DR. COSTAS DIKEOS
ASSISTANT PROFESSOR
DEP. SOCIAL ADMINISTRATION
DEMOCRITUS UNIVERSITY THRACE.
[email protected]
STREAM 8/ HEALTH AND SOCIAL CARE.
TWO-PARTY SYSTEMS AND CONSENSUS OVER HEALTH
CARE POLICY IN GREECE AND THE UNITED KINGDOM. A
macro observance.
Abstract:
The paper questions the challenge put by the welfare regimes problematique to the
significance of the role of party-systems. Observing that both Greece and the United
Kingdom have a two-party system, with a social-democratic and a conservative-neoliberal party it also notes that for significant segments of this period these countries
have been governed concurrently by parties of opposing political orientations.
However, both countries perform National Health Services with universal coverage,
cost-free at the point of use (the Greek system being a hybrid between Bismarckian
and Beveridge-ian giving emphasis on secondary and tertiary health provision, the
UK system purely Beveridgian, giving emphasis on primary health provision), whilst
state expenditure for health is at close levels. Recent legislation has concentrated upon
administrative and managerial issues (both Greece and UK), and internal competition
(UK), leaving accessibility (and finances -of the entire system-) almost unscathed.
The paper concentrates on political developments in Greece and the United Kingdom
(focusing upon health care provision and financing) after 1979 (year of first signs of
adoption of a national health service in Greece and Mrs. –now Lady- Thatcher’s
ascent to government). This is pursued through examination of public health
expenditure as a percentage of the GDP, rate of change of public health expenditure in
standardised prices, and the public/private mix in health care expenditure vis-à-vis
governing party in office for both countries.
Overall, the paper wishes to investigate the significance of political parties and partysystems through a macro observance cross-party consensus over principles
concerning health care, which (consensus) is drugging parties towards the middle
ground and the political centre, despite ideological party differences.
DR. COSTAS DIKEOS
ASSISTANT PROFESSOR
DEP. SOCIAL ADMINISTRATION
DEMOCRITUS UNIVERSITY THRACE.
TWO-PARTY SYSTEMS AND CONSENSUS OVER HEALTH
CARE POLICY IN GREECE AND THE UNITED KINGDOM. A
macro observance.
Introduction.
It needs no effort to claim, despite it might lack stunning originality, that Greece and
the United Kingdom have significant differences regarding their social policy history
and structure, alongside differences in their respective political histories. As for the
latter, the array of Greek unstable and short lived governments in the early twentieth
century, pre-war Metaxas dictatorship, axis occupation, civil war, authoritarian
regimes despite a democratic façade, further political instability and colonels’
dictatorship up to 1974 do not exactly mirror the smooth British way of solving
problems regardless of adversarial argumentations either in- or out-side the Palace of
Westminster. Differences regarding social policy are also evident and have been
manifested in the work of most commentators, notably in the models of welfare
regimes problematique developed by Esping-Andersen (1998). Differences can be
discovered also through the absence of Greece (and other Southern European states
for that matter) in approaches up to the early or even mid 1990s and the explanation
mentioning rudimentary development, low national income and undemocratic
governments given by Castles (1995), or –more in line with the Esping-Andresen
argument- through the Fererra-Katrougalos debate about the existence or not of a
fourth ‘Southern European’ model of welfare regime, or alternatively the existence of
a discount model of the Central-European/Continental model. The argument against
(Katrougalos) a fourth ‘Southern’ model gives emphasis to health and the transition
from contributory to comprehensive services, challenging also the points regarding
fragmentation and the role of the Church (Fererra) (see Fererra 1996, 1999;
Katrougalos 1996). On the other hand though, all agree in the universalism of Greek
health care coverage in line with the UK National Health Service, despite their minor
differences in funding with the British system being purely Beveridgean and funded
by taxation, and the Greek being a hybrid between Beveridgean and Bismarckian
funded by both taxation and insurance funds contributions (eg Freeman 2000). It has
to be said though that these similarities cease once we observe the two systems in a
little more detail as the British one gives emphasis upon primary care and the Greek
upon secondary and tertiary on the one hand, and present rather different picture
regarding the public/private mix as far as expenditure gets under question, since
private expenditure is much higher in Greece. Returning to political analysis though,
we would like to note that after mid 1970s Greece and the United Kingdom present us
with more similarities than differences as far as party politics is investigated, since
both are two party systems with a conservative-neoliberal and a social democratic
party forming single party governments for most of the time 1. Alas! New differences
arise since usually the two countries are governed by parties of opposing political
orientations and ideologies.
This paper will therefore attempt a departure from the welfare regimes model
problematique based upon the political economy mix and de-commodification
(Esping-Andersen 1998) by investigating the significance of party politics, party
ideologies and party systems (converging two-parties system for that matter), for
health care systems a parametre disputed by Esping-Andersen (1998, 17). Such an
approach does not challenge to de-commodification and political economy mix
argument, but just wishes to bring the significance of party-systems back, since
political parties are the key players in contemporary states (alongside pressure
groups), form governments that shape policies etc. Obviously policy decisions are
made within a political economy mix and regards inter alia de-commodifiacation.
Examining the relation between party systems and health policy will be attempted
through presenting the rate of change of health care expenditure in standard prices and
the public/private mix in health care expenditure vis-à-vis party in office in Greece
and the United Kingdom.
In this pursuit this paper will initially present the respective party systems as to
examine the ‘two-party system’ claim, it will subsequently turn to the ‘inconcurrence’
of governing parties, and then it will examine similarities and differences regarding
health care financing with a view to growth in real terms, share of the GDP and the
The presentation of party-politics will be self-restricted to the commencement of duties of the current
governments (PASOK for Greece and Conservative-Liberal Democrats coalition for the UK
respectively, or in other words up to the general elections of October 2009 for Greece and May 2010
for UK)
1
public/private mix. Issues of services structure such as hospital management, health
authorities in a district or regional level, acute trusts, ambulance trusts and foundation
trusts etc (see eg Thompson 2009 for UK, Dikeos 2007 for Greece) will not be dealt
with in detail, as the wish is to make a macro-approach predominantly in financing
and secondarily in accessibility, vis-à-vis party systems and party politics. To achieve
this the paper will further examine election results, party ideologies and expenditure
data in both countries.
