctor visits, by major specialty Specialties/independent variables β p-value Internal medicine Educational status of family head Urbanization of place of residence Number of family members Obstetricians gynecologists Urbanization of place of residence Net monthly family income Educational status of the family head Other surgical specialties Educational status of the family head Urbanization of place of residence Dentists orthodontists Number of family members general practitioners rather than visiting surgical specialties on their own self diagnosis. Table 8 shows that the size of payments to surgeons and dentists is not related to the socioeconomic characteristics of the family. Moreover, the size of payments to obstetricians gynecologists is related with residence, in the sense that families in rural areas pay more money to obstetricians gynecologists relative to those living in urban areas Hospital care Our findings show that almost one in four families (23.4%) had at least one admission to a hospital during the last year. Of the 405 families reporting a total of 569 hospital admissions, the vast majority had only one admission (Table 9). The majority (81%) of admissions were in a public hospital, and from the remaining, 16% Table 8 Variables associated with the amount paid to doctors on a private basis β p-value Internal medicine Educational status of family head Number of family members Obstetricians gynecologists Educational status of family head Urbanization of place of residence Dentists orthodontists Urbanization of place of residence
9 290 O. Siskou et al. / Health Policy 88 (2008) Table 9 Distribution of hospital admissions (A) Number of admissions (B) Number of families reported at least one admission C = A B % Cumulative total % Total were admitted to private hospitals in Greece and 3% sought care in hospitals abroad. The low number of admissions to private hospitals (16%), is close to that (18%) reported by the National Statistical Service, and is probably due to the considerably high cost of private hospital care. Our results show that family disposable income is highly correlated with the probability of admission to a private hospital. Of the families reporting at least one hospital admission, the odds of seeking care in a private hospital is 3.5 (OR = 3.57, 95% CI = , p = 0.008) and 3 (OR = 3, 95% CI = , p = 0.004) times greater for families with a monthly income of D and D , respectively, compared to those with a monthly income below D The odds of treatment in a private hospital is 2.2 times greater for families covered by private health insurance compared to those without (OR = 2.207, 95% CI = , p = 0.02). Such families, however, are only a small part of the total number. Our findings show that only 9% of those interviewed had private health insurance. 11 Even out of this small number, the majority had coverage only for basic hospital care, with yearly premiums not exceeding D 900. Our findings show, therefore, that only a relatively small share of the population can access private hospital care. Of the total of those treated in private hospitals, 64% were surgical cases, while the corresponding percentage for those entering public hospitals was 44%. One reason, for this difference might be the high quality of surgical services standards provided by a few prestigious private hospitals in which the freedom to choose a particular surgeon is much higher than in the public 11 Higher percentages of coverage by private health insurance reported in other studies include the total of life and health contracts. sector. Moreover, the probability of waiting for surgery in high-profile public hospitals often forces patients to seek alternative care in the private sector . 4. Conclusions The high rate of utilization of private health services in Greece seems to be due to the problematic organizational characteristics of the health system. Insufficient public funding and the corresponding deficiencies of primary health care services [4,37,38] in a way force households to look for care in the private sector. This is apparent from our study results (Table 6), which give evidence contrary to some hitherto held tenets of conventional wisdom in Greece: (i) The frequency of visiting a private doctor in rural areas is higher than in urban areas. This is probably related to the serious shortcomings of rural health centers in both the internal medicine and surgical specialties. According to evidence from previous research, the lack of doctors in these facilities is as much as 50% of legal requirements . This is a significant (and surprising) result, since we would expect the income and education effect, which is stronger in urban areas, to give us the opposite results. (ii) Families headed by a person with lower education tend to visit doctors in surgical specialties privately more often. This finding may be explained by the fact that economically active persons with lower education tend to be employed more at menial jobs, and are insured by the Social Security Administration (IKA), the health services of which are characterized by a low level of public satisfaction. Workers at menial jobs are also probably more prone to accidents, or other problems
