Care by communities: Greece’s shadow zero-cash health care system

You enter the Metropolitan Community Clinic at Helliniko from a nondescript parking lot in suburban Athens, in an area that hosts a decommissioned American military base. It does not look like much. But it is. It is a very big deal indeed.

The MCCH saves people. It provides health care to down-on-their-luck Greeks who have no access to public health care and no money to pay for private clinics. There are many such people, because in Greece access to the national health service is tied to employment. When Greeks lose their jobs, they have a grace period of one year: they’d better find another job within that period, because if they don’t they are out of health insurance. If they fall sick, they have to come up with something, or die.

It’s not just Greeks. It turns out in every European Union countries but the United Kingdom and Italy, employment is a pre-requisite for access to health care. But Greece was it hardest by the 2008 crisis: many more people than elsewhere have turned into long-term unemployed. Everyone is struggling: “We had poor people ten years ago, too – shrugs Maria, a psychologist volunteering at MCCH – but at that time people could fall back on their families, or their neighbors, for help. Not anymore: their families and neighbors are themselves in trouble, and there’s little they can do. People are getting desperate.”

In 2011, some senior doctors started comparing notes, and they saw a perfect health care storm brewing at the horizon. “We knew something very bad was coming, and people would die – says Maria – so we decided we must do something.”

“Something” in this case turned out to be the MCCH itself. This is a very strange animal as health care providers go.

  • It has no legal existence. Its literature proudly proclaims: “ MCCH is a volunteer organization without Legal or Taxable status and it is not a ‘Non-Profit-Making-Organisation’.” Maria: “We are technically illegal”.
  • It does not accept donations in money. It does accept donations in kind: medicines, equipment, blood sample analyses.
  • It operates from a building that belongs to the Municipality of Helliniko-Argyropoulis. Though none of its employees works in the building, the Municipality still pays the electricity and phone bills that the MCCH generates. My heart goes out to the anonymous “bureaucrat hacker” that entrusted a government building to an informal group of citizens, which by definition cannot sign contracts or participate in tenders.
  • It is very autonomous with respect to institutions and power. MCCH was recently proposed for the European Parliament European Citizen’s Prize 2015, but they very publicly turned it down. Reason: “Europe is an important cause of the problem we exist to address. Don’t give us award, change your policy”.
  • It treats only people who have no access to the public health care system. One exception: low-income families with many children, who are living hand-to-mouth on 450 euro a day and simply cannot afford to buy medicines (Maria: “It happens”).
  • On top of diagnosis/prognosis, MCCH supplies free medicines, baby food and nappies.
  • It has 300 volunteers, of which a little over half are doctors of various specialisations and pharmacists.
  • It operates with practically no hierarchy and no management. People decide by themselves what role to play, by joining one of several groups (about 10 members to a group) which exist to carry on specific tasks (like onboarding new patients). An organising committee does its best to keep people on the same page. A weekly meeting votes on general issues. A mailing list deals with specific matters.
  • When they are not volunteering with MCCH, volunteers exchange services and small favours through a time bank: two massages against one hour of English lessons etc.

There are now 68 such clinics in Greece. Take a moment to think about what this means: in four years, thousands of enterprising Greeks with no money, no command structure and who do not even know each other have created a parallel health care system that succeeds where the public health service and private sector services both fail: it keeps reasonably safe the poorest strata of the population. Notice that the Greek health care budget in 2011 was over 6 billion euro.

Wait. Self-organised people with no money and no organisation that beat credentialed, moneyed professionals at their own game? We’ve seen this before. It was Wikipedia outcompeting Encyclopedia Britannica. It was OpenStreetMap pushing to the curbs Garmin and TomTom. It was Facebook groups coordinating disaster relief after the Nepal 2015 earthquakes and the Tbilisi 2015 flash flood, way before the government and NGOs could get their act together. It was Internet-coordinated young newcomers changing the rules of the political game, and even bringing down entire regimes who seemed to have all the power and all the money, in Egypt, Tunisia and Ukraine.