The Greek and the UK party-systems
As previously mentioned mid seventies was a watershed for Greek politics. Political
freedom, stability and unhindered participation of a kind not experienced before
characterise the Greek political system since 1974, alongside political stability
expressed both in government tenure and duration of the major political parties,
usually after the change (or even death) of the party founder and/or leader too. In the
almost 36 years since ‘metapolitefsi’ Greece has seen 12 General Elections which
gives an average of 3 years tenure for a government (out of the constitutional
maximum of 4 years), and notwithstanding a 10-11 month period in 1989-90 Greece
has seen stable single party governments (with the exception of the Nea Democratia
government of 1990-93 which had a fragile majority of 1, and again 2007-09 with a
majority of 2 initially and 1 soon after) formed by either Nea Democratia or PASOK.
Additionally the aggregate vote for the two major parties remains usually over 80%,
while after 1981 that the system is consolidated the difference between the second and
third party is high usually about 2,7 times the score of the third party. On top of that
PASOK has changed three party leaders, whereas Nea Demokratia seven, and despite
various turbulences due to party defections (eg DIKKI or Politiki Anixi) both parties
have survived successfully long compared to their pre-dictatorship predecessors and
‘counterparts’. Therefore, we observe a two-party system (for an overall description
of two-party systems see Mair P (ed) The Western European Party System, (Oxford
University Press, Oxford 1990) whilst stakes are usually high and political
confrontation adversarial.
GREEK ELECTION RESULTS 1974-2009
Nov 1974
ND
54.37*
EKND
20.42%
PASOK
13.58%
EA Un
Left.
9.74%
Nov 1977
ND
41.84*
PASOK
25.34
EDK (Un
Dem
Cent)
11.95
KKE
(Com Par
Gr) 9.36
Oct 1981
PASOK
48.07*
ND 35.88
June 1985
PASOK
45.82*
ND 40.84
KKE
10.94
KKE 9.89
KKE es
(inter).
1.34
EP (Nat
Block)
6.82
June 1989
ND
44.28@
PASOK
39.13
SYN
(coalit
left)
13.13@
DIANA
(dem
regen)
1.01
Empist
Trust. 0.38
All left
2.72
Nov 1989
ND
46.19@
PASOK
40.68@
SYN
(coalit
left)
10.97@
Ecolog.
0.58
Apr 1990
ND
46.89*
PASOK
38.61
SYN
(coalit
left) 10.28
Empist
Trust. 0.37
Perp Fate.
0.17
DIANA
(dem
regen)
0.67
Empist
Trust. 0.45
(1.04)
86.87
29.71
3.70
Perp
Destiny.
0.25
single seat
const.
1.02.
(1.06)
85.5
28.33
3.75
NF neoliber 1.08
Other part
1st+2nd
2nd>3d
2nd:3d
(1.89)
74.79
6.84
1.50
(0.89)
67.27
13.39
2.12
(5.11)
83.95
24.94
3.28
(2.11)
86.66
30.95
4.13
(2.07)
83.41
26.00
2.98
Ecolog.
0.77
Oct 1993
PASOK
46.88*
ND 39.30
Sept 1996
PASOK
41.49*
ND 38.12
Apr 2000
PASOK
43.79*
ND 42.74
KKE 5.52
Mar 2004
ND
45.36*
PASOK
40.55
KKE 5.90
Oct 07
ND
41.84*
PASOK
38.10
KKE
8.15
POLAN
(pol
spring)
4.87
KKE 4.54
KKE 5.61
Syn 5.12
Syn 3.20
Syn 3.26
SYRIZA
5.04
(#Syn
2.94#
1.47)
DIKKI
(Dem Soc
Mov) 4.43
LAOS
3.80
(#POLAN
2.94# 2.29)
(4.41)&
86.18
34.43
8.07
(5.23)&
79.61
32.51
6.79
(4.75)&
86.53
37.22
7.74
(4.93)&
85.91
34.65
6.87
(3.07)&
79.94
29.95
4.67
* Single party government @Coalition Government
& 3% threshold for entering Parliament.
http://www.ypes.gr/el/Elections/NationalElections/Results/ own calculations
It should be also noted that the November 1974 elections were contested in such a
political environment and context (almost four months after the junta, with a war not
been fought but still looming, segments of army officers wishing ‘revenge’ and
‘come-back’, segments of the left wishing overall change of the system) that despite
their absolute and undisputable legality, compliance with, and conformity to
procedural standards cannot be used as an indicator of political parties’ strength and
appeal to voters 2 . It can be claimed therefore, that the Greek party-political system
commences being formed soon after the November 1977 election and gets
consolidated just before the October 1981 election, whereas despite its two-party form
it is dominated by the left of centre PASOK that has remained longer in office.
The United Kingdom on its part has for much longer performed a two-party system
(thanks also to the electoral law) initially between Conservatives and Liberals, and
after the Second World War (moreover for our period of emphasis after the 1970s)
between Conservatives and Labour, with the two parties alternating in power enjoying
(usually, except of the mid seventies) comfortable majorities.
The mid-seventies were not as a significant turning point in British political history as
in Greek, despite the fact of EEC membership, that altered the UK’s stance in
international matters and was achieved through political acrimony. It should be also
noted that the United Kingdom has had single party governments for most of its
history an overall two-party system at least as far as governance is under question.
