Skip to main content Accessibility help

Integrated people-centred primary health care in Greece: unravelling Ariadne’s thread

  • Christos Lionis (a1) (a2), Emmanouil K. Symvoulakis (a1), Adelais Markaki (a1) (a3), Elena Petelos (a1) (a4), Sophia Papadakis (a1) (a5) (a6), Dimitra Sifaki-Pistolla (a1), Maria Papadakakis (a1) (a7), Kyriakos Souliotis (a8) and Chariklia Tziraki (a9)...


The 40th anniversary of the World Health Organization Alma-Ata Declaration in Astana offered the impetus to discuss the extent to which integrated primary health care (PHC) has been successfully implemented and its impact on research and practice. This paper focuses on the experiences from Greece in implementing primary health care reform and lessons learned from the conduct of evidence-based research. It critically examines what appears to be impeding the effective implementation of integrated PHC in a country affected by the financial and refugee crisis. The key challenges for establishing integrated people-centred primary care include availability of family physicians, information and communication technology, the prevention and management of chronic disease and migrant and refugees’ health. Policy recommendations are formulated to guide the primary health care reform in Greece, while attempting to inform efforts in other countries with similar conditions.

  • View HTML
    • Send article to Kindle

      To send this article to your Kindle, first ensure is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle. Find out more about sending to your Kindle.

      Note you can select to send to either the or variations. ‘’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

      Find out more about the Kindle Personal Document Service.

      Integrated people-centred primary health care in Greece: unravelling Ariadne’s thread
      Available formats

      Send article to Dropbox

      To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Dropbox.

      Integrated people-centred primary health care in Greece: unravelling Ariadne’s thread
      Available formats

      Send article to Google Drive

      To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Google Drive.

      Integrated people-centred primary health care in Greece: unravelling Ariadne’s thread
      Available formats


This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (, which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.

Corresponding author

Author for correspondence: Christos Lionis, Clinic of Social and Family Medicine, Faculty of Medicine, University of Crete, P.O. Box 2208, 71003 Heraklion, Crete, Greece. Email:


Hide All
Auffray, C, Balling, R, Barroso, I, Bencze, L, Benson, M, Bergeron, J, Bernal-Delgado, E, Blomberg, N, Bock, C, Conesa, A, Del Signore, S, Delogne, C, Devilee, P, Di Meglio, A, Eijkemans, M, Flicek, P, Graf, N, Grimm, V, Guchelaar, HJ, Guo, YK, Gut, IG, Hanbury, A, Hanif, S, Hilgers, RD, Honrado, Á, Hose, DR, Houwing-Duistermaat, J, Hubbard, T, Janacek, SH, Karanikas, H, Kievets, T, Kohler, M, Kremer, A, Lanfear, J, Lengauer, T, Maes, E, Meert, T, Müller, W, Nickel, D, Oledzki, P, Pedersen, B, Petkovic, M, Pliakos, K, Rattray, M, I Màs, JR, Schneider, R, Sengstag, T, Schneider, R, Sengstag, T, Serra-Picamal, X, Spek, W, Vaas, LA, van Batenburg, O, Vandelaer, M, Varnai, P, Villoslada, P, Vizcaíno, JA, Wubbe, JP and Zanetti, G (2016) Making sense of big data in health research: towards an EU action plan. Genome Medicine 8, 71.
Barberan-Garcia, A, Vogiatzis, I, Solberg, HS, Vilaró, J, Rodriguez, DA, Garåsen, HM, Troosters, T, Garcia-Aymerich, J, Roca, J and NEXES Consortium (2014) Effects and barriers to deployment of telehealth wellness programs for chronic patients across 3 European countries. Respiratory Medicine 108, 628637.
Boult, C, Karm, L and Groves, C (2008) Improving chronic care: the “guided care” model. Permanenente Journal 12, 5054.
deWaard, AM, Hollander, M, Korevaar, JC, Nielen, MMJ, Carlsson, AC, Lionis, C, Seifert, B, Thilsing, T, de Wit, NJ, Schellevis, FG and SPIMEU Project Group (2018b) Selective prevention of cardiometabolic diseases: activities and attitudes of general practitioners across Europe. European Journal of Public Health, 29, 8893.
deWaard, AM, Wändell, PE, Holzmann, MJ, Korevaar, JC, Hollander, M, Gornitzki, C, de Wit, NJ, Schellevis, FG, Lionis, C, Søndergaard, J, Seifert, B, Carlsson, AC and SPIMEU Research Group (2018a) Barriers and facilitators to participation in a health check for cardiometabolic diseases in primary care: a systematic review. European Journal of Preventive Cardiology 25, 13261340.
Economou, C (2015) Barriers and facilitating factors in access to health services in Greece. World Health Organization. Retrieved 27 September 2018 from
Eurostat (2018) Healthcare personnel statistics – physicians. Retrieved 27 September 2018 from
Donabedian, A (1976) Benefits in medical care programs. Cambridge: Harvard University Press.
Hernandez, C, Alonso, A, Garcia-Aymerich, J, Grimsmo, A, Vontetsianos, T, Cuyàs, FG et al. (2015) Integrated care services: lessons learned from the deployment of the NEXES project. International Journal of Integrated Care 15, e006.
Kanavos, P and Souliotis, K (2017) Reforming health care in Greece: balancing fiscal adjustment with health care needs. In Meghir, C, Pissarides, C, Vayanos, D and Vettas, N, editors, Beyond austerity: reforming the Greek economy. Cambridge: MIT Press Ltd., 359402.
Koetsenruijter, J, van Eikelenboom, N, van Lieshout, J, Vassilev, I, Lionis, C, Todorova, E, Portillo, MC, Foss, C, Serrano, GM, Roukova, P, Angelaki, A, Mujika, A, Knutsen, IR, Rogers, A and Wensing, M (2016) Social support and self-management capabilities in diabetes patients: an international observational study. Patient Education and Counseling 99, 638643.
Kounalakis, DK, Lionis, C, Okkes, I and Lamberts, H (2003) Developing an appropriate EPR system for the Greek primary care setting. Journal of Medical Systems 27, 239246.
Kringos, DS, Boerma, WG, Bourgueil, Y, Cartier, T, Hasvold, T, Hutchinson, A, Lember, M, Oleszczyk, M, Pavlic, DR, Svab, I, Tedeschi, P, Wilson, A, Windak, A, Dedeu, T and Wilm, S (2010a) The European primary care monitor: structure, process and outcome indicators. BMC Family Practice 11, 81.
Kringos, DS, Boerma, WG, Hutchinson, A, van der Zee, J and Groenewegen, PP (2010b) The breadth of primary care: a systematic literature review of its core dimensions. BMC Health Services Research 10, 65.