We have a word for these phenomena: we call them disruption. They are associated with supplying goods or services in a new way, that substitutes collective intelligence and distributed effort for vertical organisations. This new way happens to be vastly more efficient than the old ones.

I think the time has come for disruption in health care, and in care services in general. Why? Because, as the OECD pointed out, per capita health care expenditure grows much faster than GDP. In 1970, health care absorbed a respectable 5.2% of the GDP of the average OECD country. In 2008, it absorbed 10.1% (source). The system is under strain, and often – like in Greece, it reacts by denying care to those who most need it.

Per capita health care expenditure in some OECD countries, 1970-2015

This is morally unacceptable, wasteful and stupid – especially when the Metropolitan Community Clinic at Helliniko and so many other experiences like it, in the world of care and outside it, has proven how much farther communities can go in taking care of their members when they are enabled to do it.

So, we are getting involved. Edgeryders has partnered up with five world-class organisations in research (University of Bordeaux, Stockholm School of Economics, ScimPulse Foundation), welfare policy-making (City of Milan) and digital fabrication (WeMake) to find, learn from, and enhance the experiences like MCCH all around the world. Our goal is a model of community-driven care services, based on modern science and open technology, but with the low overhead and human touch that communities can provide and large bureaucracies cannot. Our project is called OpenCare; the European Commission has generously agreed to support it through its Collective Awareness Platforms programme.

Whoever you are you are welcome to join us. After all, if you are human, you have considerable experience of giving and receiving care, and that makes you an expert. If you want to participate, or simply to know more, start here.

Photo: Theophilos Papadopoulos on

From left: Giovanni, Ilaria, Alberto, Nadia, Kasia, Pierre

Living social in Brussels: growing the family

“Wait a minute: is this a co-living space?” I was asked this question a few weeks ago by designer Ezio Manzini, who was in town to present a recent book of his and had come over for dinner. We were standing in the courtyard of our new home, just a week or so into the moving. All I could do was stare at him. To me that was just home, but he was right: we do live in a co-living space. How did that happen? We are hardly commune material.

Here is the back story: a few years ago, Nadia and I tried the life of a migrant nuclear family, and hated it. Upon moving to Brussels in 2012, we decided to rent a larger apartment than we needed, and look for flatmates. Eventually a young couple, Kasia and Pierre (expats, like us), moved in with us, and we really enjoyed their company. When our landlord reclaimed his flat, we decided to stay together, and went about looking for a new home that could accommodate the four of us. And then we thought, wait a minute. This is working out quite well, so maybe we should consider growing the family: find an even bigger place, and look for two extra housemates.

So, I wrote a post on this blog, telling the full story of why we enjoy so much living with Kasia and Pierre. And then two wonderful things happened.

The first one was that we bumped into a creative real estate agent, Isabelle Sandbergen. We needed that, because, guess what: the real estate market does not serve people with non-traditional familial constellations. It is heavily geared towards the nuclear family or the swinging single; you can find large dwellings if you are prepared to pay a high rent, but they typically do not accommodate the need to mix socialisation and privacy; for example, at least in Brussels, they tend not to have enough bathrooms. Good luck finding anything with three or four bathrooms. Isabelle called us on an intuition: the same landlord, she said, was renting out two newly renovated lofts facing each other. They were individually too small for us, but how about we take both? They were separated by a simple fence, but that could be taken down to allow unimpeded access to both lofts for everybody. And we would have a very nice, huge private court on top of two open spaces (one kitchen-living, one office), four bedrooms, two bathrooms, two toilets and some extras. Were we interested? We were. We signed the contract after a week from that call.