It is widely reported that the choice in that election was between ‘Karamanlis or tanks’ meaning the
pre-1961 leader of the conservative right and the colonels’ regime.
2
UK ELECTIONS RESULTS 1974-2009.
Share of the vote for three major parties.
Cons+Lab
2>3
2:3
1974 Feb
37.9 Cons
37.2 Lab
mingov
19.3
Lib>SDP>
Alli>LiDe
(*)
75.1
17.9
1.92
1974 Oct
39.2 Lab
35.8 Cons
1979
43.9 Cons
36.9 Lab
1983
42.3 Cons
27.6 Lab
1987
42.2 Cons
30.8 Lab
1992
41.9 Cons
34.4 Lab
1997
43.2 Lab
30.7 Cons
2001
40.7 Lab
31.7 Cons
18.3
Lib>SDP>
Alli>LiDe
13.8
Lib>SDP>
Alli>LiDe
25.4
Lib>SDP>
Alli>LiDe
22.6
Lib>SDP>
Alli>LiDe
17.8
Lib>SDP>
Alli>LiDe
16.8
18.3
22.1
Lib>SDP> Lib>SDP> Lib>SDP>
Alli>LiDe Alli>LiDe Alli>LiDe
75.0
17.5
1.95
80.8
23.1
2,67
69.9
2.2
1.08
73.0
8.2
1.36
76.3
16.6
1.93
73.9
13.9
1.82
72.4
13.4
1,73
2005
35.3 Lab
32.5 Cons
67.6
10.2
1.46
mingov: Minority Government formed by the Labour Party with tacit support by Liberals (Labour winning smaller share of the national vote, but
more seats due to better distribution in first past the post system)
(*) The sequence of centrist political parties from Liberals to Social Democratic Party to the Liberal SDP Alliance to Liberal Democrats is
presented as one ‘module’ of the UK Party system due to their ideological, structural and political personnel similarities, overlappings and
continuation with view to simplify the table too.
The only reason to see the mid-seventies as a watershed in British politics is the
change in voting patterns and the surge of the centrist party(-ies) 3. In the 1970
election the Conservatives Party won 46.44% of the vote, Labour 43.13% (aggregate
89.57%) and the Liberal Party a mere 7.48%, whereas in previous elections the two
major parties’ aggregate vote ranged from 96.1% (1955), to 93.19% (1959), to
88.53% (1964) and to 89.92% (1966). Therefore, the cessation of the two-party
system in the UK as far as the share of the vote is under question commences in the
mid seventies (with the Liberals almost tripling their performance, but never really
challenging the second party –except of 1983-) and becomes more evident in the
1980s and 1990s with the major parties’ aggregate being only once (1992) above
75%. Due to the electoral law however, the two-party system remains intact as single
party governments are formed by the two major parties which perform better in the
governance relevance parametre too (till May 2010!). Another minor ‘deviation’ from
the pure two-party system is the duration or dominance of parties in office especially
since the late 1970s (four consecutive victories for the Conservatives, three for
Labour) that could tend towards a kind of a system of a ‘dominant’ party 4.
In a nutshell the United Kingdom has a two-party system at least as far as governance
is under question and has faced stability and the formation of a consensus (upon new
ground, after the demise of the butskellite one) especially since mid 1980s, whereas it
resembles a two and a half-parties system as far as share of the vote is under question,
and has shown trends towards ‘dominant’ party-system as far as tenure is under
question.
It should be noted however that similarities are restricted in the two-party
(governance) system, as the two states have been concurrently governed by parties of
opposing ideologies.
The turning point for UK politics and health policy and politics in particular was the landslide
election of 1945, after the second world war (and after a coalition -or national unity bettergovernment)
4
In the current analysis I have not looked in the minor parties of the UK Parliament and politics such
as the Northern Irish Parties and the SNP and Plaid Cymru, as they could not shape the key policies
(such as healthcare) in the UK. It should be noted though that these parties perform better both in share
of votes and number of MPs after the mid seventies too.
3
GOVERNMENTS IN GREECE AND THE UNITED KINGDOM, ‘INCONCURRENCE’ IN OFFICE 1974-2009
GR
UK
1974(*)
ND
75
ND
Cons/La La
76
ND
La(**
77
ND
La
78
ND
La
79
ND
80
81
ND(***) ND
82
PA
83
PA
84
PA
85
PA
86
PA
87
PA
88
PA
89
90
(****) ND
/PA
Con Con Con Con Con Con Con Con Con
La/Con Con
91
ND
92
ND
Con Con Con
)
GR
UK
1990
91
92
93
94
95
96
97
ND
ND ND ND/PA PA PA PA PA
Con(*****) Con Con Con
Con Con Con Con/L
98
PA
La
2000 01
PA
PA
La
La
02
PA
La
03
PA
La
04
05
PA/ND ND
La
La
06
ND
La
07
ND
La
08
ND
La
09
ND/PA
La
a
ND: Nea Demokratia right/centre right PA: PASOK centre left/ social democratic, Con: Conservative, La: Labour
(*) 1974 is a peculiar year for both Greece and the UK. The first sees the fall of the dictatorship in July, has a government of national unity till November and a Nea
Demokratia government after November (through a ‘forcibly set questions’ election). The second experiences the rare fact of two election contests in one year in its history
the first giving a minority government (with a smaller share of the vote too), and the second a fragile majority.
(**) Change of Prime-Minister (from Wilson to Callaghan), fiscal constraints.
(***) Change of Prime-Minister (from Karamanlis to Rallis) the ND party feels weak.
(****) 1989-90 is a period of high tensions and instability in Greek politics due to the so called ‘Bank of Crete embezzlement’ affair. The country experienced 3 election
contests in approximately 9 months. The first produced a coalition of conservative/neo-liberal ND with the leftish Synaspismos, the second a government of all (then major)
parties (viz PASOK too), and the third a fragile and slim majority of ND. Very little apart of acrimony about the said affair was contemplated and achieved during that
period.
