Can Cyprus overcome its health-care challenges?

Abstract

The divided island of Cyprus is the only EU member state that lacks a universal health system. Public and private schemes operate in isolation, resulting in duplication and waste. Myria Antoniadou takes a look at Cyprus' unusual system and asks why it is taking so long to change.Ask a Cypriot what he or she thinks of the country's national health scheme and watch a wry smile break out on their face. “What health system?”, would be a typical response.The Republic of Cyprus, which consists of the southern portion of the third largest island in the Mediterranean, is home to only around 700 000 people. But despite its small population—a feature which should give the country a relative advantage when it comes to providing efficient health services—Cyprus is alone among the 25 member states of the EU in that it lacks a health scheme that covers the entire population. Around 200 000 more people live in the northern Turkish-occupied zone of the island—although the government of Cyprus has no access to health information about these individuals, and no control over their health care.The present health system for citizens of the Republic, parts of which are an inheritance from pre-1960 British colonial rule, covers some 80% of the population. But the heavily criticised way in which the state health facilities operate has been forcing even those entitled to free health care to turn to the burgeoning private sector for help.Citizens of the Republic of Cyprus complain there has not been sufficient pressure on the government to adopt a universal health plan because relatively cheap private health care abounds, and Cypriots can seek public care for emergency cases or complicated treatments. Another factor fuelling the government's reticence is the fact that Cyprus has only recently started to experience the health consequences of an ageing population. But changing lifestyle patterns are pushing up the prevalence of diseases that demand expensive therapies, making health-system reform increasingly pressing.The need for health-system reform has been an ongoing debate in Cyprus for more than a decade. A 1992 study done by an international team of consultants first suggested unifying Cyprus' health care under one national insurance fund. But since then, the only major step towards reform has been the approval of a law in April, 2001, introducing a National Health Scheme (NHS) and establishing the Health Insurance Organisation (HIO) to implement it.4 years on, health sector workers remain cautious about the likelihood of reform and warn of the difficulties involved in unifying health care. Most believe that without real political will, a universal health scheme will probably never materialise.“Any major change like this will affect the interests of numerous groups and we expect that we will face resistance in the process of implementation”, says HIO director Andreas Demetriades. “Any change is complex and we must follow a detailed programme of implementation to which we should all be committed”, he adds.A comparable situation exists in the northern areas of Cyprus, in which most Turkish Cypriots have been living since the 1974 Turkish invasion and occupation of nearly 37% of the island. Turkish Cypriots also lack a scheme covering the entire population and most seek care in the private sector.Despite the 30-year divide, the similarities between health issues in northern and southern Cyprus are striking, not only in what is offered, but also in terms of burdens of disease and causes of death. There is, however, one very important difference: health provisions in the south are of a uniformly higher standard than in the north, causing thousands of Turkish Cypriots to go in search of better care across the border (see panel).PanelHealth care on a divided islandDespite the 30-year rigid divide on this small, eastern Mediterranean island, similarities between the health situation of the Turkish Cypriots living in the north and the Greek Cypriots in the south are remarkable. According to Turkish-Cypriot sources, who asked not to be named, discussions mirroring the Cypriot government's debate over a national health service have also been raging in the north for the past few years. Numerous Turkish Cypriots use private clinics when in need of health services, seeking hospital care only for emergency cases. Like in the south, private health prices are considered reasonable. And the past 5 or so years has seen an increase in “polyclinics”, which provide a wide range of services for out-patient care, although treatments are generally basic. Northern Cyprus' small population is largely to blame for the dearth in specialist care. With only 200 000 people living in the region, it is not deemed cost-effective to offer complicated, expensive treatments for the few who require them. Medical technology and specialist doctors are therefore scarce—a situation that forces thousands of Turkish Cypriots to seek help either in Turkey, or the southern parts of Cyprus, each year. Since April, 2003, when crossings along the so-called Green Line dividing the northern and southern parts of the island were partially relaxed, more and more Turkish Cypriots have been seeking care in the south. As a goodwill gesture to the north, the Republic's government has been offering all Turkish Cypriots who prove they are of Cypriot nationality free medical care, despite the fact that they do not pay social insurance or taxes to the south. According to statistics given to The Lancet by the health ministry's permanent secretary Sotiris Soteriou between April, 2003, and December, 2004, 24 420 Turkish Cypriots were treated in government medical institutions. This includes the Bank of Cyprus Oncology Centre and the Institute of Neurology and Genetics providing services financed by the government, and patients sent abroad for therapy or at the private American Heart Institute in Nicosia. If, however, there is