Greece in the time of the coronavirus

Dimitris Karellas and Stamatis Vardaros* write from Greece

At the time of writing, the officially recorded cases of the virus in Greece amount to 1,884¹, while the number of deceased is 83. These numbers are comparable to most EU countries and indeed with a better prognosis, while the measures taken by the neoliberal and overly conservative New Democracy government are more or less identical to the measures adopted all over the world – with the exception of the class-blind and fatal Trump and Johnson nonsense.

Almost all measures in Greece were adopted 10 to 20 days before their implementation in most other European countries: successive closure of schools, universities, restaurants and cafes, art, culture and entertainment venues, retail stores, partial circulation ban for ports and airports, support (inadequate) for workers and (biased in favour of) employers. All of the above has been accompanied by a wide information campaign and constant calls to stay home. It is true that concerning the lock-down measures for limiting the spread of the virus, the Mitsotakis government is so far following the recommendations of the experts. It is adopting most of the restrictive measures that have already been tested in Europe and beyond; and it is now imposing a universal prohibition of traffic, with only a small number of possible exceptions and the obligation to report any such movement to the competent authorities.

However, on the other important front of the pandemic, the strengthening of the National Health System (NHS), much less has been done than is really needed. There is already a noticeable shortage of personal protective equipment, a reinforcement of the NHS with additional staff (medical and other health professionals) is long overdue, a lack of planning for permanent posts and a reluctance to complete the pending procedures for already-hired permanent staff to enter in the Service. Furthermore, there was no provision for incorporating the Primary Health Care structures into the Ministry of Health‘s planning to tackle the pandemic, and a lack in developing or even properly utilising home care services for vulnerable groups. The NHS and University laboratories soon reached their maximum capacity for the diagnosis of coronavirus infections, there is a real risk of deterioration in the regular monitoring and treatment of patients with chronic or other serious diseases. There are long queues and tribulation for citizens visiting the public pharmacies of the National Organisation for the Provision of Health Services (EOPYY) for the provision of high-cost medicines, increasing shortages of simple but vital medicines in the market, lack of blood to meet the country’s needs, and more specifically the needs of polytransfused patients.

There is also a lack of targeted measures for vulnerable groups, such as refugees, Roma, prisoners, homeless, drug addicts, people living in nursing homes or welfare institutions, people living in crowded housing conditions or with inadequate means of protection and incapacity to observe even the basic rules of personal hygiene. This is a situation conducive to the creation of a “social Darwinism” and “natural choice” context for those who are more powerful and more resilient to the pandemic.

An obligatory policy

In reality, the neoliberal Mitsotakis government is called upon to confront the pandemic using the plan and weapons of its left opponent. While before the elections, but also during the first months of the new government’s term from July 2019 onwards, their health policy amounted to a passive privatisation of the NHS, preparing the active privatisation phase with the introduction of the first PPPs (Public–Private Partnerships), they are now obliged to tackle the pandemic brandishing the NHS as their main weapon. Not surprisingly, the NHS currently enjoys levels of social acceptance and political consensus comparable only to the first period of its establishment in the early 1980s.

This swift reaction by the right-wing government was dictated by two reasons. First, an attempt to save the tourist season, at least the 2020 July-September period, as tourism accounts for about 23% of Greek GDP and, directly or indirectly, 35% of jobs. The second reason was the relatively fragile structure of the welfare state following the collapse of the country due to the economic crisis, the harsh austerity memoranda imposed by the IMF, the European Commission and the European Bank (the infamous Troika) and the scary numbers one can read after a (lost!) war in 2009-2015: 25% fall in GDP, 28% unemployment, 40% income reduction, collapse of the national health and social protection systems, 25% of the population excluded from the social insurance and health system, increase of the material deprivation rate to about 22% compared to the approximately 8% in the other EU countries. This war image was complemented by the pressure put by hundreds of thousands of refugees and immigrants who have passed through the country, and the tens of thousands who still remain trapped after the central European countries closed their borders.