(*****) Change of Prime-Minister (from Thatcher to Major) the government is strongly challenged over Poll-Tax and Europe.
In the time-spell of about 35 years Greece and the United Kingdom have had
governing parties of the same (or at least not opposing) political orientation and
ideologies for a maximum of 11 years (mid 1979 to late 1981 right wing; early 1990
to late 1993 right wing; 1997 to 2004 centre left).
Turning to health care provision we observe that both countries have well developed
National Health Services covering all their populations. These NHS-s were
established in turning points of the political history of both countries (after 1945 for
the UK –1948 actually-, after 1974 and mainly after 1981 –1983 actually- for Greece)
and faced minimal changes following their setting.
The Greek and the UK NHS-s.
Legislative tug-of-war and long term indecision over social policy issues (and social
security in particular) has a protracted history in Greece. Relative legislation was
initially past (and annulled and counter past etc) in the 1910s, and the major insurance
funds were established in 1936, but collapsed following the war, occupation and civil
war afterwards, to commence really operating in the mid 1950s or early 1960s. As for
health care systems it could be also noted that the first attempt for the creation of a
comprehensive National Health Service providing all Greeks with equal access and
coverage was made by Prof. Patras the Secretary of Health of the dictatorship in 1968,
referring to health insurance funds unification and a single national provider. Such a
plan resembled to systems introduced to other European countries by centrist or
social-democratic governments, but also to a ‘military’ structure and view. The
‘Patras’ plan was never materialised, however it is estimated that as early as late
1960s Greece had achieved an almost full coverage for most health needs of (most of)
the population, albeit badly organised and inadequately funded (cf. Yfantopoulos
1993: pp 255ff; Yfantopoulos 2003: pp 184 ff and table 2 p 186). As previously
mentioned the fall of the dictatorship in July 1974 was a turning point in Greek
politics and political history. For an initial period of about 6 years little was done
regarding health care policy as the government(s) had to deal with more pressing key
priorities
such
as
the
Cyprus
issue,
consolidation
of
democracy
and
parliamentarianism, legalisation of the Communist Party, relations with Turkey, EEC
membership etc.
Commencing a presentation of the development of health care provision during the
third Greek republic we notice a combination of agreement upon some principles,
with a legislative tug-of-war often on subjects of minor importance. It was the Nea
Democratia government that in 1980 presented draft legislation to introduce a
National Health Service in Greece, under the influence of the late Professor Spyros
Doxiadis then secretary of State for Health. However this draft (known as the
‘Doxiadis plan’) was never turned to law as it was met by skepticism by the ND
parliamentary group, and with lack of support by PASOK who, despite agreement in
principle, was not willing to support as it hoped to have the opportunity to present
such a draft itself after the (then) forthcoming general election. Once the Gr-NHS
ESY was established in 1983 we observe a long period of PASOK governments (up to
1989 and 1993-2004) in office. The spells of Nea Democratia governments alongside
the PASOK returns provide us with a legislative tug-of-war. Mutual law annulling
was however predominantly nominal and lead to small policy change regarding the
function of and accessibility to a publicly funded system of health-care provision 5.
On a matter more related to an ideological stance, both Nea Democratia (who was the
first to introduce the term), and PASOK (who expanded it), refer to the rights of the
‘patient’ –initially- and the ‘user’ of the system. Little later (under PASOK) the term
becomes ‘citizen’ denoting a more ‘leftish’ approach. In any case, both parties
consider protection of these rights an important responsibility of the state indicating
pro public ideological stances. (Dikeos 2006; Dikeos 2007).
Turning to health care management we observe convergence and consensus too as
both parties are in favour of hospital management that aims to the achievement of
5
The Nea Democratia legislation of 1990 and 1992 foremost dealt with opportunities for private
practice such as private practice for medics working in the public sector (with a small pay-cut) after
their main duties –an opportunity taken by few-, and allowing expansion and regulating the function of
private diagnostic centres. These policy changes were mainly related to a free to choose neo-liberal
ideological approach, without seriously affecting the core of public and publicly funded health-care
provision (Souliotis 2000, Yfantopoulos 2003, Dikeos 2006). Other parts of this legislation referred
mainly to Health Centres funding, management and accountability and chain of command). In a
broader political framework, health care was not an issue during the first governing party change
(1989-93) in Greece. The key issues debated in 1989-90 were the Bank of Crete (embezzlement) affair
and the need for a clean-hands approach to politics, vis-à-vis claims of a witch-hunt against PASOK
politicians. These trends (in health care) were annulled by PASOK after returning to power (in 1993).
Law 2194/94 for ‘Restoring’ the Gr-NHS stopped public medics from private practice, while other
changes were mainly administrative and managerial. Further legislation (by PASOK) concentrated
upon bioethics, quality assurance (2519/97) hospital management and health-care management at
regional level (2920/01, 2955/01) A small shift towards pro-private practice was made in the Law
2889/01 (by PASOK) as it provided for private practice (after hours and under strict regulations) by
public medics in public hospitals. This was a key departure from earlier PASOK stances concerning
sole public provision of and public pay for health care provision.
micro and macro economic efficiency with the role of managers being enhanced and
their public accountability being reduced, alongside changes in the hospitals’
committee of management reminiscent of changes from Cogwheel to Griffith system
in British NHS, by legislation passed by both parties (Dikaios, 2007).
A minor albeit significant change in health care policy can be observed in the case of
free (or better covering by a significant contribution by insurance funds) prescription
of pharmaceuticals. One of the changes brought forward by Nea Democratia initiated
the free or else ‘negative’ list for prescriptions according to which doctors may
prescribe (and insurance funds will finance) any medical drug that is not written in the
list. Such a stance can be attributed rather to a free to choose neo-liberal ideology and
an acknowledgement of doctors’ authority and need of clinical flexibility, whilst
another reason could be the close relations between Nea Democratia and some drug
producing and importing companies. Therefore, as Davaki and Mossialos (2006: 286)
also observe “despite several changes since its establishment, the overall objectives of
the Greek health care system have remained relatively unchanged”.