Living room and courtyard

The second wonderful thing was finding two more great flatmates. They are both Italian, and both lived abroad before moving in with us: Giovanni in London, Ilaria here in Brussels. Ilaria lived here for a long time, and is practically a local; Giovanni is a total newcomer. She works in the Eurospace; he is currently focusing on a startup company. Ilaria planted a herbal garden in the courtyard, and Giovanni’s tiramisu became the everyone’s favourite treat. There’s even more diversity in the home. How did we find them? In the usual way, through the Internet. When they showed up, they told us they had been inspired by my post, so they had at least an idea of what to expect. This reassured us they were likely to have the flexibility necessary for Living Social in Brussels; and flexibility we are going to need, a lot of it, because the journey is fascinating but there are no maps for it.

With six people, you might think we could get tired of the crowd. But the opposite is true: we have different lifestyles, plenty of space (about 200 square meters, plus the courtyard and a huge hallway) and we end up not seeing much of each other – not enough, in my opinion. In fact, I am trying to make a point of organising “family dinners” with the six of us at least once a month, because they are great fun but do not happen without somebody passing word around to save the date – though sharing a meal in smaller numbers, three or four, is far more common.

Ezio told me that his group at Politecnico di Milano was involved in designing some co-living spaces, but he had never been in one that actually worked. He was fascinated in discovering that real life had somehow overtaken R&D, and that we – not knowing that co-living is very difficult to do successfully – had gone out and simply done it. We do not think of what we do as design, but we are aware we need to learn how to live together and enjoy each other’s company over the long run. So, we experiment: we use plenty of hacks like shared documents, an online calendar, spreadsheets for shared expenses and so on; we try stuff, keep what works, discard what does not. It’s a lot like life.

Thank you for all your messages of sympathy, and for sharing our posts on the various social media: you helped Ilaria and Giovanni find us, and so enriched our life. And if you find yourselves in Brussels, come over for coffee, or a glass of wine!

[The wandering economist] Does Egypt run on hyper-Schumpeter?

In this period I am consulting for the United Nations Development Programme and United Nations Volunteers. What it is I am doing exactly is a story for when I have finished doing it. But an interesting (for me, and for this blog) feature of this job is that it requires me to get a broad idea of employment and social inclusion policies in six countries (Armenia, Belarus, Egypt, Georgia, Morocco, Ukraine), and to do it in just a few days. To do this, I read policy documents and check statistics; and visit each of these countries, walk into government offices and ask civil servants questions; then talk to businessmen, NGOs and international development organizations and cross-check the information I get.

It will not make me an expert, but it seems like a great way to learn about these countries and what they are trying to achieve, and to do so very quickly. And there is an added bonus: by looking at how different countries, with their different economic fundamentals and policy styles, approach the same issues, I can learn much about what these issues really look like, when seen from different angles. I thought others might be interested, too, so I will be posting occasional notes from the journey – starting from my impressions of Egypt. As with everything else in this blog, views expressed here are my own and may differ from my employer’s.

Egypt seems to run on a hyper-Schumpeterian ideology. Entrepreneurship is seen as the silver bullet that will solve everything. Social problems will be solved… by social entrepreneurship. There are even talks to teach entrepreneurship in schools, in the curriculum.

Treating entrepreneurship as the critical tool towards improving Egypt’s overall social and economic health appears to be, according to interviewees, a logical move. Every year, 600,000 young Egyptians join the labour market (CAPMAS, 2013). The public sector is already bloated with more people than it can use, and cannot absorb but few of those young people. 70% of job creation is driven by the private sector; and private sector has its own labor needs, which are similar to those of most countries: more “cream of the crop” highly qualified people with specific skills that happen to be in need at this point in time, not so many middle-of-the-road graduates. Labour demand – supply matching and retraining policies can help a little, but they are already being done, so they cannot be expected to bring any additional benefits. That leaves new business as the most likely candidate for creating new jobs.

