ORIGINAL RESEARCH article
Front. Health Serv.
Sec. Health Policy and Management
Health inequalities under decentralized governance: challenges in resource allocation and funding in Greece
Provisionally accepted
Stefanos Karakolias1*
Nikolaos Polyzos2- 1Department of Nursing, Democritus University of Thrace, Alexandroupolis, Greece
- 2Demokriteio Panepistemio Thrakes Tmema Iatrikes, Alexandroupoli, Greece
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Background: Decentralization in health systems aims to enhance responsiveness and equity but is often accompanied by uneven implementation and resource disparities. Greece's health system has undergone successive phases of decentralization, culminating in 2015 when Regional Health Authorities (RHAs) assumed operational responsibility for public primary health care (PHC). This study presents the first comprehensive assessment of this transition, examining funding adequacy and resource allocation across RHAs. Methods: Financial and operational analyses were performed to assess disparities among RHAs and between RHAs and hospitals. Data were drawn from publicly available sources, including financial statements, Ministry of Health reports, and national statistics. The analysis examined patient visits, staffing levels, infrastructure, funding, labor productivity, and efficiency across health regions. Results: Between 2018 and 2023, patient visits declined in most RHAs. Staffing composition shifted toward nursing personnel, while medical staff numbers declined. Substantial intra-and inter-regional disparities were observed in service utilization, staffing, infrastructure, funding, labor productivity, and efficiency. Hospitals continued to absorb a large share of PHC demand and funding, whereas RHA units held markedly fewer assets and received lower financial support. Funding imbalances among RHAs were evident, and the overall negative return on assets indicated systemic underfunding of public PHC. Conclusion: The ongoing decentralization of Greece's health system faces structural challenges, including overlapping territorial jurisdictions and uneven, occasionally insufficient resource allocation. These challenges hinder progress toward health equity. Policy interventions should prioritize evidence-based resource allocation, standardized financing frameworks, and strengthened PHC integration to promote equitable and sustainable healthcare delivery under decentralized governance.
Keywords: Decentralization, Regional Health Authorities, Primary Health Care, Resourceallocation, funding, health inequalities
Received: 09 Sep 2025; Accepted: 27 Oct 2025.
Copyright: © 2025 Karakolias and Polyzos. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
* Correspondence: Stefanos Karakolias, s.karakolias@gmail.com
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