At the same time, the government’s ability to implement these measures and their widespread acceptance by the population is based on the conviction of the people that the reinstatement of the welfare state during the term of the SYRIZA government (2015-2019) will have the required continuity, especially after having seen even hardline neoliberal politicians expressing vows of faith to the (public of course!) welfare state as the only available shield in times of crisis.²

A few words about recent past

In 2015, the SYRIZA government, in a state of financial strangulation and faced with a severe humanitarian crisis, chose to pursue three, immediately effective, measures for citizens, all free of charge:

• provision of food and other basic material, as well as electricity and rent allowance for about 400,000 people in extreme (or absolute) poverty ³

• unimpeded access to health care for nearly 2,500,000 people

• free public transportation for the unemployed

The elimination of the phenomenon of people looking for food in the trash bins, of sick people dying helpless in their home or pauperised people being forced to sell–off all of their assets in order to pay for basic items or medicines, treatments, hospitalisation, were the first signs that the policies were changing “class indicators” even within the context of an austerity environment. A whole range of policies has been implemented since then, with a focus on reducing unemployment and job insecurity, as well as rebuilding the welfare state, not only to support the needs of the majority but also to restore human dignity in its diversity.

Given that the course and impact of the current crisis are determined not only by the current government policy but also by the previous SYRIZA government policy and its already measured performance results, we will seek to describe the current crisis in relation to everything we know regarding key pillar reforms in the health and social welfare sectors, while we were working at the respective Ministries. Thus, among many other things, we will not speak about the reduction of unemployment by almost 10 percentage points or the increase in the minimum wage by 11% or the obligation for employers to justify lay-offs. By the way, the latter is one of the first measures the right-wing government has cancelled – and rightly so: no neoliberal (i.e. capitalist!) would ever tolerate the slightest restriction on the employers’ management rights.

The situation in the field of Social Welfare

As the exercise of fundamental social rights is an obligation of the state, the functioning of an effective welfare state and the access of the whole population to its benefits and services are essential elements of the identity of any left-wing party worthy of that name. All the more so for the radical left, which has the additional obligation to implement policies that point the way towards and also highlight the actuality of another society, of equality and generalised social solidarity.

Based on the concept of universal social protection, the measures over the four year period 2015-2019 were grouped around several key axes. In the area of social welfare, the focus was on the fight against poverty and social exclusion, child support, and the elimination of inequalities for disabled people.

In the fight against poverty and social exclusion, the first immediate measures mentioned above were creatively incorporated into the Social Solidarity Income (SSI), a minimum guaranteed income program that replaced a failed and poorly targeted pilot implementation imposed by the Troika upon the previous governments. The Troika, under the almost extortionate pressure of the IMF, has sought to integrate the neoliberal notion that focuses only on “extreme” poverty, arguing that inequality is a normal condition, that people should rely only on themselves for a decent life⁴, that the state will try to reduce inequalities only if and when GDP is on the rise (hence, without the constant redistribution of social wealth), that charity by the “fortunate” is called upon to cover for the shortcomings of the state.

The SSI was designed to offer, in addition to direct financial support, free use of services (nurseries, school meals, electricity and water supply, special programs for food and essentials) and, more importantly, jobs for 10% of the unemployed program beneficiaries. At the start of the program in 2017, the number of the beneficiaries was 650,000, 50% of which were unemployed. Currently, the SSI beneficiaries, following the introduction in early 2019 of a completely new benefit for rent support and along with all other social policy measures, including the fight against unemployment, have been reduced to 450,000.⁵ The election of the neoliberal Mitsotakis government has halted the implementation of already prepared enhancements, such as the increase in the cash SSI allowance, its correlation to the minimum wage, and the automatic increase to 30% of the unemployed eligible to secure a job, with the aim to reach 100% by 2025.

One of the worst interventions by the right-wing government was the abolition of the Special Secretariat for the Coordination of Roma Policies and the consequent interruption of several holistic intervention programs (health, education, housing, work) for a depleted group of citizens.

For the child, the budget from 822 million in 2015 reached 1,424 million in 2019, to (a) extend the child allowance for an additional 160.00 children⁶ (b) implement a new program for free school meals offered to 150,000 primary school children, with the aim to cover all 600,000 students in primary schools by 2021-22 (c) increase free childcare placements from 78,000 in 2015 to 150,000 in 2019 (d) promote de-institutionalisation through the implementation of a new, innovative law on adoption and foster care, and (e) establish and implement a comprehensive guardianship system for unaccompanied refugee minors.

For disabled people, first and foremost no benefit or allowance was reduced, despite the fierce pressure exercised by the IMF for three years; moreover, special benefits were no longer connected to employment status. A number of other measures, such as prioritising 15% of public sector jobs for disabled people and their families, finalising funding for the creation of a large number of Supported Living Units to promote a pilot de-institutionalisation program, a nationwide remote support system for the hearing impaired using video and lip reading technologies, have shown that equality was not only a demand of the disabled people’s movement but also a firm belief of the SYRIZA government.

