HEPL blog series: Country Responses to the Covid19 Pandemic

Greece’s response to the coronavirus pandemic

Aris Angelis¹, Ilias Kyriopoulos¹, Irene Papanicolas^1,2, Sotiris Vandoros^2,3

¹ Department of Health Policy, London School of Economics and Political Science, London, UK
² Harvard T.H. Chan School of Public Health, Harvard University, Boston, US
³ King’s Business School, King’s College London, London, UK

Since the first announcement of SARS-Cov-2 in China on January 8 2020, and the first confirmed COVID-19 case in Greece on February 26, 2020, Greece has adopted a range of preventive health measures and protective economic measures. The government’s response has been informed by the recommendations of a Special Committee on Infectious Diseases (consisting of 26 experts in epidemiology, infectious diseases and microbiology), and academics from the areas of health policy and public health, notably Prof Elias Mossialos who has since been appointed as the government’s representative to national organizations for all issues relating to COVID-19. The Greek health system response has targeted both the demand and supply side of the health care system, to reduce the rate of infection while also expanding the health system’s capacity.

Supply side-measures – building up health care system capacity
The Greek health system has suffered from some areas of limited capacity as well as hospital inefficiency and poor allocation of resources. Health spending in Greece accounts for 7.8% of GDP as compared to an OECD average of 8.8%. Although Greece has the highest number of physicians per capita among OECD countries (6.1 per 1,000 population vs. OECD average of 3.5), the number of nurses is among the lowest (3.3 per 1,000 population vs. OECD average of 8.8). The total numbers of hospital and critical care beds are also below the EU average at 421 per 100,000 population (vs. 504 EU average)  and 6 per 100,000 population (vs. 11.5 EU average), respectively.

In response to potential suspected cases of COVID-19, the Greek Organization of Public Health (EODY) issued a call for 200 new health care staff on February 25^th. On March 3^rd, a COVID-19 hotline was set up. Further instructions for health care providers and private doctors were issued on March 13^th, while laboratory testing criteria prioritised high-risk groups and health personnel. Wider participation of research laboratories was also introduced to increase testing capacity.

As the crisis spread, additional recruitment calls were issued, for another 2,000 health professionals through a fast-track process, which then expanded to 4,200. In addition, the health system increased its intensive care units from 565 to 870 beds. Following the Prime Minister’s announcement for expanded capacity and more medical equipment, the Minister of Finance committed to an increase in the annual health care budget by more than €200 million.

Demand-side measures – flattening the curve
The first COVID-19 related information was issued on the 16^th of January 2020, in the form of precautionary travel advice, including screening for early detection and isolation. By the end of February, the EODY issued detailed self-isolation instructions for individuals coming in close contact with a suspected or known case, alongside measures for vulnerable hospitalised patients, and general guidelines for educational institutions and refugee and migrant reception centres.

Early March saw an increase in cases which prompted new instructions for the management of suspected COVID-19 cases at home, at sea, and in hotels; as well as guidance for those with children and adolescents. On March 8^th, all Open Care Centres for the Elderly, conferences, school trips, and sporting events were suspended. Following the targeted closure of schools with suspected cases, on March 10^th, the Minister of Health announced the closure of all educational institutions, shortly before the first COVID-19 related death in the country.

Alongside appeals citizens to follow guidelines for their individual protection and social responsibility and guidelines for home isolation, the government mandated strict physical distancing measures on March 13^th , by suspending public events and mass gatherings in public spaces such as cinemas, theatres, sports stadiums, gyms, playgrounds, clubs, cafes, restaurants, bars, museums and archaeological sites. Only pharmacies, supermarkets and selected food outlets were exempt from these measures.

On March 23, a national lockdown was enforced with exceptions for the purposes of commuting to work if working remotely was not an option, purchasing food and medicines, visiting health services, assisting a person in need of care, exercising (individually or in pairs), attending certain ceremonies (e.g. funerals), walking a pet, or bank visits.

Economic measures
Following a Eurogroup meeting in mid-March, Greece’s primary surplus target of 3.5% GDP was abolished, with expenditure for health and the concurrent immigration crisis being excluded from government budget targets. After securing substantial fiscal space, the government enacted temporary measures to support the economy. According to the Government Spokesperson, the fiscal measures amount to €6.8 billion (or 3.5% of GDP – well above the respective EU average).

Payments for taxes and insurance contributions were suspended for a four-month period for companies or the self-employed that had ceased operations, while also allowing for more flexible labour regulations. Payment suspensions were gradually extended to all forms of private household and company debt affected, including repayment of bank loans. Overall, these schemes applied to 76% of legal entities and 75% of the self-employed.

Several measures were adopted to stimulate liquidity and support employment for the business sectors most affected. For example, a new business financing scheme of €1 billion (payments on account) was introduced to support SMEs and bolster employment amid the outbreak.

Private sector employees whose contracts were temporarily suspended received a lump sum subsidy of €800, while their respective insurance contributions were covered in full by the state and their tax obligations were suspended for a four-month period. The measure currently covers 1.7 million employees, accounting for almost 81% of private sector employees. Finally, companies that suspended operations, and their respective employees, are entitled to pay 60% of rent during the next two months, while property owners will be exempt from various obligations including property tax. In addition, VAT for personal hygiene products that offer protection against COVID-19 decreased from 24% to 6%.

Discussion of measures
Greece is among the earliest European adopters of preventive measures. Schools throughout the country were closed before any COVID-19-related deaths occurred, in line with the literature that shows that school closure is more effective when done sooner.

These measures led to a steep decrease in community mobility and have so far been effective in limiting the rate of infection transmission, with a total of 1,735 confirmed cases (1.62 per 10,000 population – a figure that does, however, depend on the number of tests) and 76 deaths (case fatality rate of 4.4%) as of 6^th of April.

Early adoption of the measures might have been triggered by the relatively low number of hospital and intensive care beds, and a chronically underfunded health system with structural problems that would be unable to cope with large patient numbers. Another risk factor that may have contributed to early adoption of policies is an ageing population, while intergenerational family ties are also very strong.

There are over 100 inhabited islands in the country, most of which have no or few hospital beds, and serious cases have to be airlifted to the mainland. Sealing off the islands earlier could have protected the local population, while funds used for costly airlifting could be invested elsewhere in healthcare. More could have also been done earlier on to secure more ventilators and protective equipment for medical staff.

Among OECD members, Greece is expected to be hit the hardest financially, with an estimated decrease in GDP by over 30%. Tourism, which accounts for a large part of GDP, is currently virtually zero due to the lockdown, with severe consequences for the economy. In addition, Greece does not have independent monetary policy, which leaves the government with fewer financial tools.

As a next step, Greece should now focus on intensifying the wider use and dissemination of diagnostic tests (22,437 people had been tested as of 3^rd of April). This will allow estimating the number of people infected and recovered, which will help plan when and how to lift the lockdown. Securing medical supplies, ventilators and protective equipment remains an ongoing challenge, amid global competition for such equipment. Any gradual easing of the lockdown should be supported by continuous disease monitoring.

Overall, the country is now facing a major public health and financial threat, and the biggest challenges appear to still lie ahead.

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