This case study exemplifies the importance of a stable and coherent institutional framework for the consistent and systematic integration of health-related considerations into regional planning. In Crete, where strong inter-institutional cooperation and broad-based consultations have taken place to produce a development strategy for the region, outcomes have been rather disappointing in terms of health-oriented, cross-sectoral thinking. Most consulted stakeholders convened that explicit EU-level Guidelines would contribute to bring about this kind of thinking.

In Greece, the National Strategic Reference Framework (NSRF) is the main document for the programming of EU funds at the national level. During the elaboration of the 2007 – 2013 NSRF, a significant number of proposals were submitted to the Ministry of Economy and Finance, which was then the responsible institution (currently the responsible institution is the Ministry of Regional Development and Competitiveness). The national development planning was the outcome of a very broad consultation among various Ministries (including the Ministry of Health and Social Solidarity), regions, agencies and social and economic partners.

Greece’s strategic planning for the 2007 – 2013 period is implemented through eight sectoral Operational Programmes and five regional Operational Programmes. The regional OP for Crete and the Aegean Islands is financed exclusively through the European Regional Development Fund (EUR 871 million) and covers three regions: Crete, the Northern Aegean islands (both “Convergence”) and the Southern Aegean islands (“Competitiveness and Employment”). The Intermediate Managing Authority of Crete is the authority responsible for managing the actions of the OP “Crete and the Aegean Islands 2007 – 2013” within the administrative boundaries of the Region of Crete.

Most health references in the “OP for Crete and the Aegean Islands 2007 – 2013” with regard to the region of Crete are related to direct spending on healthcare and especially on health infrastructure under Priority Axis 7 Sustainable Development and Qualify of Life in Crete. Direct references to health are also made in the SWOT analysis and the summary of the Strategic Environmental Impact Assessment. Health is also given consideration when assessing the consistency of the OP with the Strategic Guidelines on Cohesion Policy as well as when assessing the effectiveness of the strategies employed by the OP.

The interview with the Department of Regional Health and Welfare Chart of Crete (DRH) expert revealed that cooperation between the regional health authority and the Intermediate Managing Authority of Crete is very good; nevertheless, although “there is still room for improvement”. With regards to DRH’s organization and participation in the region’s policy-making, the DRH expert noted that the continuous changes in the form and administration of his authority prevent it from having coherent policy objectives; moreover, he argued that the Ministry of Health and Social Solidarity could have participated more dynamically in the drafting of the NSRF so that more direct references to health were included in both the NSRF and the OP for Crete and the Aegean Islands. Finally, the DRH expert underlined that his authority is interested in the health effects of both health and non-health Structural Fund Investments.

 

Background information

Crete is the largest and most populous of the Greek islands and the fifth largest island in the Mediterranean Sea. It is located in the southern Aegean Sea and separates the Aegean from the Libyan Sea. The island has an elongated shape and covers an area of 8,336 km2 (6.3% of Greece’s total surface) with a 1,046 km coastline. To the north, it broaches the Sea of Crete; to the South, the Libyan Sea; in the west, the Myrtoan Sea and towards the east the Karpathion Sea. It lies approximately 160 km south of the Greek mainland.

Source: DG Regional Policy - Inforegio

Crete has a population of 608,000 inhabitants (2008) with 72.9 inhabitants per km2. According to the Hellenic Statistical Authority, 31.96% of the population was under 24 while 15.96% of the population was above 65 in 2001.[1] In 2007, life expectancy at birth in Crete was 77.5 years for men and 82.6 years for women, which is slightly higher than the EU 27 average of 75.8 (men) and 82 (women).

In terms of overall development, however, Crete scored below the EU average on the EU version of the UN’s Human Development Index (HDI).[2] This index includes healthy life expectancy, household income, and educational attainment levels. Crete scored 55 out of 100 compared to an average value of 62 for EU regions.

Table 1: Crete: the region at-a-glance

Population (inh., 2008)

608,000

Surface area (km2)

8,336

GDP per capita in EUR (PPS, 2008)

23,500 

GDP per capita as % of EU 27 (PPS, 2008)

94%

Cohesion Policy status

Convergence*

Life expectancy at birth, male (2007)

77.5

Life expectancy at birth, female (2007)

82.6

Sources: Eurostat and Fifth report on economic, social and territorial cohesion

*The regional Operational Programme “Crete and the Aegean islands” is a multi-objective programme as it falls within the framework laid out for both the Convergence (Crete and North Aegean Islands) and Regional Competitiveness and Employment (South Aegean Islands) objectives.