Two labour policy asides (not directly relevant to the project, but useful as part of the background):

  1. Labour policies seem to be, in some cases, overengineered. A scheme that was reported to us is a scheme of demand-supply matching for apprenticeships and internships directed to boys and girls who are still in school, and therefore are _unqualified_. The thinking behind it is that having a summer job can help youth develop personal and relational skills that will be useful when applying for, or holding, a job. But is there really any need to match schoolboys with farms, and paying the overhead cost of the matching structure?
  2. Entrepreneurship policies have reached the point where they risk distorting the incentives for the budding entrepreneurs. One of the interviewees reported that some young, obviously smart people perceive it as viable to just go from competition to competition, from grant to grant, and stop business when the grant or award dries up.

The Egyptian government appears to be working with the main stakeholders to build an ecosystem conducive to entrepreneurs reaching their full potential. Many efforts are directed towards building funnels that find entrepreneurial ideas and bring them to market in the form of startups. We heard of several startup programs (Injaz Startup Incubator Programme, Misr el-Kheir’s Gesr Programme, Nile University’s NU100 competition). Microsoft offers online coaching for startuppers. The main tools in use seem to be competitions, mentoring, coaching, and incubators. Most of this effort focuses on nano-bio, ICT, greentech.

There are many remaining challenges for the full potential of entrepreneurship to bear fruit. Specifically:

  • the regulatory environment for new business is stiff and unfriendly.
  • regulation on key areas pertaining to startups (patents, IPR, data protection, openness of public sector information) is still missing.
  • university research is subpar.
  • services for tech startups are expensive or missing. There are only two law firms serving startups, and no specialized accountants at all; very few consultants on the specifics of startupping.
  • angel investors are there, but they do not appear to be having a large impact.
  • private sector companies get involved in entrepreneurship competitions, but they tend to recruit the smartest competitors rather than invest in their business.
    incubated firms struggle to move forward and scale.

As a consequence, the funnel is missing pieces both at the beginning (pre-idea) and at the end (second and third round, post-incubator). There are signals that the government is working on improving regulation to make Egypt more business-friendly, but some of the interviewees expected that this would not really accelerate until a parliament is elected.

Social entrepreneurship/social innovation is attracting attention, but it does not feature as prominently in Egyptian policy as it does in Europe. We know of one already active pipeline for social entrepreneurship (Misr el-Kheir), and of another one being considered. (Injaz). The active one, however, insists on “high profitability”, so that the term “social” becomes a bit diluted (and could even be interpreted as a constraint). The Egyptian legal system does not have a specific legal form designed for social entrepreneurs, like the CIC in the UK and the cooperativa sociale in Italy.

Over the past year, we at Edgeryders have met many Egyptians involved in social entrepreneurship and other grassroots initiatives. They seem to have two main focuses. One is greentech (solar, water sanitation, waste recycling etc.), which is supposedly cared for by the fledgling ecosystem of policies directed towards entrepreneurship.

The other one is reclaiming and repurposing public spaces for the common good, with the Al-Mutamidiya ring road ramps story being the most impressive example of self-organization we found so far. UNDP itself has been involved in this scene, with a successful initiative to have young people contribute to designing the renovation of a central street in Giza (the governor of Giza turned out to have urban planning background, which makes him a potential champion for these initiatives). This line of work does not appear to be part of the startup ecosystem.

Other examples include the many coworking spaces that flourished in Egypt (many of which do not appear to have a viable business model, but they do signal a drive of youth to claim spaces), like Mesaha, Rasheed 22. Megawra and Cairo Hackerspace (learn more). Of these, at least the first one is fully grant-free, surviving on a very community oriented “pay what you can” model. The Darb al-Labbanah initiative, currently in its planning stages, strives to revitalise Historic Cairo by adaptively reusing long neglected properties as a hub for social enterprises and cultural businesses.

Cairo is also home to Cluster, an urban planning studio that achieved international fame for doing work on informal settlements and “tactical urbanism” – another sign of societal interest in the matter and a reservoir of high-level technical expertise.

Overall, there seems to some space for Egyptian social entrepreneurs to leverage the hyper-Schumpeterian ideology now prevailing in the country to gain a more central position in society. I certainly wish them my best!