10 O. Siskou et al. / Health Policy 88 (2008) requiring urgent attention, which usually cannot be provided by the free public primary care services. (iii) The size of payments to dentists is not related with the socioeconomic characteristics of the family. This finding is something that odds previous research . With only 1.23% of total public health expenditure devoted to dental care in 1998 , the use of private services is the only recourse for the majority of the population. For those who cannot afford it, the health implications are dire, and not limited to dental problems . Contrary to primary health services, the public sector showed greater political will in developing public hospitals . As a result, the private sector accounts for only 18% of admissions (National Statistical Service data). Our research results show that among families reporting a hospital admission, the probability of seeking care in a private facility is higher among families of higher income and those with private insurance coverage. This agrees with previous research results [30 32]. Despite the well-documented access problems, which we found to lead four out of ten patients to seek some form of intermediation for admission , public hospitals attract the vast majority of patients. One out of three patients uses informal payments in order to ensure quick access to public hospitals and in order to obtain upgraded quality of care. However, we found no evidence that informal payments are the major driver of total household health expenditure (THHE), as they account for only 2.9% of THHE. Moreover, the staffing problems associated with public hospital care, such as the serious shortage of nurses, estimated at 30% of nursing posts , leads to the use of outside professionals, such as privately paid non-professional nursing assistants. This substitution of private for public resources was not found to be associated with any of the family socioeconomic characteristics in our study, which means that it is considered to be an essential aspect of public hospital care. Even when public social insurance claims to cover the full cost of services, such as with cardiac surgery reimbursement set at D 8800, the health market seems to consider the reimbursement insufficient. This results in informal complementary payments which we found to be D 5300 on average. All our results seem to corroborate a widely held belief that the public system has still not lived up to the constitutional guarantee of full coverage by the National Health System, to all and free at the point of service. Besides the considerable gaps in public entitlement, such as in the case of dental care, the main problem is timely access to public infrastructures, especially in rural areas. Reverting to private care seems to be a rather inequitable phenomenon, as it seems to be dominant for those that can least afford it, such as rural populations and families with lower income and educational level, for seeking care from specific specialties, e.g. surgeons. 5. Policy implications The complementary nature of private care in Greece is no longer disputed. The original objective of free care to all as a responsibility of the public sector is gradually replaced by a doctrine of sufficient access to services irrespective of supplier. Health policy is increasingly aimed at two directions. First, to the need to strengthen and upgrade public services, and, second, to a collaboration with the private sector in order to increase the supply of privately provided and publicly reimbursed services The need to upgrade services offered by the public sector NHS under financing , together with serious public management problems , has seriously undermined the public health system, on the supply side. At the same time, public health insurance administered by 39 health funds, leads to major inefficiencies on the demand side . Our study showed that a great number of low-income people have problems in negotiating the obstacles posed by the bureaucratic organization, delays in reimbursement, and uncertainties as to the coverage they are entitled to. These problems often oblige even those that can ill afford it to private payments to doctors and hospitals. The health policy implications point to the need for a major overhaul of both the supply and the demand sides of the public system. On the supply side, a major effort was made six years ago, with the regionalization of the NHS and major changes in hospital manage-