Legislation is one of the two pillars of health care policy (or of any form of policy for
that matter), the other being financing. As quite everyone knows and perhaps has at
least once uttered ‘it is money that makes the world go round’. Therefore, turning to
the broader concept of 'Mode of Health Maintenance' that covers the overall complex
of pay (either public or private) for service (either public or private).
Public health-care provision in Greece is financed through a combination of
compulsory social insurance6 that covers predominantly fee-for-service and per-diem
expenditure; and taxation that pays mainly for NHS-GR ESY salaries and deficits (see
eg Davaki and Mossialos 2006, Souliotis 2000).
Public payment also covers (through some insurance funds) private service by
'affiliated' physicians for expert primary care.
Private heal payments are mainly out of pocket (and not that much through private
health insurance) for out of hospital private practice (diagnostic or therapeutic).
Private payment for private hospitalisation concerns mainly the large urban centres
and concentrates on maternity hospitals with good 'hotel' services.
There are many social insurance funds in Greece covering health care. However we could refer to
mainly four IKA for salaried employees in the private sector, OPAD for public sector employees,
OAEE for the self employed and OGA for farmers. These cover approximately 85% of the population.
On the other hand taxation contribute to health care expenditure more than insurance.
6
Three ways of measuring public health expenditure will by used. Public health
expenditure as percentage of the GDP; and public health expenditure in standard
prices (focusing upon the rate of change from one year to another). As the paper is
interested in the broader 'Mode of Health Maintenance' and the role and size of the
private sector (mainly private pay for private service) as an indicator and outcome of
political ideology. Thus, a fourth parametre will examine the public/private mix in
health care expenditure. These are going to be matched with references to which party
was in office each period as to examine whether there are differences in this policy
aspect.
HEALTH EXPENDITURE GREECE 1987-2005
Year
Gov
1987
pas
1988
pas
Public
Health
%gdp
Publ he
Exp st
prices
Rate of
change
Public
% tot
4.44
4.44
3957
59.9
3344
-15.4
9
61.9
1989
Pas
june
nd+S
YN
Nov
ND+
PAS+
SYN
4.68
3942
17.88
63.5
1990
Apr
ND
1991
ND
1992
ND
1993
ND
Oct
pas
1994
pas
1995
pas
1996
pas
1997
pas
1998
pas
1999
pas
2000*
pas
2001*
pas
2002*
pas
2003*
pas
2004*
Pas
Mar
ND
2005*
ND
4.73
4.73
4.19
4.66
4.69
5.01
5.07
4.99
4.88
5.15
4.12
4.66
4.57
4.65
4.30
4.32
6353 e
7357 e
7375 e
7752 e
7648 e
5.83
48.5
15.80
52.2
0.24
52.3
5.11
52.0
-1.34
50.7
3836
-2.69
62.7
3842
0.15
61.1
4323
12.52
58.1
4749
9.85
57.9
4879
2.74
52.8
5145
5.45
52.0
5335
3.69
53.0
5441
1.98
52.8
5494
0.97
52.1
6003
9.26
53.4
*Provisional data. Data after 2000 are related to the revision of national accounts (according to which GDP was estimated higher) undertaken in September 2006.
Source: National Statistics Office ESYE.(for % gdp and public % total), OECD (for standard prices. Rate of change own estimate after OECD data).
48.3
Concerning public expenditure for health as a percentage of the GDP we observe that
during PASOK years in office it ranges between 4.12% in 2000 and 5.15% in 1999
(however we should take into account the revision of national accounts). Whereas for
Nea Democratia the corresponding figures are ranging between 4.19% in 1992 and
4,73% in 1990 (whilst under the current government and revised figures) public
health expenditure is at 4.3% of GDP. Therefore, there is not too great a difference in
the expenditure choices of the two parties, and it can be said that despite the
legislative tug-of-war seen these years, there is a financial ‘tug-together’ towards an
average 4.5% of the GDP.
Turning to public expenditure for health in standard (2000) prices we observe a
gradual increase, which however commences with an important plunging under
PASOK and contains two more decreases both under Nea Democratia governments.
Focusing on the rate of change we see that for 2004 as compared to 1987 increase by
93,28% or average 5.48% per annum. If we break the data down by party in office we
get a picture that is a little different. Thus we first see a plunging of -15.49% in 1988
as compared with 1987 under PASOK. As for the period of coalition governments and
the instability that followed we see the highest increase of 17.88%. For the Nea
Dimocratia (Mitsotakis) government of 1990-93 we observe for 1993 as compared to
1989 increase by 9.66% or an average of 1.93% per annum, particularly due to the
decrease (-2.69%) in 1990 and almost unchanged expenditure in 1991 (+0.15%),
which could indicate a monetarist inclination. This is however followed by high
increase in 1992 and 1993. PASOK took office (Papandreou) in October 1993 and
surprisingly we see slow growth even in the first Simitis (1996) years with a very low
1998 and 2002. On the other hand though the trend after 1999 and up to 2003 is one
of high increase in expenditure. Referring to an overall performance by PASOK we
see 2003 as compared to 1993 increase by 63.23% or average 5.75% per annum. Nea
Dimocratia (Karamanlis) returned in office in March 2004, and there was a decrease
of the rate of change of public health expenditure in standard prices by –1.34%.