no settlement over the reunification of Cyprus by the time the Republic's new health system emerges, Soteriou says the matter will need to be re-examined. “We must take into account the conditions prevailing at the time, with a view to providing suitable health care to all citizens of the Republic”, he comments. But the north's lack of trained medical staff means it will have trouble coping without even limited access to services in the south. Since most Turkish Cypriots study in Turkey—where education is free—large numbers of medical graduates stay on and get jobs, rather than returning to Cyprus to set up home.Free care, for someCyprus' public health-care scheme is income-related, and free care is guaranteed to certain groups, including government employees, individuals earning less than 9000 Cyprus pounds (CYP; US$20 650), households earning less than CYP18 000 ($41 000) per year, and households with more than four children. Individuals with an income between CYP9000 and CYP12 000 ($20 650–$27 536) and households with an income between CYP12 000 and CYP22 000 ($27 536–$50 482) pay 50% of the prescribed rates. Complementary schemes combining public and private health also exist, mainly for government-funded agencies (semi-official organisations). Free medical care is provided for all in the accident and emergency departments.“There are two systems which operate in parallel: the private health sector and public health sector”, says Demetriades. He explains that this situation results in duplication and waste, a point also mentioned in the 1992 consultants report on Cyprus' health care. Demetriades says the funding split means there is little continuity of care between the private and public sectors, and poor communication between doctors. Several other major issues affect the quality of care: public sector hospitals are poorly organised and inconvenient for users; there is no organised system of primary care; and inadequate regulation of private sector providers means that poor-quality clinical services are allowed to proliferate.According to a 2004 report on Cyprus by the European Observatory on Health Systems and Policies, the organisation and management of the health system is outdated and inefficient. It also notes that very often those entitled to public health care “seek complimentary medical care in the private sector to secure more personalised treatment”.Citizens have been turning to the private sector in droves, with polyclinics springing up in numerous towns and villages. Many individuals prefer to pay for private medical care—especially primary care—rather than take their chances with the public system, citing badly managed hospitals operating on civil service hours (0730–1430 h), and non-patient-friendly attitudes of staff as major concerns. As a result of these issues, public health care is used mainly by lower-income groups and individuals with difficult illnesses, such as cardiovascular diseases and cancer, where provisions in the public system are indisputably of a high standard.The report notes that a high number of out-of-pocket payments contribute to financing the health system, although private health insurance schemes are only just becoming popular.In 2002, some CYP360 million ($826 million) were spent on health care, mainly from the private sector. But the European Observatory has reported that the overall expenditure on health is low compared with the the rest of the EU countries.Demetriades explains: “On average the EU spends 8·3% on health. Cyprus spends only 5·8% of its GDP on health of which 40% on public and 60% in private health. Bearing in mind public health covers 80% of the population, these figures speak for themselves on people's satisfaction with the public health provided.”Another reason why expenditure appears low is because it is likely to be underestimated in official statistics. According to a 1997 study by William Hsiao, public expenditure in 1996 accounted for 44% of total expenditure, “a much higher percentage than that reported in official statistics”. Official data does not, for example, include salaries for the health ministry staff or expenditure for maintenance work undertaken by, for example, the communication ministry.A fragmented ministryTwo other major concerns hindering efforts to implement the national health scheme are the outdated way that hospitals are run and the curious operational structure of the Cyprus health ministry.In a 1998 report by the Nuffield Institute for Health of Leeds University (UK), the health ministry is described as operating on the basis of a division between three basic functions: administrative, technical, and operational. Such a simple and divisive system, based on the fragmented ministerial system, was characterised as “inappropriate to modern systems of management”.The report also identified a need for hospital reform after finding that some features of the system date back to British colonial rule. Government hospitals form part of an integrated system of civil service and ministerial control of management, leading to centralised decision-making which takes place outside the hospitals. It also notes that hospital staff are civil servants, hired and allocated to their posts by a central staffing system. The report concludes that such a bureaucratic hierarchy does not offer staff direction, support, or professional growth. Overall, it concludes, the present system constitutes “a serious hurdle to the continuing development of effective and efficient management tools and the reinforcement of hospitals' competitiveness”.These findings were confirmed to The Lancet by Andreas Polynikis, a health ministry expert and adviser on Cyprus' health system. He strongly emphasises the need for the ministry to change the way it operates and for hospitals to adopt a more modern form of management. “The health ministry policy is handled on a day-by-day level and there is no strategic management”, he explains, adding that a group