11 292 O. Siskou et al. / Health Policy 88 (2008) ment with the reform introduced by Law 2889 of The country was divided in 17 Regional Health Systems (PESY), responsible for planning and control of regional resources, and a reform of the hospital management system with the appointment of professional managers. It was also accompanied by major changes in hospital procurement legislation and a serious attempt to introduce modern information systems. Unfortunately, political changes in 2004 and in 2007 resulted in serious retrenchment, negating most of the aspects of the 2001 health reform including reduction in the number of regional systems to 7. The resulting downgrading of the public system has caused a rapid increase in private spending and has given a new impetus to the private sector, which appears to be surging ahead with investment in modern medical technology and infrastructure development through M & As and the infusion of private equity capital from abroad. 12 On the demand side, the policy implications are more demanding. The fragmentation of health insurance, but, more important, the dependence of public health insurance on revenues based on employment, poses serious solvency problems. As the experience in many countries and even in the United States has shown, the globalization of the world economies leads to a relative decline of work income in favor of profits and interest on capital [45 47]. The diminution of the funding basis for employment-related health insurance points to the need for the establishment of a National Health Insurance scheme, funded by tax revenues from all sources of income. It is our belief that macroeconomic imperatives in the era of globalization will gradually shift health systems away from the Beveridge type system towards the Bismarck model. The very serious political debate which is just beginning, even in the US, should affect developments throughout the developed world Complementarities between the public and private sectors In an era of excess liquidity, the private sector has the resource, lacking from a public sector faced with 12 A major recent development has been a huge investment by an Arab Fund, through MARFIN BANK, for the acquisition of the largest maternity hospital and controlling interest in two large private hospitals. The government has quietly applauded the move. the inexorable need to keep budget deficits at or near zero. This abundance of cash, seeking to be profitably invested, points to the need for collaboration of the two sectors to a mutual advantage. In Europe, this cannot lead to a gradual shift in the locus of power in favor of the private sector. The European welfare state is politically non-negotiable, but, nevertheless, it must remain efficient and effective, and, if possible, become more so. One solution may be offered by the much-tooted Public Private Partnerships (PPPs), which, however, showed major weaknesses in Britain where they were mostly utilized. A search for effective means of public private collaboration must begin at European level, and in this, Greece, with a large private sector, and the highest share of private expenditure may have much to offer. This paper is a small contribution in this effort. References  Thomson S, Mossialos E, Jemiai N. Cost sharing for health services in the European Union. European observatory on health care systems. LSE health and social care. London School of Economics and Political Science;  OECD. Electronic health data base. Paris: Organization for Economic Co-operation and Development; 2006 and 2007 versions.  Liaropoulos L. Private health insurance in Greece. Athens: Forum; 1996 [in Greek].  Mossialos E, Allin S, Davaki K. Analyzing the Greek health system: a tale of fragmentation and inertia. Health Economics 2005;14:S  Tountas Y, Karnaki P, Pavi E, Souliotis K. The unexpected growth of the private health sector in Greece. Health Policy 2005;74(2):  Boutsioli Z. Concentration in the Greek private hospital sector: a descriptive analysis. Health Policy 2007;82:  A system of health accounts (SHA). Paris: Organization for Economic Co-operation and Development;  Orosz E., Morgan D., SHA-based national health accounts in thirteen oecd countries: a comparative analysis. OECD Health Working Papers. Paris;  Liaropoulos L, Siskou O, Kaitelidou D, et al. Informal payments in public hospitals in Greece. Health Policy 2008;87:  Mossialos E, Dixon A, Figueras J, Kutzin J. Funding health care: options for Europe. In: European observatory on health care systems series. Buckingham Philadelphia: Open University Press;  Social Budgets of various years. Ministry of Economy, General National Countinghouse.  Liaropoulos L. Ethics and the management of health care in greece: a health economist s perspective. In: Dracopoulou S,