Closing this section we may conclude that though both parties are not starving the GrNHS ESY, PASOK is a little more prone to increase public spending for it, than Nea
Democratia. It should be also noted that these financing trends occur under the fiscal
restraints of pursuing meeting the criteria for participation in the EMU. However as
we observe a relatively high rate of change of public expenditure between 1993 and
2000 (when participation was achieved), alongside a stable part of the GDP spent on
public health (post 2000 changes can be attributed to national accounts revision) we
are not inclined to agree with Davaki and Mossialos (2006) who suggest that the
governments were pressed to make such cuts.
The public/private mix in health-care expenditure is the last parametre to be examined
concerning expenditure. Greece has long seen a large private health care sector
functioning, financed predominantly by out-of-pocket payments. The share of the
public sector grew in the first years of the GR-NHS ESY as many private clinics had
to close. Meanwhile private practice turned to diagnostic centres often financed
through public insurance funds (Souliotis 2000; Kouris et al 2007). A gradual decline
of the public sector can be observed since 1987, despite the fact that occasional years
show a higher public share than the previous one. Thus the highest share was under
the coalition governments of 1989 (63.5%), and the lowest under Nea Democratia in
2005 (48.3%). However, PASOK of 1993-2004 performs considerably lower than
Nea Democratia of 1990-93. Anyhow, changes in the public/private share can be
attributed to other reasons than financing such as wider opportunities for the private
sector (diagnostic centres, special maternity clinics with very high standards of ‘hotel’
accommodation), which gets an enlarged share of expenses (often due to high
charges) (Davaki and Mossialos 2006), rather than an underfunding of the public
sector. It can be however concluded that both parties are prone to see an enlarged
private sector functioning.
Capitulating as far as health care financing is under examination, we may see a
difference from legislation tug-of-war, as a tug-together is almost evident, with the
exception of public expenditure rate of change with PASOK scoring higher than Nea
Democratia.
This short reference to the Greek Health-Care System has shown that long term
Health Policy is among the results of the two party system prevailing during the third
Hellenic Republic. There is policy convergence and consensus regarding the most
important aspects of health care provision. Truly in the late seventies and early
eighties Nea Democratia faced a wide public health care system with reluctance (thus
the Doxiadis plan was coldly received by MPs and rank and file), while PASOK was
fierce against private activity in health care. With the consolidation of the two party
system after the mid eighties and mainly early nineties, once GR-NHS ESY was
formed by PASOK in 1983 we have a gradual policy shift by both parties towards a
more centre ground. Nea Dimocratia now on accepts and supports a wide public
sector health care provision, whereas PASOK is less fierce against private practice, as
both legislation and financing show. We therefore observe a two party system leading
to policy convergence and consensus. Both parties are tugged towards a political
central ground. Differences are observes in ideological pillars usually expressed in the
wording of party manifestoes and Laws, but not in policy making as the changes are
mainly nominal. Obviously as regards to ideology and ideological premises Nea
Dimocratia is more pro-private and more ‘free to choose’ based upon neo-liberalism,
whereas PASOK more pro-public commencing from social-democratic stances. On
the other hand though, PASOK is less anti private than in the past, and ND accepts
public provision, freely accessible. Finally, they are both reluctant to spend much.
Despite trends being traced either well back in the Poor Laws or better in the Liberal
Governments’ social security legislation in the early 1910s, the UK NHS is an
offspring of policy changes related to the Great Depression and the Second World
War alongside the Labour Party landslide victory of 1945 and the overall changes (eg
broad nationalization of key services –aviation, railways, telecommunications,
banking- and industry –coal, gas, steel-) that followed. Moreover it is the related to
the implementation of the Beveridge Report (1942) and the attack upon ‘want’ and
‘disease’ (alongside other ‘bad giants’), issues closely related to a revamped liberal
ideology that aimed to bring ‘freedom from’ and ‘positive freedom’. All these were
pursued in a general framework of construction of a Welfare State alongside a
Keynes-ian management of the economy 7. The NHS was established in 1948 and it
was a publicly funded (mainly through taxation) and publicly provided service free
and equal for all population at the point of treatment, offering free pharmaceuticals
too. It became the largest employer in the UK and one of the largest in the world, and
went on operating with few changes –predominantly managerial up to the early
1990s- when internal competition and an attempt to control expenditure were
Thus the earlier point of 1945 being a watershed in UK politics. The two-party system remains but
Liberals are replaced by Labour, and a ‘new Jerusalem’ (to use terminology of the then era) is pursued,
alongside changes in key matters of economic policy such as nationalizations and the vanishing of the
‘invisible hand’!
7
introduced under Conserviative governments (Widgery, 1979; Dikeos, 1992;
Addison, 1994; Fraser, 2003).
HEALTH EXPENDITURE UNITED KINGDOM 1987-2006
Year
Gov
Public
Health %
GDP(**)
Publ.
Hea. Exp
. st. prices
Rate of
change%
Public %
total.
Years
beginning
with the
first
(oecd)***
198788
Cons
198889
Cons
198990
Cons
199091
Cons*
199192
Cons
199293
Cons
199394
Cons
199495
Cons
199596
Cons
199697
Cons
199899
Lab
19992000
Lab
200001
Lab
200102
Lab
200203
Lab
200304
Lab
200405
Lab
200506
Lab
5.5%
199798
Cons/
Lab
5.4%
4.7%
4.7%
4.6%
4.8%
5.2%
5.5%
5.6%
5.7%
5.6%
5.3%
5.3%
5.6%
5.9%
6.2%
6.6%
6.9%
7.2%
39,
928
41,
455
41,
730
43,
378
46,
459
49,
558
51,
553
54,
633
55,
903
55,
772
56,
414
58,
167
60,
008
65,
067
70,
296
75,
482
82,
863
89,
467
94,
703
1.5
3.8
0.7
3.9
7.1
6.7
4.0
6.0
2.3
-0.2
1.2
3.1
3.2
8.4
8.0
7.4
9.8
8.0
5.9
84.3
83.8
83.2
83.6
83.3
84.6
85.1
83.9
82.9
80.4
80.4
80.6
79.3
80.0
79.9
80.1
81.6
81.9
82.0
* Change of Prime-Minister (Thatcher to Major, November)
** Data given by the Treasury at htpp: www.hm-treasury.gov.uk/d/pesa2010_chapter4_tables_xls differ by a slight 0.1% for some years. This difference does not affect the
broader picture.