To support the above measures, and many more, a digitised National Social Welfare System was created, building on a new network of 240 structures across the country’s Municipalities (“Community Centers”), where citizens in need of help can get useful information promptly and are referred, when needed, to the appropriate social care services in their community, both state and private. The same System supports the de-institutionalisation process for the network of the state institutions, covering all 13 administrative Regions, with the aim to promote community care for children, the disabled and chronically ill, and to transform these institutions into co-ordination centers for all welfare policies in their Region.

In addition to the enormous effort to implement these programs, measures and changes, and in the midst of a continuing war from the Troika in a context of budgetary strangulation, it was necessary to quadruple the Social Welfare budget from 2015 to 2019 and redirect European funds to infrastructure and social utility programs. Table 1 depicts these visible results, with poverty and child poverty rates dropping already since 2017 to the pre-crisis levels of 2009. It should be noted that actual results do not yet incorporate the financial years 2018 and 2019, when the indicators are expected to be even lower.

Table 1

Social Welfare Budgets and Poverty Indicators

Statistical Reference Year	2010	2013	2014	2015	2016	2017	2018	2019
Financial Reference Year	2009	2012	2013	2014	2015	2016	2017	2018
Welfare Budget (€ millions)	941,8	785,5	677,4	789,7	883,0	1.525,7	1.836,5	3.268,2
Percentage of population at risk of poverty and social exclusion (AROPE index)	27,7	35,7	36,0	35,7	35,6	34,8	31,8
Percentage of Poverty (AROP index)	20,1	23,1	22,1	21,4	21,2	20,2	18,5
Percentage of Child Poverty	23,0	28,8	25,5	26,6	26,3	24,5	22,7

Source: Hellenic Statistical Authority (ELSTAT)

For more data see https://www.statistics.gr/en/statistics/-/publication/SFA10/2018

The outbreak of the Covid-19 pandemic found the most vulnerable members of the population under the protection of a functional, universal social welfare system, as the neoliberal government was forced to “tolerate” SYRIZA’s policies, still hesitating to declare a new war on SYRIZA voters.⁷ But very soon they showed their true intentions: reductions in the welfare budget for 2020, freezing of the new, fair and transparent system for adoption and foster care, delays in the de-institutionalisation program for the disabled, poor implementation of the school meal program. And this is no accident, since these fields are very attractive for the private sector – and in the case of adoptions, for infant and hope traffickers.

A widely accepted “Help at Home” program at the municipal level for the elderly and the disabled had been functioning for nearly 20 years (!) with workers on short-term contracts. The regional Social Welfare Centers were understaffed for years. The SYRIZA government voted a bill giving permanent civil servant status to the “Help at Home” workers and allowing the hiring of new permanent staff for the Centers plus auxiliary personnel for at least two years. The current government’s 8 month refusal to abide by the law’s provisions, turned into panic and an attempt to speed up procedures, as the spread of the coronavirus to institutions for the vulnerable threatened to turn them into cemeteries, and the lock-down measures showed the valuable contribution of programs such as “Help at Home”.

The situation in the field of Health

The protracted economic and social crisis in Greece and the austerity measures of the first Memorandum period have inflicted wounds on institutions, the political system, public administration, the welfare state and of course the public health system. For it is well-documented that the crisis not only produces unemployment and poverty, it also produces psychosomatic vulnerability and illness. It creates the need for increased health and psychosocial care. This has been the case in the country but because of the political choice in the initial 2010-2014 Memorandum period to drastically cut health care costs, reduce public health care, pass on much of the cost to citizens, and exclude uninsured people from the NHS, these needs were left unaddressed. This has created a widespread “zone of health poverty“ in society that has endangered the country’s health standards, social cohesion and dignity. The “bottom-up“ social clinics, the civil society solidarity initiatives, the voluntary work of many health-care professionals and the sensitivity of the NHS staff have prevented a real health tragedy in Greece.