of inter-ministry officials has been tasked with discussing this and other relevant issues. “Today, national health providers are not managed but administered”, he asserts.Polynikis warns that the public sector is not yet ready to deal with the provisions of the national health insurance scheme and that health providers are not in a position to face future competition. He blames the delays in implementing the new health scheme on procedural problems rather than lack of funds or human resources.According to Polynikis, there are three main aims for Cyprus' health system today: making hospitals autonomous, getting the new Nicosia Hospital up and running, and introducing a quality assurance system. He considers the capital's new hospital a milestone for public health.According to the HIO director Demetriades, Cyprus is now facing a chicken or egg situation. “Before the introduction of the new system the public health sector should be completed, but only when real competition is introduced will these changes be expedited”, he says.Continuing challengesInitial figures quoted in 2003, when the new health system was enshrined in law, included estimates that the national health insurance scheme would be up and running within 5 years of the law's enactment—a target of 2008.The scheme, which covers every citizen of the Republic (and foreign residents willing to pay), will be financed by contributions from the government, employers, self-employed individuals, pensioners, and all those with non-employment-related incomes (interests, dividends, rents, etc). All contributions will be paid into the HIO which will bear the cost and be in charge of purchasing health services, public or private, with 50% of funds coming from the government and the remainder will be made up by equal amounts from employers and employees.However, the HIO is also facing major hurdles—not least because it is only semi-official, which means it is governed by a board of directors comprising representatives from the government, trade unions, and employers' organisations. “It is faced with many delays in its operation due to the bureaucratic procedures of the public sector with which we have to comply”, says Demetriades. He believes that to become effective, the HIO must find ways to make its procedural framework more flexible.Commenting on what the new system will bring to Cyprus' citizens, Demetriades says one major change will be the introduction of primary health care and improvements to the network of family doctors. The role of the family doctor as a gatekeeper is important, he says, describing prevention as the key for keeping the health system solvent and its cost under control. “With the ageing population and new technologies, the costs of the health system are soaring”, he notes.However, there are concerns that the 2001 law creating the HIO has not incorporated all of the suggestions made in the 1992 consultant's report. Critics believe that without changes to the law, Cyprus may be storing up problems for the future.“The law is the result of consensus achieved between all the actors and we must admit there are things that should be in the law but are not covered”, says Demetriades.According to a study of the costs of the national health insurance scheme prepared in July 1993 by William Hsiao and Melitta Jakob the law “left several key points ambivalent that could impair achieving the original intent of NHI”.Stella Playbell, whose doctoral thesis was on health behaviour in Cyprus, believes that “the scheme is based on the policy of parternalisation”, which prevents patients taking an active part in decision making. She is concerned that the new health system plans reflect the “marketisation and commodification of health care”, and believes this furthers the trend towards pushing doctors into being managers. She says there is substantial evidence to imply that these policies will lead to a deadlock, leaving the health system unable to meet increased demands for health care. Based on her research, Playbell concludes that Cypriot patients “will not be satisfied [with the health system reforms] and consequently will not comply as expected to the proposed scheme”.A cure for all ills?It is said that medicine in Cyprus dates from the Hellenistic period. “It was found on the island of Cyprus that there was a mountain larger and higher than all others, which was called Troodos, where there were many different kinds of plants useful for the art of medicine, and if I attempt to talk about each one individually, time will not be sufficient to tell everything”, wrote Aristotle in the 4th Century BC.Cypriots, says Polynikis, are blessed to live in a country with a good climate, high standard of housing, a healthy traditional diet, and small distances making it convenient to reach health facilities. Studies show that health standards in Cyprus compare favourably to those of other developed countries, and common infections and diseases—including thalassaemia—have been successfully combated. However, Cypriots are beginning to experience the consequences of a lifestyle change. People are abandoning traditional Mediterranean eating habits and obesity is soaring: 44·3% of men and 29·7% of women are now obese. There is an extremely high tobacco consumption (68% higher than the EU average), and sedentary lifestyles are becoming more common.As with other developed countries, the European Health Observatory reports, current health concerns in Cyprus are mainly related to diseases associated with the demographic changes. Cyprus exhibits the demographic characteristics of an ageing country. And, in addition to decreasing marriage and fertility rates, the country is plagued by increasing divorce rates. The implications of these trends include a diminishing labour force and concomitant shrinking social security revenues; increasing health-care costs because of long-term chronic-degenerative diseases; and increasing requirements for nursing care for the elderly. These