12 O. Siskou et al. / Health Policy 88 (2008) editor. Ethics and values in health care management. London: Routledge;  Liaropoulos L, Kaitelidou D. Changing the public private mix: an assessment of the health reforms in Greece. Health Care Analysis 1998;6:  Siskou O. An analysis of private health expenditure in Greece. Ph. D. dissertation. Department of Nursing, University of Athens;  Blendon R, Kim M, Benson J. The public versus the World Health Organization on health system performance. Health Affairs 2001;20(3):  Moumtzoglou A, Dafogianni C, Karra V, Michailidou D, Lazarou P, Bartsocas C. Development and application of a questionnaire for assessing parent satisfaction with care. International Journal of Quality Health Care 2000;12(4):  Eurobarometer. Citizens and health systems: main results from a Eurobarometer survey. Luxembourg;  Niakas D, Gnardelis H. Patient satisfaction in a regional hospital. IATRIKI 2000;77(5):464-L470 [in Greek].  Niakas D, Theodorou M, Liaropoulos L. Can privatising selected services benefit the public healthcare system? Applied Health Economics Health Policy 2005;4(3):  Liberaki A. The findings of the survey of health ageing and retirement in Europe (SHARE). Athens: Institute of Regional Development, Panteion University; 2005 [in Greek].  Toundas J. Organization and evaluation of health services. In: Trichopoulos D, Kalapothaki V, Peridou E, editors. Preventive medicine. Athens: BETA Publ; 2000 [in Greek].  Philippant D, Van Tielen R, Sturbois G, Peys F. Descriptive analysis of the pharmaceutical prescription evolution in the Belgian ambulatory Sector between 1986 and Archives of Public Health 2000;58(2):  Hanlon P, Walsh D, Whyte BW, Scott SN, Lightbody P, Gilhooly ML. Hospital use by an aging cohort: an investigation into the association between biological, behavioural and social risk markets and subsequent hospital utilization. Journal of Public Health Medicine 1998;20(4):  Lostao L, Redigor E, Calle ME, Navarro P, Dominguez V. Changes in socioeconomic differences in the utilization of and accessibility to health services in Spain between 1987 and 1995/97. Revista Espanola De Salud Publica 2001;75(2):  Mendosa-Sassi R, Beria JU. Health Services utilization: a systematic review of related factors. Cadernos De Saude Publica 2001;17(4):  Toundas J. Health needs and the utilization of health services. IATRIKI 2005;88(4): [in Greek].  Cartwright A. Health surveys in practice and in potential: a critical review of their scope and methods. London: King s Fund Publishing Office;  Moss L, Goldstein H. The recall method in social surveys. London: University of London, Institute of Education;  Lanara V, Plati Ch, Priami M. The impact of private paid nonprofessional nursing helpers in general hospitals. In: Beazoglou, et al., editors. Human resources supply and cost containment in the health system. Athens: Exandas Press; 1997, pp  Donelan K, DesRoches CM, Schoen C. Inadequate health insurance: costs and consequences. Medscape General Medicine 2000;11(6):E37.  Kyriopoulos J. The use of economic indicators as a tool for health policy. In: Kyriopoulos J, Souliotis K, editors. Health expenditure in Greece. Athens: Papazisis Pub; p [in Greek].  Faulkner LA, Schauffler HH. The effect of health insurance coverage on the appropriate use of recommended clinical preventive services. American Journal of Preventive Medicine 1997;13(6):  Kontozamanis B, Kousoulakou H. Private expenditure for health and drugs, according to the Household Budget Survey. Athens: Foundation for Economic and Industrial Studies (IOBE); 2004 [in Greek].  Theodorou M. Ambulatory care in social security administration (IKA). Athens: IMOSY; 1993 [in Greek].  Kyriopoulos J, Gregory S, Oikonomou H. Health services for the Greek population. Athens: Papazisis Pub.; 2003 [in Greek].  Van Doorslaer E, Masseria C. Income-related inequality in the use of medical care in 21 OECD countries. Paris: Organization for Economic Co-operation and Development;  Souliotis K, Kyriopoulos J. The hidden economy and health expenditures in Greece: measurement problems and policy issues. Applied Health Economics Health Policy 2005;2(3):  Zilidis H, Philalithis A. Regional differentiations in private health expenditure in Greece. Society and Health 1994;3(4) [in Greek].  Theodorou M, Siskou O, Kaitelidou D, Farasteli O, Liaropoulos L. Management of primary health care services in Greece. In: Theory and practice of primary health care. Athens: 3rd PESY; 2005 [in Greek].  Kyriopoulos J, Souliotis K. Health expenditure in Greece. Athens: Papazisis Pub; 2002 [in Greek].  Gladwell M. The moral hazard myth. In: The New Yorker; August 29, pp  GNA. Greek National Association of Professional Nurses. Bulletin; September 2004 [in Greek).  Davaki K, Mossialos E. Plus ca change: health sector reforms in Greece. Journal of Health Politics Policy and Law 2005;30(1):  Liaropoulos L. The health insurance funds should be abolished. Kosmos tou Ependyti July, 2005 [in Greek].  Liaropoulos L. Globalization and social policy: Europe and USA. Athens: Papazisis Pub; 2006 [in Greek].  McMurray C, Smith R. Diseases of globalization. Socioeconomic transitions and health. London: Earthscan;  Petrella R. Globalization and Internationalization. The dynamics of the emerging world order. In: Boyer R, Drache D, editors. States against markets. The limits of globalization. London: Routledge; 1996.