Kringos, D, Boerma, W, Bourgueil, Y, Cartier, T, Dedeu, T, Hasvold, T, Hutchinson, A, Lember, M, Oleszczyk, M, Rotar Pavlic, D, Svab, I, Tedeschi, P, Wilm, S, Wilson, A, Windak, A, Van der Zee, J and Groenewegen, P (2013) The strength of primary care in Europe: an international comparative study. British Journal General Practice 63, e742e750.
Leder, K, Borwein, S, Chanthavanich, P, Chatterjee, S, Htun, K, Marma, ASP, Nakatani, I, Ok, JJ, Pakasi, L, Pandey, P, Piyaphanee, W, Rupali, P, Schwartz, E, Shinozuka, T, Phu, PTH, Watanabe, H, Visser, J, Wilder-Smith, A, Zhang, M, McGuinness, SL (2017) Travel medicine perspectives of select travel medicine experts practicing in the Asia-Pacific region. Journal of Travel Medicine 24, 16.
Lionis, C and Midlöv, P (2017) Prevention in the elderly: a necessary priority for general practitioners. European Journal of General Practice 23, 202207.
Lionis, C and Petelos, E (2015) The patient-centered medical home model within an integrated primary care system: towards a European model? In O’Donohue, W and Maragakis, A, editors, Integrated primary and behavioral care role in medical homes and chronic disease management. Springer International Publishing: Switzerland.
Lionis, C, Papadakis, S, Tatsi, C, Bertsias, A, Duijker, G, Mekouris, PB, Boerma, W and Schäfer, W (2017) Informing primary care reform in Greece: patient expectations and experiences (the QUALICOPC study). BMC Health Services Research 17, 255.
Lionis, C, Papadakaki, M, Saridaki, A, Dowrick, C, O’Donnell, CA, Mair, FS, van den Muijsenbergh, M, Burns, N, de Brún, T, O’Reilly de Brún, M, van Weel-Baumgarten, E, Spiegel, W and MacFarlane, A (2016) Engaging migrants and other stakeholders to improve communication in cross-cultural consultation in primary care: a theoretically informed participatory study. BMJ Open 22, e010822.
Lionis, C, Petelos, E, Mechili, EA, Sifaki-Pistolla, D, Chatzea, VE, Angelaki, A, Rurik, I, Pavlic, DR, Dowrick, C, Dückers, M, Ajdukovic, D, Bakic, H, Jirovsky, E, Mayrhuber, ES, van den Muijsenbergh, M and Hoffmann, K (2018a) Assessing refugee healthcare needs in Europe and implementing educational interventions in primary care: a focus on methods. BMC International Health and Human Rights 18, 11.
Lionis, C, Petelos, E, Papadakis, S, Tsiligianni, I, Anastasaki, M, Angelaki, A, Bertsias, A, Mechili, EA, Papadakaki, M, Sifaki-Pistola, D and Symvoulakis, E (2018b) Towards evidence-informed integration of public health and primary care: experiences from Crete. Public Health Panorama 4, 699714.
Lionis, C, Symvoulakis, EK, Markaki, A, Vardavas, C, Papadakaki, M, Daniilidou, N and Kyriopoulos, I (2009) Integrated primary health care in Greece, a missing issue in the current health policy agenda: a systematic review. International Journal of Integrated Care 9, 114.
Markaki, A, Alegakis, A, Antonakis, N, Kalokerinou-Anagnostopoulou, A and Lionis, C (2009) Exploring training needs of nursing staff in rural Cretan primary care settings. Applied Nursing Research 22, 138143.
Markaki, A, Antonakis, N, Hicks, CM and Lionis, C (2007) Translating and validating a Training Needs Assessment tool into Greek. BMC Health Services Research 2, 65.
Markaki, A, Antonakis, N, Philalithis, A and Lionis, C (2006) Primary health care nursing staff in Crete: an emerging profile. International Nursing Review 53, 1618.
Papadakaki, M, Petridou, E, Kogevinas, M and Lionis, C (2013) Measuring the effectiveness of an intensive IPV training program offered to Greek general practitioners and residents of general practice. BMC Medical Education 13, 46.
Papadakaki, M, Prokopiadou, D, Petridou, E, Kogevinas, M and Lionis, C (2012) Defining physicians’ readiness to screen and manage intimate partner violence in Greek primary care settings. Evaluation and the Health Profession 35, 199220.
Papadakaki, M, Lionis, C, Saridaki, A, Dowrick, C, de Brún, T, O’ Reilly-de Brún, M, O’Donnell, CA, Burns, N, van Weel-Baumgarten, E, van den Muijsenbergh, M, Spiegel, W and MacFarlane, A (2017) Exploring service providers’ perspective on barriers to primary care for migrants: a qualitative study in the Greek primary care in times of austerity. European Journal of General Practice 23, 128134.
