Seven years after its implementation, the debate around the GHS is often trapped in numbers, surpluses and abuses, overlooking the most basic principle: The GHS is not just a mechanism for financing health services but a specific social model, with a clearly defined philosophy, architecture and character.
Three ingredients that do not need any change at all since, on their own, not only do they not create problems for patients but, on the contrary, they act as a shield for their protection.
The philosophy of the GHS is social solidarity, equal access and social security.
Its architecture is the single-insurance system, the single fund, the personal doctor, the free choice of provider and the participation of the public and private sectors in the same operating framework.
Its character is social, solidarity, universal, non-profit and anthropocentric.
Simply put, philosophy answers why the GHS exists, the architecture in how it is structured and the character in what kind of system it is. And if any of these three elements change, then we will not be talking about corrections to distortions. We will be talking about a different health system. For something else and not for the GHS that was designed, legislated and embraced by society.
This is why the discussion should not be about the philosophy, the architecture or the character of the System. The debate must be about the rules, procedures and distortions that have been created over the course of these seven years.
The discussion should not be about the abuses, which have become a "slogan" for those who do not get into the essence of the System, but only about some of the causes that lead to the exploitation and misuse of the GHS by providers and citizens.
It should be about how the money from the GHS Fund is properly used for the benefit of patients and not how much reserves are and how much they increase every year. The GHS Fund, after all, does not have a mission to add surpluses every year but to take care of Cypriot citizens.
The time has come for this discussion to open because the financial viability of the System, the saving of resources and the correct allocation of money, can be achieved when the HIO starts investing more in patients, to meet all their needs if possible.
However, in order to be able to reach the level of being able to have this discussion, we must first analyze some basic data that do not concern "what the GHS offers" but "what the GHS does NOT offer" to citizens.
Stressing, therefore, once again that the GHS is a blessing for each of its beneficiaries individually and recognizing its enormous value, we must record the gaps in services, the distortions caused by some regulations applied by the HIO, the abuses or overuse to which these regulations often lead but also how the "tight" economic policy that is followed, in the end, it results in larger bills, per patient, for the Fund.
Long-Term Care, Rehabilitation, Palliative Care
Huge gaps in the services offered are long-term care, which is almost non-existent, rehabilitation, which is offered by dropper, and palliative care, which is offered only to cancer patients, leaving out thousands of other patients who need it.
But what does the absence of organized long-term health care services mean in practice for the GHS Fund?
Cyprus is aging rapidly. Today, almost one in five residents is over 65 years old, a percentage that amounted to 18.3% of the population in 2024, compared to only 11.3% in 2000.
Based on the official published national and European statistical data, Cypriots live on average about 66 healthy years (women about 66.3 healthy years and men about 65.7).
This means that, while life expectancy in Cyprus now exceeds 82 years, citizens spend an average of 16-17 years of their lives with a chronic condition, disability or functional limitation.
According to the well-known European GALI index used by Eurostat, data for Cyprus show that about 45%-50% of people aged 65 and over state that they face moderate or severe restrictions in at least one daily activity, while 15.9% of women aged 65+ and 12.9% of men aged 65+ (i.e., almost 30,000 citizens in Cyprus face serious restrictions in their daily lives due to health problems).
To this number must be added a few thousand more chronic patients and people with severe disabilities and comorbidities, who also face significant restrictions in their daily lives, due to the problems they present.
The provision of home nursing, medical or palliative care services is the key to less serious complications and reduces the need for inpatient care, which costs the Fund much more than a doctor, nurse or physiotherapist or psychologist at home, at regular intervals.
If a nurse's visit to the home costs, for example, €30 to the HIO, the patient's hospitalization costs €200 and in the case of these people, who due to the problems they face do not recover in 3 or 4 days of hospitalization, the amounts are multiplied.
In even simpler words, if an elderly person with serious problems and restrictions in his movements receives a visit once a week from a nurse, he can prevent serious complications, such as bedsores, he can prevent the worsening of his symptoms in cases of infections and so on and certainly the need to admit him to a hospital can be prevented (an admission that will be done through A&E, with all that this entails).
And because the argument is often put forward that the HIO does not offer social services, it must be clarified that these issues concern the health sector and the management before their deterioration is directly linked to both the GHS and its Fund (as much as this may not sound so good to our ears).
Similar reasoning should be followed in the case of the provision of various consumables and medical equipment to patients who need them.
If, for example, a specific consumable is not suitable for the patient who uses it, in addition to the effects on the person's daily life and most likely on their dignified living, the impact will also be seen in the GHS Fund itself.
An unsuitable product can lead to complications, in some cases serious, potentially dangerous infections and the person may also end up in long-term hospitalization.