VOLUNTARY HEALTH INSURANCE AS A METHOD OF HEALTH CARE FINANCING IN EUROPEAN COUNTRIES Marta Borda Department of Insurance, Wroclaw University of Economics Komandorska St. No. 118/120, 53-345 Wroclaw, Poland
Student Research Projects/Outputs No.031 What can China learn from Hungarian healthcare reform? Stephanie XU MBA 2009 China Europe International Business School 699, Hong Feng Road Pudong, Shanghai People
Social health insurance in Belgium Charlotte Wilgos & Thomas Rousseau Attachés NIHDI Content History Today Values Organizational overview Financial overview Evolutions and challenges Content History Today
Social insurance, private insurance and social protection. The example of health care systems in some OECD countries References OECD publications on Health care Swiss Re publications Sigma No 6/2007 on
INEQUALITIES IN HEALTH CARE UTILISATION IN OECD COUNTRIES Marion Devaux, OECD Health Division EU Expert Group Meeting on Social Determinants and Health Inequalities, 21-Jan-2013 1 Equity OECD framework
Overview of Medical Service Regime in Japan 75 years or older 10% copayment (Those with income comparable to current workforce have a copayment of 30%) 70 to 74 years old 20% copayment* (Those with income
INEQUALITIES IN HEALTH CARE SERVICES UTILISATION IN OECD COUNTRIES Marion Devaux, OECD Health Division 2014 QICSS International Conference on Social Policy and Health Inequalities, Montreal, 9-May-2014
APPENDIX D COMPARISON WITH OVERSEAS ECONOMIES HEALTHCARE FINANCING ARRANGEMENTS Table D.1 Comparison of Healthcare Systems in Selected Economies Part I Predominant funding source Hong Kong Australia Canada
Health Systems: Type, Coverage and Mechanisms Austria Belgium Bulgaria (2007) Czech Republic Denmark (2007) Estonia (2008). Supplementary private health Complementary voluntary and private health Public
Public / private mix in health care financing Dominique Polton Director of strategy, research and statistics National Health Insurance, France Couverture Public / private mix in health care financing 1.
Public and private health insurance: where to mark to boundaries? June 16, 2009 Kranjska Gora, Slovenia Valérie Paris - OECD 1 Outline of the presentation Respective roles of public and private funding
APPENDIX C HONG KONG S CURRENT HEALTHCARE FINANCING ARRANGEMENTS and Healthcare Expenditures C.1 Apart from the dedication of our healthcare professionals, the current healthcare system is also the cumulative
Private Health insurance in the OECD Benefits and costs for individuals and health systems Francesca Colombo, OECD AES, Madrid, 26-28 May 2003 http://www.oecd.org/health 1 Outline Background, method Overview
HEALTH INSURANCE COVERAGE AND ADVERSE SELECTION Philippe Lambert, Sergio Perelman, Pierre Pestieau, Jérôme Schoenmaeckers 229-2010 20 Health Insurance Coverage and Adverse Selection Philippe Lambert, Sergio
4 Distribution of Income and Wealth 53 54 Indicator 4.1 Income per capita in the EU Indicator defined National income (GDP) in per capita (per head of population) terms expressed in Euro and adjusted for
Voluntary health insurance in Europe a structured introduction into objectives and status-quo Reinhard Busse, Prof. Dr. med. MPH FFPH Dept. Health Care Management, Technische Universität Berlin (WHO Collaborating
Background Briefing Hungary s Healthcare System By Shannon C. Ferguson and Ben Irvine (2003) In the aftermath of communist rule, Hungary transformed its healthcare system from centralised Semashko state
PUBLIC & PRIVATE HEALTH CARE IN CANADA by Norma Kozhaya, Ph.D. Economist, Montreal Economic Institute before the Canadian Pension & Benefits Institute Winnipeg - June 15, 2007 Possible private contribution
EUROPEAN COMMISSION MEMO Brussels, 12 November 2014 SMEs access to finance survey 2014 This memo outlines the results of a survey undertaken by the European Commission to provide policy makers with evidence
Submission to the Parliament of Australia Senate Community Affairs Committee Enquiry into Health Policy, Administration and Expenditure September 2014 Introduction The Australian Women s Health Network
