Reforms in health policy during the Greek bailout: what makes reform successful and why?

Despite consecutive MoUs (2010, 2012, 2015), Greek health reforms have been slow-moving with some successes and failures. Why did some reforms succeed while others failed to be implemented? Using the Multiple Streams Framework (MSF), this working paper presents evidence collected from interviews with health policy-related elites and stakeholders in Greece and traces the process of implementation to identify sticky points and configurations of pro- and anti-change coalitions. We hypothesise implementation outcomes are due to three factors: the strategies and power of the main non-state coalition partner (the medical profession), the size of resources needed for successful implementation, and the ability (or not) of government to mobilise public opinion. We examine three cases: the liberalisation of the pharmacy profession (successful implementation), family doctor reforms (partial implementation), and the referral system (mainly unsuccessful implementation). The working paper concludes with implications about policy implementation and practical lessons for policymakers considering possible implementation obstacles

The strategy of venue creation: Explaining health policy change in Greece

How do policy entrepreneurs affect policy change in environments of institutional instability? The literature has predominantly explored policy entrepreneur strategizing in contexts with established institutional settings. In this paper, we argue that under conditions of institutional fluidity and a weak and politicized public administration, venue creation is the more frequently encountered and the more likely successful strategy. We define venue creation as the entrepreneurial strategy of setting-up institutional arrangements of finite duration, predominantly in the form of committees, delegated exclusively with designing reforms. We test our hypothesis in the Greek health policy sector. We explore two policy instances: the unsuccessful attempt at a public health reform in 1992 and the successful introduction of radical policy change for public health in 2003. We employ a process tracing approach spanning thirty years, processing primary data (elite interviews and documents) applying the Multiple Streams Framework (MSF). We find that under conditions of institutional fluidity and administrative weakness, policy entrepreneurs failed in their pursuit of change using venue shopping in 1992 but succeeded through venue creation in 2003, confirming our hypothesis. We conclude with insights for contingent policy entrepreneurship success, the MSF and patterns of policymaking in Greece