would large challenges for any national health scheme, but they promise to be especially difficult for Cyprus' fledgling system to handle.Government officials, political parties, health officials, doctors, and even the public are aware that national health provisions on the island are sick and desperately need treatment. But whether a cure can be found soon, only time will show. The divided island of Cyprus is the only EU member state that lacks a universal health system. Public and private schemes operate in isolation, resulting in duplication and waste. Myria Antoniadou takes a look at Cyprus' unusual system and asks why it is taking so long to change. Ask a Cypriot what he or she thinks of the country's national health scheme and watch a wry smile break out on their face. “What health system?”, would be a typical response. The Republic of Cyprus, which consists of the southern portion of the third largest island in the Mediterranean, is home to only around 700 000 people. But despite its small population—a feature which should give the country a relative advantage when it comes to providing efficient health services—Cyprus is alone among the 25 member states of the EU in that it lacks a health scheme that covers the entire population. Around 200 000 more people live in the northern Turkish-occupied zone of the island—although the government of Cyprus has no access to health information about these individuals, and no control over their health care. The present health system for citizens of the Republic, parts of which are an inheritance from pre-1960 British colonial rule, covers some 80% of the population. But the heavily criticised way in which the state health facilities operate has been forcing even those entitled to free health care to turn to the burgeoning private sector for help. Citizens of the Republic of Cyprus complain there has not been sufficient pressure on the government to adopt a universal health plan because relatively cheap private health care abounds, and Cypriots can seek public care for emergency cases or complicated treatments. Another factor fuelling the government's reticence is the fact that Cyprus has only recently started to experience the health consequences of an ageing population. But changing lifestyle patterns are pushing up the prevalence of diseases that demand expensive therapies, making health-system reform increasingly pressing. The need for health-system reform has been an ongoing debate in Cyprus for more than a decade. A 1992 study done by an international team of consultants first suggested unifying Cyprus' health care under one national insurance fund. But since then, the only major step towards reform has been the approval of a law in April, 2001, introducing a National Health Scheme (NHS) and establishing the Health Insurance Organisation (HIO) to implement it. 4 years on, health sector workers remain cautious about the likelihood of reform and warn of the difficulties involved in unifying health care. Most believe that without real political will, a universal health scheme will probably never materialise. “Any major change like this will affect the interests of numerous groups and we expect that we will face resistance in the process of implementation”, says HIO director Andreas Demetriades. “Any change is complex and we must follow a detailed programme of implementation to which we should all be committed”, he adds. A comparable situation exists in the northern areas of Cyprus, in which most Turkish Cypriots have been living since the 1974 Turkish invasion and occupation of nearly 37% of the island. Turkish Cypriots also lack a scheme covering the entire population and most seek care in the private sector. Despite the 30-year divide, the similarities between health issues in northern and southern Cyprus are striking, not only in what is offered, but also in terms of burdens of disease and causes of death. There is, however, one very important difference: health provisions in the south are of a uniformly higher standard than in the north, causing thousands of Turkish Cypriots to go in search of better care across the border (see panel). Despite the 30-year rigid divide on this small, eastern Mediterranean island, similarities between the health situation of the Turkish Cypriots living in the north and the Greek Cypriots in the south are remarkable. According to Turkish-Cypriot sources, who asked not to be named, discussions mirroring the Cypriot government's debate over a national health service have also been raging in the north for the past few years. Numerous Turkish Cypriots use private clinics when in need of health services, seeking hospital care only for emergency cases. Like in the south, private health prices are considered reasonable. And the past 5 or so years has seen an increase in “polyclinics”, which provide a wide range of services for out-patient care, although treatments are generally basic. Northern Cyprus' small population is largely to blame for the dearth in specialist care. With only 200 000 people living in the region, it is not deemed cost-effective to offer complicated, expensive treatments for the few who require them. Medical technology and specialist doctors are therefore scarce—a situation that forces thousands of Turkish Cypriots to seek help either in Turkey, or the southern parts of Cyprus, each year. Since April, 2003, when crossings along the so-called Green Line dividing the northern and southern parts of the island were partially relaxed, more and more Turkish Cypriots have been seeking care in the south. As a goodwill gesture to the north, the Republic's government has been offering all Turkish Cypriots who prove they are of Cypriot nationality free medical care, despite the fact that they do not pay social insurance or taxes to the south. According to statistics given to The Lancet by the health ministry's permanent secretary Sotiris Soteriou between April, 2003, and December, 2004, 24 420 Turkish Cypriots