The top political priority of the SYRIZA government was to ensure equal access for the uninsured to health care, prevent the functional black out of the NHS and reorganise the public health system. In spite of ongoing and historical problems, despite difficulties and limitations, this key objective has been achieved. In the Greece of severe austerity and under fiscal controls, cuts in public health spending stopped in 2015, the recruitment/retirement rate in the NHS has been positive since 2016, and following Law 4368 of 2016, more than 2 million uninsured citizens enjoy guaranteed and free access to public health facilities, exams, medicines and nursing care. The decoupling of the fundamental right to health from employment, insurance status and income is the major reform in the country’s health and social policy. Health poverty has been tackled drastically and inequality in health care has been measurably reduced: citizens with unmet health needs represented 12% of the population in 2016, while in 2018 the percentage has dropped to 8,3%.⁸.

Budget constraints and budgets “locked” by line item would not allow a significant increase in public health funding. However, under SYRIZA rule, with the utilisation of European resources (NSRF), the redistribution of resources from the private sector to the public health system, cost containment mechanisms for private providers and the pharmaceutical industry, and without passing on additional costs to citizens, we were able to meet more health needs and to move ahead with some crucial reforms.

Health needs were addressed through the strengthening of the National Health System with material and human resources. The largest investment project ever was initiated, which focused on equipment and infrastructure exceeding € 300 million, including investment in expensive and innovative therapeutic technology. At the same time, the NHS saw the largest human resource “injection” in the past 20 years, including 3360 permanent doctors, 5026 permanent nurses and other health professionals, and a total of more than 19,000 NHS employees.

At the same time, important interventions were made in the field of medicinal products, including, inter alia, an initiative for transnational cooperation between the countries of the South (the so-called “Valletta Initiative“), a partnership based on a single trading logic to facilitate access to pharmaceuticals, starting with negotiating better prices.

Another important intervention was made in the field of medical education, as well as physical medicine and rehabilitation with an ambitious program for activating 28 new public structures in major cities for recovery and rehabilitation. Much emphasis has also been placed on the reorganisation of the blood donation system, as well as on interventions in the field of mental health, addiction treatment and health care for refugees, immigrants and other vulnerable groups.

Most important of all is the reform of Primary Health Care, an intervention that completed the major breakthrough that the SYRIZA Government has made in the health system by ensuring coverage for the uninsured. The reform of Primary Health Care has begun to expand the “public space” in Health and to specify the subsidiary role of the private sector, always aiming at universal coverage of the population, equality of access and financial protection in particular for the weaker members of society. Public Primary Health Care was restructured into a human-centered model of health care delivery with the recipient at its core, through functional and targeted changes in order to facilitate the provision of health services and to liaise service providers on the basis of a vertical management system.

New decentralized structures have been created, the Local Health Units (TOMY), targeting a specific population, and staffed by an interdisciplinary team, comprising family doctors, paediatricians, nurses, health visitors, and social workers. TOMY and their health care teams have begun to develop a new example in the National Health System. They established family medicine units, focusing on preventive medicine, school health, vaccinations, chronic patient management, on continuous and holistic citizen care. TOMY are for citizens their first point of contact with the NHS, but at the same time they develop extrovert and community-based interventions (vaccinations for vulnerable groups, information campaigns for the general public, regular visits to schools, workplaces, centers for the elderly).

The goal of the reform was for every citizen, insured or uninsured, to have their own family doctor, their own health advisor, a person responsible for monitoring and managing their health problems, keeping their Individual E-record, for providing holistic and quality care.

Particular emphasis was placed on the re-occupation of the Primary Health Care space by the NHS, at the expense of private interests. The Primary Health Care sector, especially in urban centers, had been open to private sector practices since the establishment of the NHS in 1983 up until 2017. The SYRIZA government strategic choice was to re-occupy this space with the public system. The starting point for institutional intervention in primary health care lies in the pivotal role of the public system, making full use of its capacity and of the potential of the private sector to meet actual NHS needs.

Ideologically, the reform of Primary Health Care is a paradigm shift for the NHS. Until then, citizens used health services mainly, if not exclusively, when they became patients, when they were actually ill. And what’s more they used these public or private services as they thought best, acting as consumers. However, these consumers were lacking sufficient knowledge of the field (as non-experts). The result was that not only did they not maximize, as neoclassical economists say, the benefit through their “consumer choices”, but they often consumed services (exams, medicines, visits to specialists) that were inappropriate for their case. This practice, in the absence of valid and reliable information, often led citizens to seek an appropriate service through hear-say, following recommendations by family or friends (“I know a good doctor over there“), following referrals by specialists mainly of the private sector to other specialists or “appropriate” diagnostic centers, offering bargain packages. This situation obviously had consequences not only for the citizens’ health, but also for the financial capabilities of the health system, due to the arduous demand for health services and the many informal networks flourishing among the various health care providers.