Designing public health policies

This doctoral thesis studies the evolution of Public Health (PH) policymaking in Greece through the lens of modern Public Policy theory. The analysis covers two time periods: 1975-2003, where policy formulation is analysed, identifying the drivers behind Greece’s first dedicated PH bill in 2003 as well as the resisting factors towards policy change in the years prior, and 2003-2020, where the aftermath of the reform is studied, examining the evolution of Public Health policymaking since as well as the field’s major challenges. For the study of policy formulation, a qualitative approach, driven by the Multiple Streams Framework (MSF) (J.W.Kingdon, 1984) was applied. The MSF proposes that public policy change is the product of the coupling of three ever-flowing independent streams – Problem, Policy and Politics – through the strategic action of Policy Entrepreneurs during Windows of Opportunity. The analysis utilizes 42 structured elite interviews, legislative documents, conference and parliament proceedings, policy reports, the relevant literature and unpublished material regarding proposed policy alternatives. The study of agenda-setting and policy formulation uncovered significant discrepancies between the formal policymaking process and the prevailing policymaking norms employed during policy design. Specifically, the practice of “venue creation” – as was labelled in the thesis – seems to dominate; a process of setting-up dedicated reform design committees and assigning the drafting of bills exclusively to their jurisdiction. The practice was supported by the politicisation of public administration and the marginalization of the formal policymaking instruments, and it allowed governments to define the direction and magnitude of change while maintaining an appealing balance of credibility and non-accountability. In this context, the establishment of a distinct system of Public Health services became an acceptable policy alternative as long as it did not produce conflicts with the prevailing balance of interests in the Greek health policy sector.The quantitative analysis employed during the second period of study captured the opinion of Key Stakeholders regarding the ability of the Public Health system of services to achieve its policy objectives. Given the context in which the thesis was produced, it was deemed integral to also include questions about the Covid-19 pandemic response in the online survey. The research findings conclude that Public Health in Greece is still approached through a medicine-centric lens, while the existence of the field’s chronic problems (funding, staffing, infrastructure) highlight the interconnectedness between reform design and implementation, showing how instituting radical policy alternatives does not necessarily translate to structural policy change. The research findings contribute to the study of Public Health policy in Greece and raise significant insights regarding the MSF’s applicability in similar contexts.Η διατριβή μελετά την εξέλιξη της πολιτικής Δημόσιας Υγείας (ΔΥ) στην Ελλάδα υπό το πρίσμα των σύγχρονων θεωρητικών προσεγγίσεων της δημόσιας πολιτικής. Για τους σκοπούς της μελέτης ορίστηκαν δύο ιστορικοί περίοδοι. Αρχικά, κατά την περίοδο 1975 – 2003 μελετάται η σχεδιαστική διαδικασία και διερευνώνται οι παράγοντες που κατέστησαν δυνατή την θέσπιση της πολιτικής ΔΥ το 2003 καθώς και αυτοί που ανέστειλαν την αποδοχή της μέχρι τότε. Στη συνέχεια, μελετάται η εξέλιξη της μεταρρύθμισης και συζητούνται οι σύγχρονες προκλήσεις στην πολιτική Δημόσιας Υγείας στη διεθνή βιβλιογραφία και στη χώρα μας. Για την μελέτη της σχεδιαστικής περιόδου εφαρμόστηκε ποιοτική έρευνα καθοδηγούμενη από το Υπόδειγμα των Πολλαπλών Ρευμάτων (ΥΠΡ) του John Kingdon (1984) σύμφωνα με το οποίο η αλλαγή δημόσιας πολιτικής είναι το αποτέλεσμα της σύζευξης τριών ανεξάρτητων ρευμάτων – Πρόβλημα (Problem), Λύση (Policy) και Πολιτική (Politics) – μέσω της στρατηγικής δράσης επιχειρηματιών πολιτικής (policy entrepreneurs) κατά τη διάρκεια παραθύρων ευκαιρίας (windows of opportunity). Διεξήχθησαν 42 δομημένες συνεντεύξεις με δρώντες που είχαν θεσμικό ρόλο στη πολιτική διαδικασία και αξιοποιήθηκαν νομοθετικά κείμενα, πρακτικά συνεδριάσεων, η σχετική βιβλιογραφία, πορίσματα Επιτροπών και Συνεδρίων, δημοσιεύματα τύπου και αδημοσίευτο υλικό. Η ποιοτική έρευνα ανέδειξε σημαντικές αποκλίσεις μεταξύ της διαδικασίας που αποτυπώνεται στα νομοθετικά κείμενα και των πρακτικών που εφαρμόστηκαν κατά τη διαδικασία σχεδιασμού. Συγκεκριμένα, φαίνεται να επικρατεί η πρακτική «δημιουργίας συγκυριακών θεσμικών χώρων» (venue creation) – όπως ονομάστηκε από τη διατριβή - με τη μορφή επιτροπών που έχουν αντικείμενο την προετοιμασία μεταρρυθμιστικών προτάσεων. Η συγκεκριμένη πρακτική ευνοήθηκε από την πολιτικοποίηση της δημόσιας διοίκησης και τη περιθωριοποίηση των επίσημων θεσμικών δομών ενώ επέτρεψε στις κυβερνήσεις να ορίζουν το επιθυμητό εύρος των αλλαγών. Σε αυτό το πλαίσιο, η θέσπιση ενός διακριτού υποσυστήματος υπηρεσιών ΔΥ κατέστη πολιτικά αποδεκτή καθώς δεν μετάβαλε τις δυναμικές μεταξύ των υποσυστημάτων της Πολιτικής Υγείας και μεταξύ των άλλων τομεακών πολιτικών. Η ποσοτική έρευνα αποτύπωσε τη γνώμη σημαντικών Εταίρων σχετικά με την ικανότητα του συστήματος ΔΥ στην εκπλήρωση των αρχών της πολιτικής. Καθώς η έρευνα διεξήχθη κατά την περίοδο της πανδημίας του COVID-19, κρίθηκε σκόπιμη η συμπερίληψη ερωτήσεων που αφορούσαν τα μέτρα αντιμετώπισής της. Την άρρηκτη σύνδεση μεταξύ της σχεδιαστικής τεχνοτροπίας και της διαδικασίας υλοποίησης τεκμαίρουν τα ευρήματα της ποσοτικής έρευνας καθώς αναδεικνύεται μία ιατροκεντρική προσέγγιση της ΔΥ ενώ η διατήρηση καίριων ζητημάτων όπως στελέχωση, χρηματοδότηση και διοίκηση υποδεικνύουν ότι οι καινοτόμες θεσμικές παρεμβάσεις δεν οδηγούν σε μεταβολή των κυρίαρχων αντιλήψεων. Τα ευρήματα συνεισφέρουν στη μελέτη της πολιτικής Δημόσιας Υγείας στην Ελλάδα και στην εφαρμογή του ΥΠΡ σε υποσυστήματα με θεσμική ρευστότητα