Papadakaki, M, Petridou, E, Petelos, E, Germeni, E, Kogevinas, M and Lionis, C (2014) Management of victimized patients in Greek primary care settings: a pilot study. Journal of Family Violence 29, 371379.
Samoutis, G, Soteriades, ES, Kounalakis, DK, Zachariadou, T, Philalithis, A and Lionis, C (2007) Implementation of an electronic medical record system in previously computer-naïve primary care centres: a pilot study from Cyprus. Informatics in Primary Care 5, 207216.
Sbarouni, V, Tsimtsiou, Z, Symvoulakis, E, Kamekis, A, Petelos, E, Saridaki, A, Papadakis, N and Lionis, C (2012) Perceptions of primary care professionals on quality of services in rural Greece: a qualitative study. Rural and Remote Health 12, 2156.
Sifaki-Pistolla, D, Chatzea, VE, Markaki, A, Kritikos, K, Petelos, E and Lionis, C (2017) Operational integration in primary health care: patient encounters and workflows. BMC Health Services Research 17, 788.
Souliotis, K and Lionis, C (2004) Creating an integrated health care system in Greece: a primary care perspective. Journal of Medical Systems 28, 643652.
Starfield, B (2009) Primary care and equity in health: the importance of effectiveness and equity to people’s needs. Humanity and Society 33, 5673.
Teunissen, E, Tsaparas, A, Saridaki, A, Trigoni, M, van Weel-Baumgarten, E, van Weel, C, van den Muijsenbergh, M and Lionis, C (2016) Reporting mental health problems of undocumented migrants in Greece: a qualitative exploration. European Journal of General Practice 2, 119125.
Triantafillidis, JK, Vagianos, C, Gikas, A, Korontzi, M and Papalois, A (2017) Screening for colorectal cancer: the role of the primary care physician. European Journal of Gastroenterology & Hepatology 29, e1e9.
Tsiachristas, A, Lionis, C and Yfantopoulos, J (2015) Bridging knowledge to develop an action plan for integrated care for chronic diseases in Greece. International Journal of Integrated Care 15, e040.
vanLoenen, T, van den Muijsenbergh, M, Hofmeester, M, Dowrick, C, van Ginneken, N, Mechili, EA, Angelaki, A, Ajdukovic, D, Bakic, H, Pavlic, DR, Zelko, E, Hoffmann, K, Jirovsky, E, Mayrhuber, ES, Dückers, M, Mooren, T, Gouweloos-Trines, J, Kolozsvári, L, Rurik, I and Lionis, C (2018) Primary care for refugees and newly arrived migrants in Europe: a qualitative study on health needs, barriers and wishes. European Journal of Public Health 28, 8287.
vanWeel, C, Alnasir, F, Farahat, T, Usta, J, Osman, M, Abdulmalik, M, Nashat, N, Alsharief, WM, Sanousi, S, Saleh, H, Tarawneh, M, Goodyear-Smith, F, Howe, A and Kassai, R (2018) Primary Health Care Policy Implementation in the East Mediterranean region - experiences of six countries. European Journal of General Practice 24, 3944.
vanWeel, C and Rosser, WW (2004) Improving health care globally: a critical review of the necessity of family medicine research and recommendations to build research capacity. Annals of Family Medicine 26, 2 Suppl 2:S516.
White, F (2015) Primary health care and public health: foundations of universal health systems. Medical Principles Practice 24, 103116.
WHO, World Health Organization (2017) Framework on integrated people-centred health services. Retrieved 26 September 2018b from
WHO, World Health Organization (2018a) Declaration of Astana. Global conference on primary health care, Astana Kazakhstan, 25–26 October 2018. Geneva: World Health Organization. Retrieved 2 January 2019 from
WHO, World Health Organization (2018b) Primary health care: the bridge to universal health coverage in Greece. Retrieved 25 September 2018 from
WONCA, World Organization of Family Doctors (2017) Family medicine: the classic papers. Kidd, M, Heath, I, Howe, A, editors, Boca Raton, FL: CRS Press Taylor and Francis Group 6000 Broken Sound Parkway NW, Suite 300, 33487–2742.



Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed