The belated implementation of a long-awaited health system in Cyprus and the role of interest groups

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Denise Alexandrou, PhD Marios Kantaris, PhD Mamas Theodorou, PhD


It is really a paradox that 60 years were required to establish a modern health system in Cyprus, despite the expressed positive attitude οf all political parties and most governments. This article investigates the planning and implementation of the National Health System (NHS) and its delay determinants, by employing qualitative research of published sources, audio material and 33 interviews with elite key informants. A major anti-reform alliance, consisting of private doctors, private hospitals and health insurance companies was identified, further supported by doctors of the “old” public system, whose benefits were threatened. Delay contributions additionally arose from media and patient groups, whilst the pharmaceutical sector imposed insignificant influence. Τhe prevailing political, economic and social environment, along with aspects of the proposed reform, fueled this anti-reform movement. However, climate in favour of the NHS implementation gradually developed, attributed to the power balance shift supportingthe Minister of Health and the government, mobilization of important actors/stakeholders, including the Federation of Patients' Organizations of Cyprus and the Media, and significant decrease in the influence of reform-resistant groups. The new dynamics created a supportive environment leading to the NHS launch on June 1st, 2019; thus Cyprus has ceased to be the last state of the European Union (EU) without a universal health coverage system. The process of introducing this new system in Cyprus is a prime example of resource and power redistribution amongst different interest groups and of the catalysts required to exit the orbit of an extremely “path-dependent” system, potentially inspiring future reformers.

Keywords: Cyprus’ NHS, interest groups, health care system reform, health policy, qualitative research

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ALEXANDROU, Denise; KANTARIS, Marios; THEODOROU, Mamas. The belated implementation of a long-awaited health system in Cyprus and the role of interest groups. Medical Research Archives, [S.l.], v. 9, n. 7, july 2021. ISSN 2375-1924. Available at: <>. Date accessed: 19 may 2024. doi:
Research Articles


1. Hanney SR, Gonzalez-Block MA, Buxton MJ, Kogan M. The utilisation of health research in policy-making: concepts, examples and methods of assessment. Health Res. Policy Syst. 2003;1(1):2. DOI: 10.1186/1478-4505-1-2.
2. Golna C, Pashardes P, Allins S, Theodorou M, Merkur S, Mossialos E. European Observatory on Health Care Systems and Policies. Health Care Systems in Transition: Cyprus. Copenhagen: WHO Regional Office for Europe; 2004.
3. Smith BA. Assignment Report Comments on the Proposed General Health Scheme for Cyprus. World Health Organization; 1982.
4. Zoellner D. Report of the Cost of the Scheme; 1980.
5. Bridgman RF. Assignment Report: Reorganization of Medical Care Services in Cyprus.World Health Organization; 1972.
6. Piro MSd. Report to the Government of the Republic of Cyprus on the Development of Medical care within the Framework of a Social Security Scheme. Geneva: International Labour Office; 1966.
7. Weeks LD. Feasibility Study for Hospital and other Medical Facilities in Nicosia; 1988.
8. European-Commission. Recommendation on Cyprus's 2012 national reform programme and delivering a Council opinion on Cyprus's stability programme for 2012-2015. Brussels: COM; 2012.
9. Theodorou M. Is the healthcare reform process in uncharted waters? Flash report. ESPN;2019.
10. Theodorou M. Cyprus: First results of the new healthcare system. Flash report. ESPN; 2020.
11. Ham C. Health Policy in Britain. 4th ed. London: Macmillan; 1999.
12. Nikolentzos A. The influence of the medical profession on the national health service of Greece, 1983-2001. London: The London School of Hygiene & Tropical Medicine; 2008.
13. Taylor G, Hawley H. Health and society: Key debates in health care. UK: McGraw-Hill Education; 2010.
14. Waitzkin HA. Marxist view of medical care. Annals of internal medicine, 1978;89(2):264-278.DOI: 10.7326/0003-4819-89-2-264.
15. Alford RR. Health care politics: Ideological and interest group barriers to reform. Chicago and London: University of Chicago Press; 1975.
16. Hall PA, Taylor RC. Political science and the three new institutionalisms. Political studies 1996; 44(5):936-957.DOI: 10.1111/j.1467-9248.1996.tb00343.x
17. Liu K. The effects of social health insurance reform on people’s out-of-pocket health expenditure in China. Singapore: Springer;2016.
18. Yin RK. The case study crisis: Some answers. Administrative science quarterly 1981;26(1):58-65. DOI 10.2307/2392599.
19. Yin RK. Case study research: Design and methods, Applied Social Research Methods. 2nd ed. CA: SAGE Publications, Thousand Oaks; 1994.
20. Yin RK. Case study research: Design and methods. Applied Social Research. Vol. 5. London: Sage; 1989.
21. Taylor RR. Kielhofner's research in occupational therapy: Methods of inquiry for enhancing practice. Philadelphia: FA Davis; 2017.
22. Strauss A, Corbin J. Basics of Qualitative Research: Techniques and Procedures for Developing Grounded Theory. 2nd ed. CA: Sage Publications, Thousand Oaks; 1998.
23. Macnee CL, McCabe, S.: Understanding nursing research: Using research in evidence-based practice. Philadelphia: Lippincott Williams & Wilkins; 2008.
24. Onwuegbuzie AJ, Leech NL. A call for qualitative power analyses. Qual Quant. 2007;41(1):105-121.DOI:10.1007/s11135-005-1098-1.
25. Patton MQ.: Qualitative evaluation and research methods. 2nd ed. CA: SAGE Publications, inc Newbury Park; 1990.
26. Noy C. Sampling knowledge: The hermeneutics of snowball sampling in qualitative research. Int. J. Soc. Res. Methodol 2008;11(4):327-344. DOI:10.1080/13645570701401305.
27. Lodico MG. Spaulding DT. Voegtle KH. Methods in educational research: From theory to practice. Vol. 28. New York: John Wiley & Sons; 2010.
28. Lincoln YS, Guba EG. Naturalistic Inquiry. Newbury Park: Sage Publications; 1985.
29. Walt G, Gilson L. Reforming the health sector in developing countries: the central role of policy analysis. Health policy plann 1994;9(4):353-370. DOI:10.1093/heapol/9.4.353.
30. Olson M. The logic of collective action; public goods and the theory of groups. Cambridge, Mass.: Harvard University Press; 1965.
31. Tsebelis G. Decision making in political systems: Veto players in presidentialism,parliamentarism, multicameralism and multipartyism. British journal of political science 1995;25(3):289-325.doi:10.1017/S0007123400007225.
32. Elston MA. The politics of professional power: medicine in a changing health service. In: The sociology of the health service, p.p. 68-98. London: Routledge; 1991.
33. Larson MS. The rise of professionalism: A sociological analysis. Vol. 233. Berkeley, Los Angeles, CA: Univ of California Press; 1977.
34. Freidson E. Profession of Medicine: A Study of the Sociology of Applied Knowledge. New York: Dodd and Mead; 1970.
35. Freidson E. Professional Dominance: The Social Structure of Medical Care. New York: Atherton Press; 1970.
36. Kay S.J. Unexpected privatizations: Politics and social security reform in the Southern Cone. Comparative Politics 1999;31(4):403-422. doi :10.2307/422237.
37. Immergut EM. The rules of the game: The logic of health policy-making in France, Switzerland, and Sweden. Structuring politics: Historical institutionalism in comparative analysis 1992;4(4):57-89.doi:10.1017/CBO9780511528125.004.
38. Mahoney J. Path dependence in historical sociology. Theory Soc.2000;29(4):507-548.
39. Sewell WH. Three temporalities: Toward an eventful sociology. The historic turn in the human sciences, 1996;98:245-280.
40. Pierson P. Increasing returns, path dependence, and the study of politics. Am. Polit. Sci. Rev. 2000;94(2):251-267.
41. Grafstein R. Institutional realism: Social and political constraints on rational actors. CT: Yale University Press; 1992.
42. Hacker JS. The divided welfare state: The battle over public and private social benefits in the United States. Cambridge: Cambridge University Press; 2002.
43. Capoccia G, Kelemen RD. The study of critical junctures: Theory, narrative, and counterfactuals in historical institutionalism. World politics 2007;59(3):341-369. DOI:10.1017/S0043887100020852.
44. Oliver A, Mossialos E. European health systems reforms: looking backward to see forward? J Health Polit Policy Law 2005;30(1-2):7-28. DOI:10.1215/03616878-30-1-2-7.
45. Ham C. Policy-making in the National Health Service: a case study of the Leeds Regional Hospital Board. London: Macmillan International Higher Education; 1981.
46. Le Grand J. Motivation, agency, and public policy: of knights and knaves, pawns and queens. Oxford: Oxford University Press; 2003.