Molecular Advances in Preeclampsia and HELLP Syndrome

Preeclampsia (PE) constitutes one of the principal reasons for maternal and perinatal morbidity and mortality worldwide. The circumstance typically implicates formerly healthful normotensive women, after 20 weeks of gestation, typically withinside the third trimester, without regarded threat elements or past deliveries. PE can be further complicated with hemolysis and thrombocytopenia, leading to the emergence of HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low platelets). Both conditions are classified as hypertensive diseases of pregnancy (HDP), and their pathogenesis has been linked to an excessive maternal inflammatory response, accompanied by enhanced endothelial activation. Several studies have found that in pregnancies affected by PE/HELLP, von Willebrand factor (vWF) antigen levels (vWF:Ag) are significantly elevated, while its cleaving protease (ADAMTS-13, A Disintegrin-like and Metalloprotease with Thrombospondin type 1 motif, member 13) activity is normal to decreased. Furthermore, the higher urine excretion of the terminal complement complex C5b-9, as well as its greater deposition in the placental surface in preeclamptic women, imply that the utero-placental unit’s distinctive deficits are intimately tied to disproportionate complement activation. The goal of this updated evaluation is to provide the most up-to-date molecular advances in the pathophysiology of PE/HELLP syndromes. Recent medical data on vWF:Ag levels in patients with PE, ADAMTS-13, and dysregulation of the complement system, are highlighted and evaluated. Furthermore, we discuss the relationship between those entities and the progression of the disease, as well as their significance in the diagnostic process. Finally, considering the difficulties in analyzing and controlling those symptoms in pregnant women, we can provide a current diagnostic and therapeutic algorithm

An In Vitro Study of Saffron Carotenoids: The Effect of Crocin Extracts and Dimethylcrocetin on Cancer Cell Lines

Crocus sativus L. has various pharmacological properties, known for over 3600 years. These properties are attributed mainly to biologically active substances, which belong to the terpenoid group and include crocins, picrocrocin and safranal. The aim of the current work was to examine the effects of crocins (CRCs) and their methyl ester derivate dimethylcrocetin (DMCRT) on glioblastoma and rhabdomyosarcoma cell lines, in terms of cytotoxicity and gene expression, implicated in proapoptotic and cell survival pathways. Cell cytotoxicity was assessed with Alamar Blue fluorescence assay after treatment with saffron carotenoids for 24, 48 and 72 h and concentrations ranging from 22.85 to 0.18 mg/mL for CRCs and 11.43 to 0.09 mg/mL for DMCRT. In addition, BAX, BID, BCL2, MYCN, SOD1, and GSTM1 gene expression was studied by qRT-PCR analysis. Both compounds demonstrated cytotoxic effects against glioblastoma and rhabdomyosarcoma cell lines, in a dose- and time-dependent manner. They induced apoptosis, via BAX and BID upregulation, MYCN and BCL-2, SOD1, GSTM1 downregulation. The current research denotes the possible anticancer properties of saffron carotenoids, which are considered safe phytochemicals, already tested in clinical trials for their health promoting properties

Targeted Genotyping of MIS-C Patients Reveals a Potential Alternative Pathway Mediated Complement Dysregulation during COVID-19 Infection

Complement dysregulation has been documented in adults with COVID-19 and implicated in relevant pediatric inflammatory responses against SARS-CoV-2. We propose that signatures of complement missense coding SNPs associated with dysregulation could also be identified in children with multisystem inflammatory syndrome (MIS-C). We investigated 71 pediatric patients with RT-PCR validated SARS-CoV-2 hospitalized in pediatric COVID-19 care units (November 2020–March 2021) in three major groups. Seven (7) patients suffered from MIS-C (MIS-C group), 32 suffered from COVID-19 and were hospitalized (admitted group), whereas 32 suffered from COVID-19, but were sent home. All patients survived and were genotyped for variations in the C3, C5, CFB, CFD, CFH, CFHR1, CFI, CD46, CD55, MASP1, MASP2, MBL2, COLEC11, FCN1, and FCN3 genes. Upon evaluation of the missense coding SNP distribution patterns along the three study groups, we noticed similarities, but also considerably increased frequencies of the alternative pathway (AP) associated with SNPs rs12614 CFB, rs1061170, and rs1065489 CFH in the MIS-C patients. Our analysis suggests that the corresponding substitutions potentially reduce the C3b-inactivation efficiency and promote slower and weaker AP C3bBb pre-convertase assembly on virions. Under these circumstances, the complement AP opsonization capacity may be impaired, leading to compromised immune clearance and systemic inflammation in the MIS-C syndrome