21 SOUTH-WEST EUROPE SOUTH-WEST EUROPE Croatia, Cyprus, Greece, Italy, Malta, Portugal, Slovenia, Spain Access to medicines and medical devices in Mediterranean EU Member States As members of the EU, all
HEALTH CARE DELIVERY IN BRITAIN AND GERMANY: TOWARDS CONVERGENCE? Background: Two different health care systems Generally speaking, the British and the German health care systems differ not only with respect
International Social Security Association Fifteenth International Conference of Social Security Actuaries and Statisticians Helsinki, Finland, 23-25 May 2007 Methods of financing health care Finnish national
Quality in and Equality of Access to Healthcare Services Executive Summary European Commission Directorate-General for Employment, Social Affairs and Equal Opportunities Manuscript completed in March 2008
Health Policy 43 (1998) 153 169 Public/private financing in the Greek health care system: implications for equity 1 Lycurgus Liaropoulos a, *, Ellie Tragakes b a Center for Health Care Management and E
PUBLIC VS. PRIVATE HEALTH CARE IN CANADA Norma Kozhaya, Ph.D Economist, Montreal economic Institute CPBI, Winnipeg June 15, 2007 Possible private contribution Possible private contribution in the health
Sweden Single payer, universal healthcare system, with 21 county councils as the primary payer (reimburser) Administration of healthcare plan is decentralized in the hands of the county councils Central
Hong Kong s Health Spending 1989 to 2033 Gabriel M Leung School of Public Health The University of Hong Kong What are Domestic Health Accounts? Methodology used to determine a territory s health expenditure
Insurance corporations and pension funds in OECD countries Massimo COLETTA (Bank of Italy) Belén ZINNI (OECD) UNECE, Expert Group on National Accounts, Geneva - 3 May 2012 Outline Motivations Insurance
Health at a Glance: Europe 2014 (joint publication of the OECD and the European Commission) Released on December 3, 2014 http://www.oecd.org/health/health-at-a-glance-europe-23056088.htm Table of Contents
The Tax Burden of Typical Workers in the EU 28 2015 James Rogers Cécile Philippe Institut Économique Molinari, Paris Bruxelles TABLE OF CONTENTS Abstract 2 Background 2 Main Results 3 On average, a respite
(Cover page) The Tax Burden of Typical Workers in the EU 28 2014 Edition NEW DIRECTION Page 1 of 17 James Rogers & Cécile Philippe May 2014 New Direction aims to help shift the EU onto a different course
EUROPE 2020 TARGETS: RESEARCH AND DEVELOPMENT Research, development and innovation are key policy components of the EU strategy for economic growth: Europe 2020. By fostering market take-up of new, innovative
Real Ways to Drive Down Healthcare Costs Scott E. Harrington The Wharton School, University of Pennsylvania www.scottharringtonphd.com com Free Market Forum Hillsdale College October 1, 2010 Outline The
Chapter 12 SUPPLEMENTARY FINANCING OPTION (5) MANDATORY PRIVATE HEALTH INSURANCE Mandatory Private Health Insurance as Supplementary Financing 12.1 Mandatory private health insurance is where private health
Eurobarometer INNOBAROMETER 2015 - THE INNOVATION TRENDS AT EU ENTERPRISES REPORT Fieldwork: February 2015 Publication: September 2015 This survey has been requested by the European Commission, Directorate-General
TOWARDS PUBLIC PROCUREMENT KEY PERFORMANCE INDICATORS Paulo Magina Public Sector Integrity Division 10 th Public Procurement Knowledge Exchange Platform Istanbul, May 2014 The Organization for Economic
Commission on the Future of Health and Social Care in England The UK private health market The NHS may dominate the provision of health care in England, but that still leaves the country with a significant
The Tax Burden of Typical Workers in the EU 28 2016 James Rogers Cécile Philippe Institut Économique Molinari, Paris Bruxelles TABLE OF CONTENTS Abstract 2 Background 2 Main Results 3 On average, a respite
?? Directorate-General for Communication PUBLIC OPINION MONITORING UNIT 2014 EUROPEAN ELECTIONS DESK RESEARCH Brussels, April 2015 Profile of voters and abstainees in the European elections 2014 INTRODUCTION...
