According to the results of this analysis, income level is a major factor that affects access to healthcare services. High-income patients are able to overcome the barriers in access, as they can afford to pay for the quest of healthcare outside the public healthcare services frame, implying that high income can increase the alternatives, such as private services or, even, informal payments. It is noteworthy that high private spending and high informal payments are both typical characteristics of the Greek health system[16, 17]. Thus, these alternatives are consistent with the general framework of healthcare services in Greece. Geographical barriers and barriers due to waiting lists are also inevitable for low-income chronic patients, because the alternatives are not affordable for them.
The educational level was also an independent variable of the regressions of this study, as it is regarded as a crucial determinant of socioeconomic status. Generally, higher prevalence in chronic diseases is observed in the population group characterized by low education. Moreover, several findings suggest that people with higher education are less likely to suffer from chronic diseases. As shown previously, a high educational level has impact on economic barriers in access, but not in the other types of barriers. A first explanation for this claim is related to an indirect link, namely that education increases the probability of finding a good and well-paid job. Therefore, education leads to higher income and consequently to fewer barriers in access. However this claim is inadequate to explain the findings to their full extend, as a higher income also implies fewer geographical barriers and barriers due to waiting lists. Our empirical results do not verify this claim, because education does not have impact on geographical and waiting lists barriers. Another approach is associated with the claim that well-educated patients have better information about the alternatives of their treatment and they are more aware about health promotion and prevention. Therefore, they can overcome the potential economic barriers in access through self-monitoring and better information about the alternatives. Moreover, another aspect that affects access to healthcare services is related to social networks. Specifically, patients with high educational level have a stronger and more influential social network, which may reduce the economic barriers and facilitate access to healthcare.
The type of occupation has also impact on the barriers in access to healthcare services. Specifically, unemployed chronic patients are more likely to face economic barriers in access, mainly because unemployed have very low income. This finding is quite reasonable, given the high unemployment rate in Greece during the recession of the last years. It is noteworthy that unemployment also causes barriers in access due to waiting lists, partly because the low income reduces the alternatives, such as private healthcare. Moreover, geographical barriers are more likely to occur in students, and in self-employed in the family firm.
Although barriers in access to healthcare services are identified by many aspects, the main drivers which cause these difficulties are directly related to economic recession and the current restrictive fiscal policy. Specifically, low income and unemployment are the key characteristics affecting difficulties in access.
Other studies conclude to similar results, as socioeconomic status (namely income, education and occupation) affects chronic diseases prevalence. Specifically, chronic diseases are more prevalent in the lower socioeconomic groups. Moreover, the features of socioeconomic status are associated with disparities in health status and differences in access to healthcare services[22, 23].
Despite the ongoing burden of chronic diseases and the implications in access of chronic patients, health policies are not oriented toward facing and managing them[24, 25]. Nowadays, the reconsideration of health agenda through the prioritization of chronic diseases management is a crucial challenge for every health system[8, 25, 26]. Generally policy interventions are necessary not only from a public health perspective but also from an economic point of view, and they can be beneficial in terms of efficiency and equity. In his influential paper, Kenneth Arrow provided economic rationale for government intervention in healthcare sector, which is relevant to chronic diseases as well. In this framework, economic theory implies that it is reasonable for a government to intervene, as chronic diseases and their risk factors are associated with market failures, such inadequate and asymmetric information, externalities and time-inconsistent preferences.
A first dimension of a health policy plan for chronic diseases is associated to public health and prevention actions, namely that government, health organizations and NGOs should inform the population about the risk factors, (e.g. diet, physical activity and lifestyle). However, although prevention of chronic diseases is a low-cost and effective solution, political will and support towards this direction is limited. The other dimension of a strategy for chronic diseases is related to their management and the search for optimal care model. Many chronic diseases can be managed through patients’ regulation, self-management and systematic monitoring by GPs and primary care[31–34]. The development of a care model based on these aspects can reduce the needs for systematic specialty care, which is more expensive and less accessible.
Despite the importance of lifestyle and risk factors, our analysis indicates that economic and social causes are the main factors affecting barriers in access. Therefore, the aforementioned actions (namely prevention actions and chronic diseases management) should be accompanied with interventions that face the main drivers of barriers in access. In this context, social and health policies are considered as essential actions for the decrease of the adverse impact of unemployment and low income on patients’ access. Such actions are becoming more urgent, in a period of economic crisis. Therefore, a social safety net against the increasing unemployment and the income decrease could improve patients’ access, by reducing the reported barriers. These actions constitute an integral part of the agenda, and thus they should be transformed into specific policy actions for the vulnerable groups of the population.
As with any study of this kind, the present one also has some limitations that should be acknowledged. Ideally, the sample would consist of chronic patients throughout the whole chronic diseases spectrum. Unfortunately, this study selected to examine four chronic diseases, due to resource constraints. Moreover, we could not select the interviewees from a survey that is based on the total population, as it was costly and time-consuming. Thus, we chose the aforementioned methodology. In addition, this study focuses on the barriers in access in a period of economic recession and crisis. Although it would be interesting to present the determinants of barriers in access, based on the whole period of an economic cycle, we think that this approach is useful in terms of health policy. This claim is based on the fact that the abovementioned finding could be taken into consideration when governments decide to implement restrictive fiscal policy and austerity measures either by "chance" (that is, due to an economic crisis) or by "choice".