Crete is characterised by a stark duality in terms of economy and population dynamics. The productive model combines traditional agricultural activities, currently undergoing modernisation, with modern activities like tourism, services, research and technology, as well as residential development. Approximately 9% of the Regional Gross Value Added (RGVA) is derived from activities in the primary sector (agricultural activities), 13% of the RGVA from activities in the secondary sector (food and beverages sector, textile industry, mining etc.) and 78% from the tertiary sector (mainly tourism) of the economy.[3]

Figure 2: GDP per capita in PPS (EU27 average = 100)

Source: Eurostat; GDP per capita in PPS is Gross Domestic Product in purchasing power standards.

 

Policy and institutional overview

Cohesion Policy

During the previous programming period (2000 – 2006), all Greek regions were eligible areas for the highest levels of funding support (Objective 1). In the current programming period (2007 – 2013), five Greek regions exceeded the predetermined per capita GDP levels and have been included under a transitional support scheme.[4] The remaining Greek regions (Eastern Macedonia – Thraki, Ipeiros, Thessalia, Western Greece, Ionian Islands, Peloponnese, Crete and Northern Aegean Islands) are Convergence regions.

The National Strategic Reference Framework (NSFR) 2007 – 2013 made the strategic choice to reduce the number of Operational Programmes and to fund all five Regional Operational Programmes in Greece for 2007 – 2013 exclusively through the ERDF. The total amount of funding and its annual allocation are separately designated for each region. ESF Funding is reserved for sectoral Operational Programmes which are managed at the national level.

On 5 November 2007, the European Commission approved the Regional Operational Programme “Crete and the Aegean Islands” for the period 2007-2013. This Operational Programme (OP) combines EU support for three NUTS II regions of the Greek Islands: Crete, the North Aegean islands and the South Aegean islands. This geographic unit is an island area comprised of over 90 islands of varying sizes. In terms of administration it includes three Regions: the island of Crete, the South Aegean Sea region and the North Aegean Sea region. Despite their differences in size, position and productivity patterns, these three regions share the usual characteristics of islands which frequently create a complex development environment at both the European and the Mediterranean level.

The regional OP “Crete and the Aegean islands” is a multi-objective programme as it falls within the framework laid out for both the Convergence (Crete and North Aegean Islands) and Regional Competitiveness and Employment (South Aegean Islands) objectives.[5] EU assistance through the ERDF amounts to some EUR 871 million, or approximately 4.35% of the total EU money allocated to Greece under the Cohesion Policy for 2007-13. According to the NSRF, approximately EUR 731 million will be allocated for the Convergence Objective and EUR 140 million for the Regional Competitiveness and Employment Objective.[6] 48.55% (approximately € 423 million) of the total OP funding is allocated to Crete.

The OP for Crete and the Aegean Islands is structured along three thematic objectives:

  • accessible infrastructure and services;
  • digital convergence and entrepreneurship;
  • sustainable development and quality of life.

Under each objective, three sets of thematic priorities (priority axes) are designed for each of the three regions covered by the programme. A fourth priority concerns the smaller islands of the South Aegean region while another priority contains the budget for technical assistance in order to implement the thematic objectives in each of the three regions. The priority axes referring to the region of Crete and the funding allocated to them are presented in detail in Table 2 below.

Managing institutions

Overall managing responsibility for regional programmes in Greece rests with the Ministry of Regional Development and Competitiveness. Within this ministry, the Special Coordination Service for the implementation of Operational Programmes within the Directorate General for Investments and Development is the official Managing Authority (MA). Programme implementation tasks are delegated by the MA to relevant regional bodies.