Flash Eurobarometer INNOVATION IN THE PUBLIC SECTOR: ITS PERCEPTION IN AND IMPACT ON BUSINESS REPORT Fieldwork: February-March 22 Publication: June 22 This survey has been requested by the European Commission,
National Health Insurance Policy 2013 1. Background The Interim Constitution of Nepal 2007 provides for free basic health care as a fundamental right of citizens. Accordingly, the Government of Nepal has
Homeopathic and anthroposophic medicinal products A thriving European tradition A THRIVING EUROPEAN TRADITION Sales of homeopathic and anthroposophic medicinal products per inhabitant (in relation to GDP
The Tax Burden of Typical Workers in the EU 27 James Rogers Cécile Philippe Institut Économique Molinari, Paris-Bruxelles TABLE OF CONTENTS Objective of the Study 2 Study Interest 2 Main Results 3 Definitions
An Analysis of the Effect of Income on Life Insurance Justin Bryan Austin Proctor Kathryn Stoklosa 1 Abstract This paper aims to analyze the relationship between the gross national income per capita and
Austria Belgium Czech Republic Tax credit of EUR 400 for low pension income up to EUR 17,000; the tax credit is fully phased out once pension income equals EUR 25,000. pension income of maximum EUR 1,901.19.
Expenditure and Outputs in the Irish Health System: A Cross Country Comparison Paul Redmond Overview This document analyzes expenditure and outputs in the Irish health system and compares Ireland to other
EQUITY IN HEALTH CARE ACROSS FIVE NATIONS: SUMMARY FINDINGS FROM AN INTERNATIONAL HEALTH POLICY SURVEY May 2000 Cathy Schoen, Karen Davis, Catherine DesRoches, Karen Donelan, Robert Blendon, and Erin Strumpf
6 Social Welfare Payments Indicator 6.1 Indicator 6.2 Unemployment Benefits Compared to Earnings (OECD countries) Unemployment Benefits Compared to Earnings in the Republic of Ireland and the United Kingdom
Response to the New Brunswick Government Consultation on a Prescription Drug Plan for Uninsured New Brunswickers Brief submitted by The New Brunswick Nurses Union April 2012 Background The New Brunswick
SWECARE FOUNDATION Uniting the Swedish health care sector for increased international competitiveness SWEDEN IN BRIEF Population: approx. 9 800 000 (2015) GDP/capita: approx. EUR 43 300 (2015) Unemployment
Indicator What Proportion of National Wealth Is Spent on Education? In 2008, OECD countries spent 6.1% of their collective GDP on al institutions and this proportion exceeds 7.0% in Chile, Denmark, Iceland,
Single Payer Systems: Equity in Access to Care Lynn A. Blewett University of Minnesota, School of Public Health The True Workings of Single Payer Systems: Lessons or Warnings for U.S. Reform Journal of
INTERNATIONAL PRICE COMPARISON: THE CYPRIOT EXAMPLE Athos Tsinontides Health Insurance Organisation CYPRUS CYPRUS Kypros Demographics Population (2004): Gross Domestic Product (GDP): Total Health Expenditure
Prepared by First Life Financial Company. I SUMMARY Social Security Eligibility Retirement Contributions All persons gainfully employed under age 60. Self-employed are covered also. 60M/F To Social Security:
Economics of A Family Practice in Krakow Mukesh Chawla, Ph.D. Senior Health Economist and Department Associate Department of Population and International Health Harvard School of Public Health 665 Huntington
HOSPITAL SUBSECTOR ANALYSIS Fourth Health Sector Development Project (RRP MON 41243) A. Introduction 1. The health status of the people of Mongolia has generally improved over the years, and significant
Principles for application of international reference pricing systems International reference pricing (IRP) is a widely used element of price regulation in the vast majority of EU and EFTA countries. While
Development of advanced nursing roles in European and non-european countries Gaetan Lafortune, OECD Health Division DG Sanco Working Group on Health Workforce Brussels, 7 February 2011 1 Policy context