*** For the public/private mix it is full calendar years beginning 1987.
Sources: (a) for Public expenditure as % of GDP, public expenditure in standard prices and rate of change of public expenditure in standard prices Gavin Thompson, NHS
expenditure in England, SN/SG/724, House of Commons Library, p. 16; (b) for public expenditure as % of total oecd health data.
Public expenditure for health as a percentage of the GDP ranges between 4.6% and
5.7% during Conservative Party’s governments experiencing a significant increase
between the more radical right Thatcher (4.6% to 4.8% range) to the more centrist
Major (5.2% to 5.7% range) years, a fact that can be explained apart of the ideological
differences between the two leaders of the Conservative Party, also as an attempt to
overcome its unpopularity and opinion poll decline due to the poll-tax, problems with
the NHS 8, and problems regarding Europe. Labour in its turn, spends a higher
percentage of the GDP for healthcare than the Tories. It ranges from 5.3% to 7.2%
showing a constantly upwards trend, indicating a more pro-public, pro-NHS political
stance.
Data concerning expenditure in standard prices show an almost similar trend. During
the Thatcher years expenditure remains almost stagnant, its rate of change ranging
from 0.7% to 3.9%. This should not take us by surprise as the trends of the previous
Thatcher years are similar if not even lower and the NHS shrank in comparison to the
growing needs of society, become (contrary to political broadcast of the days) ‘not
safe’ in the hands of the Conservative Party (Dikeos 1992: 143, 146ff, 162), followed
by a sharp increase in the Major years (from 3.9% to 7.1%). The Major years on the
other hand, show a gradual decline of the rate of change culminating in a negative
figure (-0.2%) for 1996-97, first time since 1982 when the decline was even worse
approximating -1% (ibid). The overall increase in the decade 1987-88 to 1997-98 was
41.29% or else an average of 4.13% per annum. Spending under the Labour Party,
and moreover its rate of change is much higher, ranging between 3.1% and 9.8%,
especially in the post 2000 period it remains almost constantly over 7.0% (with a
decline to 5.9% in 2005-06). The overall increase for 1998-99 to 2005-06 was 62.81%
or else an average of 7.85% per annum It is evident that the Labour Party is more
prone to spend more for healthcare than the Conservative Party.
Surprisingly, the public share in the public/private mix is higher during Conservative
Party governments than Labour Party’s ones (a fact we observed in the Greek case
too!). Public share ranges from 80.4% to 84.6% during Conservative administration
The ‘popularity’ and significance of the British NHS should always be borne in mind. Any party that
neglects or seriously under-funds the NHS, and leaves the British public unhappy with its performance
puts itself in political jeopardy and electoral dire straits (remember eg the ‘war over Jennifer’s ear’
event in the 1992 election).
8
(that would be expected to be more ‘pro-private’), whereas it ranges between 79.3%
and 82.0% during Labour administrations, a tiny however noticeable difference.
The examination of British health expenditure data spanning in almost twenty years
indicates that the core issues in healthcare provision remain almost stable in a twoparty system with the more ‘leftish’ or social-democratic party being inclined to
support a publicly funded NHS than a conservatice-neoliberal party. We also observe
a broader general consensus over both the existence and function of publicly financed
(and publicly offered for that matter) healthcare free at the point of use covering the
entire population, and being financed through taxation. We also observe similar trends
regarding private health care provision and finance (notwithstanding the surprise of
smaller public share during social-democratic governance).
Greece and the United Kingdom: from comparison to co-examination.
This paper has so far presented both (post 1974) Greece and Britain as two-party
systems with each a prevailing conservative-neo-liberal and a social-democratic party,
that however govern their countries concurrently for short and far apart time spells. It
has also tried to prove that both states enjoy well developed National Health Services
which are (despite their difference in emphasis in primary and/or secondary or tertiary
provision, and the size of private sector) publicly funded and provided covering
almost 100% of the population.
It should always be born in mind that Greece and the Greek healthcare system can be
taken to belong to a (disputed) Southern European Model (Fererra), and moving
alongside other regional countries towards a Continental Model (Katrougalos),
whereas the United Kingdom is moving from a Social Democratic Model (regarding
the UK Keynesian/Beverigde-ian –and Attlee-ian Welfare State up to its golden years)
to a more Liberal Model.
As stated in the onset this paper will attempt to bring party-politics and party systems
back under focus. To achieve this the paper will now turn to examine some of the data
presented in previous tables together in a new table presenting and comparing parties
in office with healthcare expenditure in both countries.