The Special Service of the Regional Operational Programmes is responsible for coordinating the specialisation of the OPs and monitoring their implementation progress. In addition, it cooperates with and supervises the Intermediate Managing Authorities (IMA), which are regional-level bodies that are tasked with carrying out the OPs. The IMA of Crete manages the priority axes within the OP "Crete & the Aegean Islands, 2007-2013" which are within the administrative boundaries of the Region of Crete. The IMA of Crete has, amongst others, the authority to select the projects to be financed in accordance with the criteria set in the OP, monitor their progress, conduct on-site visits and ensure compliance with national and EU rules throughout their implementation.[7]

Health sector

Overview of institutions

In Greece, the main responsibility for health care and public health policy lies with the Ministry of Health and Social Solidarity. The goals of the Ministry of Health and Social Solidarity are to ensure the health of all Greek citizens and provide quality health care while respecting the rights and the individuality of each patient.[8]

The General Secretariat of Health within the Ministry of Health and Social Solidarity is responsible for developing and implementing public health policies as well as supervising their implementation and the functioning of public health authorities. The Sub-Secretariat for Public Health (within the General Secretariat of Health) in the Ministry of Health and Social Solidarity is entrusted with the tasks of implementing the National Strategy for Health, supervising the various public health authorities and overseeing the implementation of EU and WHO policies on public health protection. Finally, the National Council of Public Health is a scientific, supervisory, coordinating and advisory body with arbitration powers; its responsibilities include the right to issue consultations on various public health issues, either upon the Minister’s request or on its own initiative.

At the regional level, the Department of Regional Health & Welfare Authority – Chart of Crete is responsible for the planning, coordination and supervision of all health care and social service providers in the region of Crete. This includeshospitals, community health centres, mental health centres as well as all private and public entities active in the health sector as long as they fall under the authority of the Minister of Health and Social Solidarity. In addition, the Department of Regional Health & Welfare Authority Chart of Crete can submit to the Minister of Health and Social Solidarity suggestions aimed at ensuring the most comprehensive and efficient provision of health services to the inhabitants of Crete. Finally, it is responsible for monitoring how the various health care and social service providers implement the strategic goals set by the Ministry of Health and Social Solidarity.

Healthcare in Crete: Main Figures[9]

Health budget (2010)[10] €1.911 million

Primary care centres (14 PHC ‘ΚέντραΥγείας’ 111 local PHC ‘ΠεριφερειακαΙατρεία’)

10 Public hospitals

9 Private Health Clinics

5 Diagnostic Centres

3 EKAB Centres (National Centre of Rapid Help)

14 IKA (Social Security Organisation) Health Centres[11]

50.34 doctors per 10,000 inhabitants (2005)[12]

48.38 hospital beds per 10,000 inhabitants (2004)[13]

 

Overview of public health policies and objectives

Crete is one of the regions in Greece that invested the biggest part of their funding under the two previous Community Support Frameworks (1994 – 1999 and 2000 – 2006) on health. As a consequence, health infrastructure in Crete is  well developed.[14] The region of Crete has its own overall strategy for health care and public health; this strategy was prepared in the beginning of 2011 by the National School of public health and it is not publicly available. The region’s health objectives are determined by the National Strategy on Public Health 2008 – 2012 taking into consideration region-specific characteristics.

The National Strategy on Public Health objectives are the following:

The National Strategy on Public Health will be effective only if specific goals are set and their implementation is prioritised

Effective cooperation between the various Ministries and Authorities responsible for public health issues

Implementation of the strategy aimed at minimising mortality and disease rates

Improving the health of the youth

Informing the population on how to achieve a healthier lifestyle

Regular and systematic monitoring of the population’s health

Equality in the provision of health services

Creation of an online National Health Map depicting all health service providers in the country

Development of rapid reaction mechanisms to address emergencies and threats to public health.

Ensuring the quality of public health services

Ensuring the effectiveness of public health services

Increasing the number and enhancing the quality of education of the professionals providing health services

Strengthening the quality and the scientific validity of the health services provided

Involving the social partners on public health issues

 

 

Health in the Structural Fund programmes

The development vision for Crete and the Aegean Islands for 2007 – 2013 is to strengthen their competitiveness and promote their potential under conditions of sustainable development. The OP for this region sets six strategic goals, one of which is to improve the quality of life. These strategic goals are to be achieved through eight general goals which aim, amongst others, at guaranteeing the quality of life for the residents of the region. For Crete, it is explicitly stated that the improvement of the health and social welfare infrastructure will contribute to the realisation of the aforementioned strategic and general goals. These goals stem from the NSRF prepared for the whole country according to which “the overall objective is to (…) improve the quality of life for all citizens, with no exclusions whatsoever”.