1 Private health care cost containment and supply-side regulation CMS presentation to the Health Portfolio Committee 2014 2 Contents Introduction Private hospital context Economic considerations Concentration
SUBMISSION TO THE SENATE INQUIRY INTO OUT-OF- POCKET COSTS IN AUSTRALIAN HEALTHCARE Prepared by National Policy Office May 2014 COTA Australia Authorised by: Ian Yates AM Chief Executive firstname.lastname@example.org
Health Care in Crisis The Economic Imperative for Health Care Reform James Kvaal and Ben Furnas February 19, 2009 1 Center for American Progress Health Care in Crisis U.S. spends twice as much per capita
1 UNITED KINGDOM DEMOGRAPHICS AND MACROECONOMICS Data from 2008 or latest available year. 1. Ratio of over 65-year-olds the labour force. Source: OECD, various sources. COUNTRY PENSION DESIGN STRUCTURE
PUBLIC DEBT SIZE, COST AND LONG-TERM SUSTAINABILITY: PORTUGAL VS. EURO AREA PEERS 1. Introduction This note discusses the strength of government finances in, and its relative position with respect to other
SURVEY OF INVESTMENT REGULATION OF PENSION FUNDS OECD Secretariat Methodological issues The information collected concerns all forms of quantitative portfolio restrictions applied to pension funds in OECD
Special Eurobarometer 373 RETAIL FINANCIAL SERVICES REPORT Fieldwork: September 211 Publication: March 212 This survey has been requested by Directorate-General Internal Market and Services and co-ordinated
Strategic purchasing to improve health systems performance Issues and international trends Reinhard Busse, Prof. Dr. med. MPH FFPH Dept. Health Care Management, University of Technology, Berlin (WHO Collaborating
UHI Explained Frequently asked questions on the proposed new model of Universal Health Insurance Overview of Universal Health Insurance What kind of health system does Ireland currently have? At the moment
Three Ways to Consolidate the Fiscal Situation Jun Saito, Senior Research Fellow Japan Center for Economic Research February 2, 2015 Medium-term fiscal consolidation measures to be announced In exchange
3. Components of social development 3.1. Proportions of economy performance and social development Growth of household consumption fell behind the GDP growth Favourable economic development after 2 and
Austria Belgium Temporary disability The insured receives the cash sickness benefit until a decision on permanent disability is made. The employer pays 100% of earnings for up to 12 weeks (plus additional
Eucomed Six Key Principles for the Efficient and Sustainable Funding & Reimbursement of Medical Devices Contents Executive Summary 2 Introduction 3 1. Transparency 4 2. Predictability & Consistency 5 3.
China s 12th Five-Year Plan: Healthcare sector May 2011 KPMG CHINA One of the guiding principles of the 12th Five-Year Plan (5YP) is inclusive growth : helping ensure that the benefits of the country s
FINANCING AND DELIVERING ORAL HEALTH CARE: WHAT CAN WE LEARN FROM OTHER JURISDICTIONS? Stephen Birch, D. Phil. 1,2 Rob Anderson, Ph.D. 2 1. Centre for Health Economics and Policy Analysis, McMaster University,
Planned Healthcare in Europe for Lothian residents Introduction This leaflet explains what funding you may be entitled to if you normally live in Lothian (Edinburgh, West Lothian, Midlothian and East Lothian
Annals of the University of Petroşani, Economics, 11(3), 2011, 15-22 15 THE EVOLUTION AND THE FUTURE ROLE OF THE BRANCH IN DISTRIBUTION OF THE BANKING PRODUCTS AND SERVICES CĂTĂLIN NICOLAE BULGĂREA * ABSTRACT:
Differences in patterns of drug use between women and men Differences in patterns of drug use between women and men Key findings Introduction Cannabis Ecstasy Tranquillisers and sedatives Alcohol and drug
Your consent to our cookies if you continue to use this website.