This has been and remains the crucial point of the transition to the new system and this is also a red line when debating this intervention. When the Left was promoting a health system that would assume the responsibility for the citizen’s health, the opposite side was talking about a “blow to free choice”. But what is this free choice? The free choice offered by the former system, a semblance of freedom to choose between an inadequate and overburdened public service and the abundant and overpriced private sector services? The weakest citizens, before the 2016 Law on access by the uninsured to the health system, not only had no free choice but no free access at all. Freedom, Engels said, is the awareness of necessity, and that is precisely the conceptual basis of the Primary Health reform; it is the awareness of the service, the kind of care that a citizen needs, and for which the state has primary responsibility.

Obviously, this latest intervention in Primary Health Care, as well as the evolving NHS, have been targeted by the new government’s neoliberal choices from the very beginning. Before the pandemic made its appearance in Greece, the government had managed, within just eight months, to freeze the Primary Health reform, by gradually disorganising – with not much success – the 127 TOMY structures operating across the country and, at the same time, by creating a fertile ground for the entry of private interests into the NHS through PPPs. The non-renewal of contracts for staff necessary for the operation of departments or clinics, the cancellation of an ambitious recruitment program for permanent staff that the SYRIZA government had initiated, the interferences in the area of substance dependency aimed at saving resources, the centralisation of the control over relevant structures⁹, the suspension of the right to health care for asylum seekers and international protection beneficiaries, both adults and minors, the abolition of a fair framework for evaluating and selecting the NHS hospital administrators, the abolition of social control and accountability procedures at the local health structures, were all “preparatory” steps taken in the NHS in the months before the pandemic.

However, in times of crisis, as has been repeatedly documented in international literature and empirically recorded in Greece during the Memoranda period, people resort to public health systems. For they are systems offering guaranteed and universal coverage, with experienced, “battle-hardened” staff, dedicated to their duty, enjoying social acceptance and political consensus. This is the best combination when you go to battle, the battle for life.

The bottom line

We try not to think about what would had happened to the poor, the impoverished and vulnerable people in Greece in the current health crisis, if the neoliberal policies had continued after 2015, during the culmination of the country’s humanitarian, financial, social and political crisis.

We are aware that society’s current resilience is based on the incomplete, alas, establishment of an almost non-existent welfare state in the period 2015-2019.

We are fully aware that the current COVID-19 crisis is the spark for new, more serious than in 2008, global crises: economic, commercial, environmental, a crisis in the major international institutions of the 1%-99% system, (World Trade Organization, IMF, NATO, G7 v. Russia, Fed-Bank vs. Trump, European Central Bank), a political crisis in major countries (United States, UK, Germany, Brazil, Argentina, India – the list is long).

Exactly because this new crisis is being handled by the same institutions and people that handled the previous ones, namely large corporations, banks, brokers and political personnel plus the Media at their service, they continue to focus – for example – on differences in age-related mortality rates, avoiding any reference to class differences that are affecting mortality due to differences in income and social status: we can all see that access to critical health care for people over 70 varies widely between poor and rich.

Because class inequality is most bluntly captured at the time of need, it is very important that target values such as universal health coverage, strengthening of the welfare state, trust in the National Health System, care without any discrimination, and ultimately protection for the most vulnerable, are currently the central issues in the public agenda. And this is the agenda of the Left, it is a hegemonic agenda that in this critical time even neo-liberals are forced to “buy”, with the dark exceptions of the biopolitical anti-paradigm of Johnson in Britain and Trump in the USA.

When, hopefully, the pandemic subsides, what we need in order to keep our agenda at the forefront is documentation, social alliances capable of forming a front and, of course, political plans for the next day. Indeed, as the effects of the pandemic will be adding to the flammable materials of the upcoming severe and multifaceted crisis, we will need to talk not only about the developmental utility of social spending, social benefits, of the welfare state itself, but also of a political plan, so as not to burden once again the social majority with the consequences of a crisis caused by the same actors as in 2008 – not to mention other crises in the last two centuries. And that is our agenda.

*Dimitris Karellas is former Secretary General for Social Solidarity/Welfare, Ministry of Labour, Social Security and Social Solidarity, Greece

*Stamatis Vardaros is former Alternate Secretary General of Health, Ministry of Health, Greece

[Special thanks to Lina S. for helping with the translation]