A review of the OP for Crete and the Aegean Islands reveals that most health references are related to direct spending on healthcare and especially on health infrastructure. In this context, health is directly referred to in Priority Axis 7, the SWOT Analysis and the summary Strategic Environmental Assessment (SEA). Furtherreferences to health are made when assessing the consistency of the OP with the Strategic Guidelines on Cohesion Policy as well as when assessing the effectiveness of the strategies employed by the OP.

The SWOT Analysis included in the OP states that even though basic health and welfare infrastructures are established in the Region of Crete, steps need to be taken to address intra-regional inequalities on access to health services. Health is also mentioned in relation to the regional strategy for development of human resources. As such, it is explicitly mentioned that in the Region of Crete health services need to be supported so as to contribute to the modernisation of the island’s economy (Section 3.2.4.).

The SEA for the regional OP assessed the impact on human health and points out that a bigger part of the population will have access to satisfactory health services – which will also become more easily accessible – for two reasons: a) income increases will encourage people to seek such services when needed; and b) disadvantaged groups will participate in economic activities to a greater extent and will therefore have the economic means to seek health services. Furthermore, according to the SEA the OP’s expected positive effects include the improvement of working conditions, the reduction of work-related and traffic accidents as well as the improvement of the healthcare system and, in general, of the conditions of public health. Combining healthy-living programmes and recreational activities with work will also improve health conditions. It is possible that a small deterioration on health may arise from increased air pollution and noise, however, the positive effects of the OP overall prevail.[15]

Priority Axis 7 Sustainable Development and Quality of Life in Crete foresees that the citizens’ quality of life will be improved by enhancing their living conditions (health, welfare, education and environment) in both urban and rural areas. It is expected that the OP will contribute to the creation of an effective and viable public health and welfare system which will improve the quality of life of both citizens and tourists. Planned health infrastructure activities include: the creation/upgrading of health infrastructure; the development and protection of public health; and the reform of mental health services. The key objective for the region of Crete is to develop its network of primary health care centres and services in order to rationalise the use of secondary health centres.[16]

Until 2007 there was a complete lack of infrastructure for the treatment of medical waste[17]. Thus, code (44) foresees that projects on the treatment of dangerous and hazardous waste (such as medical waste) will be undertaken.[18] Finally, one of the indicators used in Priority Axis 7 is the number of hospital beds created or upgraded.

The OP stresses that Crete is considered an ideal region for the application of new technologies such as e-health services as:

  • It has the support of various research institutes based in Crete and is experienced in cooperating on a transnational level;
  • It attracts many tourists and as such, is need of high quality of health services;
  • There is a need to reduce transfers of medical cases to hospitals in Athens which are at times extremely difficult because of the insular character of the region.

Further action for the attainment of this objective is not foreseen for in the OP “Crete and the Aegean Islands” itself but can be found in the national-level sectoral Operational Programme “Digital Convergence”.

As previously mentioned, the OP refers to other potential health gains from its implementation as well as links health to the economic development of Crete.  When assessing the consistency of the OP with the Strategic Guidelines on Cohesion Policy (2007 – 2013) it is recognised that Priority Axis 7 will indirectly help maintain a healthy labour force (Section 3.6.2.). In addition, it is recognised that the improvement of health infrastructure in Crete will help redefine and enhance the quality of the tourist product offered in this region (Section 3.7).

It is thus evident that health goals for the region of Crete in the OP “Crete and the Aegean Islands 2007 – 2013” are mostly infrastructure and healthcare related while some linkages are made between the economic development of Crete, the increase in the income of its residents and public health.Tables 2 below summarises the key priorities and intervention areas of the Regional Operational Programme “Crete and the Aegean Islands” solely for the Region of Crete, as well as its correlation with the proposed briefing sheet topics. Whenever applicable, the tables also show how health is considered within each priority.