were treated in government medical institutions. This includes the Bank of Cyprus Oncology Centre and the Institute of Neurology and Genetics providing services financed by the government, and patients sent abroad for therapy or at the private American Heart Institute in Nicosia. If, however, there is no settlement over the reunification of Cyprus by the time the Republic's new health system emerges, Soteriou says the matter will need to be re-examined. “We must take into account the conditions prevailing at the time, with a view to providing suitable health care to all citizens of the Republic”, he comments. But the north's lack of trained medical staff means it will have trouble coping without even limited access to services in the south. Since most Turkish Cypriots study in Turkey—where education is free—large numbers of medical graduates stay on and get jobs, rather than returning to Cyprus to set up home. Despite the 30-year rigid divide on this small, eastern Mediterranean island, similarities between the health situation of the Turkish Cypriots living in the north and the Greek Cypriots in the south are remarkable. According to Turkish-Cypriot sources, who asked not to be named, discussions mirroring the Cypriot government's debate over a national health service have also been raging in the north for the past few years. Numerous Turkish Cypriots use private clinics when in need of health services, seeking hospital care only for emergency cases. Like in the south, private health prices are considered reasonable. And the past 5 or so years has seen an increase in “polyclinics”, which provide a wide range of services for out-patient care, although treatments are generally basic. Northern Cyprus' small population is largely to blame for the dearth in specialist care. With only 200 000 people living in the region, it is not deemed cost-effective to offer complicated, expensive treatments for the few who require them. Medical technology and specialist doctors are therefore scarce—a situation that forces thousands of Turkish Cypriots to seek help either in Turkey, or the southern parts of Cyprus, each year. Since April, 2003, when crossings along the so-called Green Line dividing the northern and southern parts of the island were partially relaxed, more and more Turkish Cypriots have been seeking care in the south. As a goodwill gesture to the north, the Republic's government has been offering all Turkish Cypriots who prove they are of Cypriot nationality free medical care, despite the fact that they do not pay social insurance or taxes to the south. According to statistics given to The Lancet by the health ministry's permanent secretary Sotiris Soteriou between April, 2003, and December, 2004, 24 420 Turkish Cypriots were treated in government medical institutions. This includes the Bank of Cyprus Oncology Centre and the Institute of Neurology and Genetics providing services financed by the government, and patients sent abroad for therapy or at the private American Heart Institute in Nicosia. If, however, there is no settlement over the reunification of Cyprus by the time the Republic's new health system emerges, Soteriou says the matter will need to be re-examined. “We must take into account the conditions prevailing at the time, with a view to providing suitable health care to all citizens of the Republic”, he comments. But the north's lack of trained medical staff means it will have trouble coping without even limited access to services in the south. Since most Turkish Cypriots study in Turkey—where education is free—large numbers of medical graduates stay on and get jobs, rather than returning to Cyprus to set up home. Free care, for someCyprus' public health-care scheme is income-related, and free care is guaranteed to certain groups, including government employees, individuals earning less than 9000 Cyprus pounds (CYP; US$20 650), households earning less than CYP18 000 ($41 000) per year, and households with more than four children. Individuals with an income between CYP9000 and CYP12 000 ($20 650–$27 536) and households with an income between CYP12 000 and CYP22 000 ($27 536–$50 482) pay 50% of the prescribed rates. Complementary schemes combining public and private health also exist, mainly for government-funded agencies (semi-official organisations). Free medical care is provided for all in the accident and emergency departments.“There are two systems which operate in parallel: the private health sector and public health sector”, says Demetriades. He explains that this situation results in duplication and waste, a point also mentioned in the 1992 consultants report on Cyprus' health care. Demetriades says the funding split means there is little continuity of care between the private and public sectors, and poor communication between doctors. Several other major issues affect the quality of care: public sector hospitals are poorly organised and inconvenient for users; there is no organised system of primary care; and inadequate regulation of private sector providers means that poor-quality clinical services are allowed to proliferate.According to a 2004 report on Cyprus by the European Observatory on Health Systems and Policies, the organisation and management of the health system is outdated and inefficient. It also notes that very often those entitled to public health care “seek complimentary medical care in the private sector to secure more personalised treatment”.Citizens have been turning to the private sector in droves, with polyclinics springing up in numerous towns and villages. Many individuals prefer to pay for private medical care—especially primary care—rather than take their chances with the public system, citing badly managed hospitals operating on civil service hours (0730–1430 h), and non-patient-friendly attitudes of staff as major concerns. As a result of these issues, public health care is used mainly by lower-income groups and individuals with difficult illnesses, such