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Background: Cognitive methodologies have been used in several areas of healthcare research for the development and evaluation of new instruments; nonetheless, their use in primary care settings along with the use of focus group methodology is rather limited. Objective: Focus group methodology was used to evaluate and improve two developing measurement tools for evaluating patients' experiences about primary healthcare services in Greece. Methodology: Two focus groups were conducted with 11 patients to test the perception, interpretation and usefulness of the questions of the new measurement tools. The agenda included 12 questions aimed at asking whether each question of the tools was understood and made sense by the participant in the same way as the researchers and if it was relevant to the primary care setting. The coding system of Willis (1999) was used to analyze the data. Results: The analysis revealed 30 problems for a number of problematic items. These included 12 clarity problems, eight response categories, one knowledge problem, one sensitive content problem, one instruction problem and one formatting problem. Moreover, six new types of problems emerged which could not be classified according to the above coding system (inapplicable problems). Conclusions: This methodological approach was useful in identifying questionnaire problems and the tool was redrafted by taking into account participants' perspectives. [ABSTRACT FROM AUTHOR]

The Health Systems in Transition (HiT) profiles are country-based reports that provide a detailed description of a health system and of policy initiatives in progress or under development. HiTs examine different approaches to the organization, financing and delivery of health services and the role of the main actors in health systems; describe the institutional framework, process, content and implementation of health and health care policies; and highlight challenges and areas that require more in-depth analysis. The health status of the Greek population has strongly improved over the last few decades and seems to compare relatively favourably with other OECD and European Union (EU) countries. The health system is a mixture of public integrated, public contract and public reimbursement models, comprising elements from both the public and private sectors and incorporating principles of different organizational patterns. Access to services is based on citizenship as well as on occupational status.The system is financed by the state budget, social insurance contributions and private payments.The largest share of health expenditure constitutes private expenditure, mainly in the form of out of pocket payments which is also the element contributing most to the overall increase in health expenditure. The delivery of health care services is based on both public and private providers. The presence of private providers is more obvious in primary care,especially in diagnostic technologies, private physicians' practices and pharmaceuticals. Despite success in improving the health of the population, the Greek health care system faces serious structural problems concerning the organization, financing and delivery of services. It suffers from the absence of cost-containment measures and defined criteria for funding, resulting in sickness funds experiencing economic constraints and budget deficits. The high percentage of private expenditure goes against the principle of fair financing and equity in access to health care services. Efficiency is in question due to the lack of incentives to improve performance in the public sector. Mechanisms for needs assessment and priority-setting are underdeveloped and, as a consequence, the regional distribution of health resources is unequal. Centralization of the system is coupled with a lack of planning and coordination, and limited managerial and administrative capacity. In addition, the oversupply of physicians, the absence of a referral system, and irrational pricing and reimbursement policies are factors encouraging under-the-table payments and the black economy. These shortcomings result in low satisfaction with the health care system expressed by citizens. The landmark in the development of the Greek health care system was the creation of the national health system (ESY) in 1983. This report describes the development of the ESY at the structural level and generally, the process of implementing reforms. The strategic targets of health reform initiatives have been to structure a unified health care sector along the lines of the original ESY proposal and to cope with current inefficiencies. However, the three reforms attempted in the 1990s were never fully implemented, while the ambitious reform project of the period 2000–2004, which provided for the regionalization of the system, new management structures, prospective reimbursement, new employment conditions for hospital doctors, modernization of public health services and reorganization of primary health care, was abolished after the elections of 2004 and a change in government. While the new strategy, launched in 2005 with the stated aims of securing the financial viability of the health care system in the short term and its sustainability in the long term, addressed specific weaknesses, it has been rather controversial: the introduction of a centralized administrative public procurement system, the development of public–private partnerships (PPPs) for the construction of public hospitals and the reform of pharmaceutical care have been accompanied by the abolition of professional hospital management and its replacement by political administration. The dominance of clientelism and party thinking instead of consensus-building has resulted in a health policy that lacks continuity and the ability to bring about change., (World Health Organization 2010, on behalf of the European Observatory on health systems and Policies.)