The same applies to medicines and, certainly, the regulations that have been imposed and the procedures that are applied do not help either doctors or their patients.
The recent complaints of doctors about months of delays in approving requests for continuation of treatment in diabetics are indicative. A diabetic who is deregulated is certainly likely to cost much more to the GHS Fund than the injectable treatment he requested.
Restoration Services
Rehabilitation services, for years, have been offered "truncated" through the GHS, since the HIO, citing the lack of legislation until recently, included only three specialized centers in the System.
From the beginning, it was announced that the integration of these services would take place gradually. Therefore, the various diagnoses were grouped, with the aim of being included in the GHS from time to time and covering the needs of patients through it.
Unfortunately, to date, not all the "diagnosis groups" have been included, while not even the legislation passed several months ago by the Parliament has begun to be implemented in substance. As a result, patients are forced to pay several thousand euros per month out of their own pocket, because their diagnosis is not included in the list of diagnoses covered by the GHS.
The inclusion of additional centers in the GHS has not yet become possible and in essence the System does not offer everything that its beneficiaries need.
The "slogan" of abuses: Rules and horizontal restrictions
Abuses have become the most frequent "slogan" for those who want to show that they know the GHS and care about the GHS.
The truth is that, to a large extent, the beneficiaries themselves are also responsible for any abuses and certainly some of the service providers of the System. There are abuses, there will always be, but as far as the main mission of the GHS is concerned, which is to meet the health needs of citizens, they do not seem to be the biggest problem.
Over the years and in its effort to manage the abuses of the first years of operation of the System, the HIO included in the System "millions" of horizontal restrictions, which slowly led to distortions, in some cases serious, which reflect, among other things, the quality of services.
Some of these rules directly affect the behaviour of doctors within the System. The HIO implements a mechanism for allocating units by specialty and hospital. When a doctor or hospital exceeds the specified unit limit, reductions are imposed on the reimbursements he receives. As a consequence, there is either a postponement of patient visits, resulting in the creation of waiting lists, or a delay in the submission of reimbursement requests by providers. Cases have already been recorded where these delays have negatively affected the patients themselves.
At the same time, when some doctors find reductions in their reimbursements, they try to compensate for the loss of income by increasing the number of operations they perform, even when some of them are not absolutely necessary.
This practice leads to an increase in the total volume of operations of the specific specialty, which affects the unit price, on the basis of which the compensations are calculated. Thus, a vicious circle is created: doctors try to maintain their income by offering more services than patients need, which ultimately exacerbates the pressures on the System instead of reducing them.
Similar distortions are observed in hospitals. Where there is a risk of deductions in compensation, it may either be discharged earlier than the appropriate time, or additional, not strictly necessary, acts may be carried out, with the aim of maintaining the level of compensation.
The need for the rational application of certain restrictions should also be underlined, in order to avoid inconvenience to both healthcare professionals and, above all, patients. Experience and available examples show that in many cases existing internal rules lead to undesirable consequences, such as the creation of waiting lists, the provision of inadequate services or even the financial burden on patients.
A typical example, often cited as indicative of the way in which certain rules are designed and implemented, is the specialty of endocrinology. Despite the identified shortage of endocrinologists, thousands of chronic patients continue to be directed - compulsorily - to this specialty, through regulations and restrictions of the System, although in many cases they could be effectively monitored by their personal doctors.
At the same time, personal doctors do not have the right to prescribe certain laboratory and diagnostic tests, which could contribute to the timely and safe diagnosis or monitoring of their patients. As a result, there is often a need to refer to other specialties, exclusively for the performance or approval of specific tests, which burdens the patient's journey, increases waiting times and puts further pressure on an already stressed system of health services.
These restrictions, if one wants to examine the issue as a whole, do not only lead to inconvenience for doctors and patients and to unnecessary mobility within the System. The specialist doctor to whom the patient will be referred for a service that he could safely receive from his personal doctor, will register a claim for compensation from the HIO.
It would be an omission not to include in the equation the decisions taken by the HIO that affect the pockets of the beneficiaries of the System.
For example, in endoscopies, the Organization, due to the bilingualism of doctors, decided that the services of an anaesthesiologist will not be covered by the GHS (except for specific criteria). This, of course, leads to a private charge for patients, which exceeds €100.
The slogan "everyone is equal, regardless of financial ability" is in question
Unfortunately, in recent years the way in which decisions and practices are made and implemented has affected the concept of equality between patients.
Indicative is the example of medical equipment, which patients of specific categories need.
The way in which the options are given to the beneficiaries automatically separates them into those who can afford and choose state-of-the-art equipment, paying contributions of hundreds of euros and those who do not have the opportunity and are limited to cheaper and possibly older technology options.
This issue has already been raised before the HIO, both by organized patients and by beneficiaries of the System.