HEALTH EXPENDITURE BY GOVERNING PARTY GREECE AND UNITED KINGDOM 1987-2005
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
4.68%
coalition &
instability
4.6% Conserv
4.73%
coa/ND Apr
4.73%
ND
4.19%
ND
4.69%
PASOK
5.01
PASOK
5.07%
PASOK
4.8%
Conserv
-2.69%
coa/ND Apr
3.9%
Conserv
62.7%
coa/ND Apr
83.6%
Conserv
5.2%
Conserv
0.15%
ND
7.1%
Conserv
61.1%
ND
83.3%
Conserv
5.5%
Conserv
12.52%
ND
6.7%
Conserv
58.1%
ND
84.6%
Conserv
4.66%
ND/PASO
K Oct
5.6%
Conserv
9.85% ND
5.7%
Conserv
2.74%
PASOK
6.0%
Conserv
52.8%
PASOK
83.9%
Conserv
5.6%
Conserv
5.45
PASOK
2.3
Conserv
52.0%
PASOK
82.9%
Conserv
5.5%
Conserv
3.69%
PASOK
-0.2%
Conserv
53%
PASOK
80.4%
Conserv
Public
health
exp as %
of GDP
GR
4.44%
PASOK
4.44%
PASOK
UK
Rate of
change in
stand pric
GR
Public
health
exp as %
of total
GR
4.7%
Conserv
na
PASOK
1.5%
Conserv
59.9%
PASOK
84.3%
Conserv
4.7%
Conserv
-15.49%
PASOK
3.8%
Conserv
61.9%
PASOK
83.3%
Conserv
UK
UK
17.88%
coalition
0.7% Conserv
63.5%
coalition
83.2%
Conserv
4.0%
Conserv
57.9% ND
85.1%
Conserv
1997
1998
1999
2000*
2001*
2002*
2003*
2004*
2005*
4.30%
PASOK/ND
March
6.9%
Labour
-1.34%
PASOK/ND
March
8.0%
Labour
50.7%
PASOK/ND
March
81.9%
Labour
4.32%
ND
Public
health
exp as %
of GDP
GR
4.99%
PASOK
4.88%
PASOK
5.15%
PASOK
4.12%
PASOK
4.66%
PASOK
4.57%
PASOK
4.65%
PASOK
UK
Rate of
change in
stand pric
GR
5.4%
Cons/Lab
1.98%
PASOK
5.3%
Labour
0.97%
PASOK
5.3%
Labour
9.26%
PASOK
5.6%
Labour
5.83%
PASOK
5.9%
Labour
15.80%
PASOK
6.2%
Labour
0.24%
PASOK
6.6%
Labour
5.11%
PASOK
1.2%
Cons/Lab
52.8%
PASOK
3.1%
Labour
52.1%
PASOK
3.2%
Labour
53.4%
PASOK
8.4%
Labour
48.5%
PASOK
8.0%
Labour
52.2%
PASOK
7.4%
Labour
52.3%
PASOK
9.8%
Labour
52.0%
PASOK
80.4%
Cons/Lab
80.6%
Labour
79.3%
Labour
80.0%
Labour
79.9%
Labour
80.1%
Labour
81.6%
Labour
UK
Public
health
exp as %
of total
GR
UK
* Data for Greece after 2000 are related to revision of national accounts in 2006
Sources as in previous tables, data for UK relate to consecutive fiscal years 1987-88 etc.
7.2%
Labour
Na
5.9%
Labour
48.3%
ND
82.0%
Labour
2006
The picture deriving from this table is mix and somehow perplexing. Focusing upon
public health expenditure as percentage of GDP we observe that overall socialdemocratic parties are inclined to spend more public funds than conservativeneoliberal ones. Also, social-democratic parties tend to show higher rates of change of
expenditure in standard prices than their counterparts. These facts and observations
should not take us by surprise. However it should be noted that the public/private mix
follows a reverse trend. Public spending is usually lower in the total mix for health
care during more left-wing governments both in Greece and the United Kingdom, a
finding that does not correspond to ideology presented either by the Labour Party or
by PASOK when constructing the respective NHS-s in late forties and mid eighties.
Last but not least, though rates of change vary considerably from year to year in both
countries, the share of GDP publicly spent for health and the public/private mix do
not fluctuate as much, moving in a narrow margin (4.12% -after revision- to 5.15% of
GDP for Greece, a larger margin of 4.6% to 7.2% for the UK, 48.3% of total public to
63.5% in Greece, and a much narrower margin 79.3% to 85.1% for the UK).
Concluding remarks.
This paper claimed that (and wished to examine whether) in our examination apart of
the welfare regimes problematique, we can use one more closely associated with
political parties and party-systems. For that matter it approached two systems of
health care provision that belong to different welfare regimes (from SouthernEuropean to Continental in one case, from social-democratic to liberal in the other),
presenting us with both similarities (universal coverage, publicly funded –with the
difference of hybrid for the Greek case-, through mainly state providers), and
differences (emphasis in secondary and tertiary vs primary health care respectively).
On the other hand, both Greece and Britain present us with stable two party-systems
at least as far as governance is under question (vote share for the UK resembles more
to a two-and-a-half party-system9 .
Though the welfare regimes argument remains valid especially if we examine the
public-private mix (while however we should bare in mind that the Greek system
provides for all equal access free of charge at the point of use), the parties and partysystems arguments have some validity too.
9
This is up to the May 2010 election.
The welfare regimes argument has already been analysed by key commentators and
needs no further support. It is the ‘back to politics’ argument that requires our
focusing.
As for the first part of the argument under investigation we have seen that both NHS-s
were set by social-democratic parties after landslide election victories in a watershed
point in the social and political history of their respective countries, having however
the tacit support of the right-wing parties. It has also been manifested that (according
to prediction, once ideological stances are taken into account) social democratic
parties are more ‘NHS friendly’ and inclined to spent more (public funds) for
healthcare provision than conservative-neo-liberal parties 10.
As for the second part of the argument it can be claimed that once an NHS is set and
goes on operating in a two-party system, it remains almost unchallenged in its key and
vital structure and function, facing limited changes as far as service provision, access
and finance (narrowly fluctuating as percentage of GDP) is concerned, and various
changes in its administrative framework, enjoying an overall and cross party
consensus.
In a nutshell, this paper wishes to bring to fore the need to examine party politics and
party-systems in our quest of healthcare without forgetting the welfare regimes
approach. To prove this it has shown both that party ideologies play their role in the
formation of National Health Services especially in watershed periods and after
landslide victories. And that two party-systems often lead to a consensus close to
middle ground over issues related to key welfare services such as healthcare, a
tendency leading to (and proving the existence of) converging two-party systems in
both Greece and the United Kingdom.
The surprise comes with the public/private mix, and UK data are contrary to trends from 1970s up
to mid 1990s.
10
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