Table 2: Overview of the regional OP, priority axes related to Crete

Regional Operational Programme for Crete and the Aegean Islands, Region of Crete, Greece

MA: Special Coordination Service for the implementation of Operational Programmes, Ministry of Regional Development and Competitiveness; priority axes for Crete implemented by the Intermediate Managing Authority of Crete

Total EU allocation: € 871.3 m

Priority Axis

Funds (€m)

Percent of total OP

Content of priority

Briefing Sheet topic(s)

Health considerations in the priority

1. Accessibility Infrastructure and Services in Crete

157.5

18.1%

Completing and upgrading the road network (at the regional and local levels) and the ports of Region of Crete.

Completing and upgrading the basic arterial roads of the urban centres of the

Region of Crete.

Transport

 

4. Digital Convergence and Entrepreneurship in Crete

27.75

3.2%

 Support productive investments, investments in tourism sector, and enterprises in order for them to provide high added value and cutting-edge products and services.

Strengthen the infrastructures of research centres in Crete.

RTD

 

7. Sustainable Development and Quality of Life in Crete

233.25

26.8%

Interventions will be carried out that aim at upgrading educational, health and social welfare infrastructure, as well as at

sustainable environmental management and the enhancement of cultural heritage

in the Region of Crete.

Infrastructure: Waste

Infrastructure: Water

Biodiversity

Transport

Environmental Protection

Culture and Heritage

Urban and rural regeneration

Employment

Social Infrastructure

Developing health infrastructure; reform of mental health services; projects to protect public health.

11. Technical assistance in Crete and NAI

10.5

1.2%

 

N/A

 

 

Integrating health in the programmes

In this section, the process and experience of integrating public health issues into the planning and implementation of the OP for the region of Crete are discussed. The section is based primarily on an interview with a representative of the Department of Regional Health and Welfare Authority – Chart of Crete (DRH).[19]

According to the DRH official, in Crete there is a good record of cooperation between the DRH and the IMA of Crete; yet, he stressed that “there is still room for improvement”. With regard to DRH’s organisation and participation in the region’s policy-making, the DRH health expert noted that the continuous changes in the form and administration of his authority prevent it from having coherent policy objectives.

Consultation with the health authorities in the 2007 – 2013 programmes

The NSRF notes that the national development planning is the outcome of a very broad consultation among ministries, regions, agencies and other social and economic partners. The document states that significant effort was undertaken to broaden partners’ responsibilities and participation to the utmost in all planning phases (submission and processing of proposals, systematic information, organisation of special meetings, input in NSRF drafts, etc.).

In order to ensure the multi-level approach in the drafting of the NSRF, an Inter-ministerial coordination and policy-setting Committee for Development Programming 2007 – 2013 chaired by the Minister for Economy and Finance was created. Numerous ministers, including the Minister of Health and Social Solidarity, took part in this Committee which was the key mechanism for setting the main NSRF policy framework. In addition, the Programme Planning Groups of Ministries and Regions were created; these groups acted as liaison between the ministries and regions and the Drafting Group and supported participation in the planning and drafting of the NSRF and OPs.[20]

Furthermore, the NSRF explicitly stated that the coordination of actions in the field of health would be ensured (a) at strategic, overall level, by an inter-ministerial body chaired by the Secretary General of the Ministry of Health and Social Solidarity and (b) at operational level, by a special service that would support the inter-ministerial body and would coordinate actions in the field of health and welfare implemented through the various OPs.

Nonetheless, the DRH health expert noted that the Ministry of Health and Social Solidarity could have participated more actively in the drafting of the NSRF and the OP for Crete and the Aegean Islands so that health considerations were included more explicitly and to a greater extent.

The DRH official said that the regional health authority’s priorities are integrated into Structural Fund documents to a certain degree; for example, with regards to the region of Crete, DRH’s objectives are realised under Priority Axis 7 as far as health infrastructure projects are concerned. In addition, DRH oversees the realisation of projects under the sectoral Operational Program “Human Resource Development” as far as the establishment of reforms such as those in the mental health sector are concerned.

Moreover, the DRH expert underlined that the regional health authority is interested in and aware of the health effects of non-health Structural Fund investments. For example, the Greek Government has decided that hospitals in Crete will merge, thus drastically reducing their number in the region. Consequently, investments in enhancing the road network will enable citizens living in areas where hospitals will cease existing and, in general, citizens living in areas far away from hospitals to have quicker access to healthcare. In addition, the DRH is also interested in investments promoting “health tourism” in Crete, i.e. investments allowing tourists to combine their vacation with the purchase of health services.