The surpluses of millions, the security and control of the System
The anniversary of the seven years of operation of the GHS perhaps offers the right occasion for a more substantial review.
Not a report that will be limited to numbers, economic indicators and accounting results, but an overall assessment of the real experience of citizens.
The history of the GHS is inextricably linked to a deep social need. For decades, access to health in Cyprus has been characterised by inequalities. The quality of care one could obtain depended largely on one's income.
For thousands of citizens, a serious illness could turn into an economic disaster at the same time. The GHS came to overturn this reality, establishing the principle that health is a social right and not a privilege of those who can afford to pay.
The results of this reform are visible. More than one million beneficiaries gained universal access to health services. Private household spending on health has been significantly reduced. Thousands of people who previously postponed tests, treatments or procedures due to cost gained access to services they now take for granted. And many serious problems were diagnosed and treated in a timely manner.
The inclusion of inpatient care, specialty medicines, mechanisms for sending patients abroad and new treatment options has created a completely different environment from the one that existed before 2019.
Precisely for this reason, the debate that is developing today should not concern the philosophy of the System. The GHS is a social achievement that must be protected.
What needs to be discussed is the way in which the System is implemented and especially whether certain practices are beginning to move the System away from its original orientation.
At the heart of this debate is the concept of sustainability. In recent years, this word has acquired almost mythical dimensions in the public debate. Politicians, economists, organized groups and various bodies constantly reiterate the need to ensure the sustainability of the GHS.
This is certainly a legitimate concern. No health system can function effectively if its finances are not healthy.
But the problem begins, and has already begun to develop, when sustainability is transformed from a means to a goal.
That is, when the discussion ceases to be about how the available resources will be used to improve services and is limited to how to maintain or increase the surpluses to ensure sustainability.
In the latest announcement of the HIO, on the occasion of the seventh anniversary of its implementation, it was stated:
"Based on the unaudited financial statements for 2025, the reserve of the HIO Fund amounted to €787 million, covering expenses of approximately 4.8 months, a level significantly higher than international best practices, which amounts to 3 months' expenses."
Nevertheless, decisions are still taken that are characterised by excessive caution regarding the extension or enhancement of services to patients.
This approach has begun to lead to the conclusion that, in some cases, the HIO operates more in the logic of a private insurance company than a social security organization.
The difference between the two models is fundamental. A private insurance company seeks to limit costs in order to maximize its financial result. A social health system, on the contrary, must maintain economic balance, but at the same time utilize the available resources to meet as many needs of citizens/patients as possible.
The need to deal with abuses has been one of the main issues that concerned the HIO from the first day of operation of the System. And rightly so. Such a large and complex system could not function without controls.
But the problem is not the existence of controls. The problem is the way in which they are applied.
Controls must be targeted. To be, as a representative of the Cyprus Federation of Patients' Associations recently pointed out, "smarter".
The philosophy that seems to have prevailed in recent years is often based on horizontal restrictions, which affect all beneficiaries and providers and instead of targeting those who actually abuse the System, they burden the right professionals and patients who are in real need equally.
So the real challenge of the next period is not to change the philosophy of the GHS. It is to bring his philosophy back to the center of decisions.
All those who manage the System should remember that the ultimate goal is not the accumulation of surpluses. The purpose is to provide health services to people who need them. The GHS Fund has and must have the safe reserves that will get us out of a difficult position when we find ourselves in crisis situations.
However, in order to stop paying contributions to the GHS Fund, from beneficiaries, employers, individuals and the public sector, the country must essentially be "closed". Even for this remote and possibly unlikely eventuality, we must have the necessary reserves.
International practice says about stocks that are enough to meet the needs of three months. The Fund already has much more.
In order to avoid misunderstandings, no one argues that the HIO should open the sack and give money with the scoop. The GHS Fund is the common bank account of all of us and needs protection.
However, when the beneficiary has confirmed that he needs two or three more physiotherapy treatments in addition to the 12 + 12 or 6 + 6 that are currently covered, we cannot deprive him of them.
When the elderly with dementia needs a visit from a nurse at least once a week, we cannot tell him that you are entitled to so many and with an extension of a set number and that's it.
When the patient needs specialized equipment, we cannot tell him if you have paid a €400 contribution and get the latest technology and if you don't, limit yourself to the €70 equipment.
When the patient needs rehabilitation services, he must receive them without thinking that the Ministry of Finance did not approve all the funds we requested.
After all, the HIO was never left alone when it needed support, claiming services and money for the citizens. In any case, he does not claim them from the state treasury but from the Fund to which we all contribute every month for our Health.
The GHS does not need any changes in its structure, architecture and philosophy. Tidying up and patient-centred targeting is needed. It is probably time to open this debate.