 

 

Conclusions

In Greece, the National Strategic Reference Framework (NSRF) is the main document for the programming of EU funds at the national level. During the elaboration of the 2007 – 2013 NSRF, a significant number of proposals were submitted to the Ministry of Economy and Finance, which was then the responsible institution (currently the responsible institution is the Ministry of Regional Development and Competitiveness). The national development planning was the outcome of a very broad consultation among various Ministries (including the Ministry of Health and Social Solidarity), regions, agencies and social and economic partners.

Greece’s strategic planning for the 2007 – 2013 period is implemented through eight sectoral Operational Programmes and five regional Operational Programmes. The regional OP for Crete and the Aegean Islands is financed exclusively through the European Regional Development Fund (EUR 871 million) and covers three regions: Crete, the Northern Aegean islands (both “Convergence”) and the Southern Aegean islands (“Competitiveness and Employment”). The Intermediate Managing Authority of Crete is the authority responsible for managing the actions of the OP “Crete and the Aegean Islands 2007 – 2013” within the administrative boundaries of the Region of Crete.

Most health references in the “OP for Crete and the Aegean Islands 2007 – 2013” with regard to the region of Crete are related to direct spending on healthcare and especially on health infrastructure under Priority Axis 7 Sustainable Development and Qualify of Life in Crete. Direct references to health are also made in the SWOT analysis and the summary of the Strategic Environmental Impact Assessment. Health is also given consideration when assessing the consistency of the OP with the Strategic Guidelines on Cohesion Policy as well as when assessing the effectiveness of the strategies employed by the OP.

The interview with the Department of Regional Health and Welfare Chart of Crete (DRH) expert revealed that cooperation between the regional health authority and the Intermediate Managing Authority of Crete is very good; nevertheless, although “there is still room for improvement”. With regards to DRH’s organization and participation in the region’s policy-making, the DRH expert noted that the continuous changes in the form and administration of his authority prevent it from having coherent policy objectives; moreover, he argued that the Ministry of Health and Social Solidarity could have participated more dynamically in the drafting of the NSRF so that more direct references to health were included in both the NSRF and the OP for Crete and the Aegean Islands. Finally, the DRH expert underlined that his authority is interested in the health effects of both health and non-health Structural Fund Investments.

References

Regional Operational Programme “Crete and the Aegean Islands” 2007 – 2013:

http://www.kriti-aigaio.gr/elibrary/Episimo_Keimeno_Kritis-Nison_Aigaiou.pdf(available only in Greek).

National Strategic Reference Framework2007 – 2013:

http://www.espa.gr/elibrary/NSRF%20document_english.pdf

National Strategy on Public Health 2008 – 2012:

http://www.yyka.gov.gr/articles/health/domes-kai-draseis-gia-thn-ygeia/ethnika-sxedia-drashs/95-ethnika-sxedia-drashs?fdl=230  (available only in Greek).

Interviews

Interview with Mr. Stamatis Kardassis, Department of Regional Health and Welfare Authority Chart of Crete, 20 May 2011.


[1]This is the latest currently available data; an update survey is ongoing at the time of writing.

[2]5TH Cohesion Policy Report.

[3]Regional Operational Programme “Crete and the Aegean Islands” 2007 – 2013, p. 29.

[4]Two regions, Sterea Ellada and Southern Aegean Islands, are phasing-in regions under the Competitiveness Objective while three, Attiki, Central Macedonia and Western Macedonia  are phasing-out regions of the Convergence Objective.

[5]The analysis of health in the programme in this case study covers the region of Crete only.

[6]National Strategic Reference Framework2007 – 2013, p. 114, 115 and 117.

[9]Apart from the NSFR 2007 – 2013, all other information was available only in Greek; it has been translated into English by the case study author.

[13]Ibid.

[14]OP for Crete and the Aegean Islands 2007 – 2013, p. 66.

[15]Ibid, p. 173.

[16]OP Crete and the Aegean Islands 2007 – 2013, p. 228.

[17]Ibidp. 55.

[18]Ibidp. 225.

[19]The IMA of Crete stated that it did not have the authority to comment on issues related to strategic planning and programming, as this is done at the national level MA and the health ministry.

[20]Ibid