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Received November 11, 2019, accepted November 21, 2019, date of publication December 1, 2019

Distribution and utilization of Radiotherapy Units 
in Greece 
By A. Dermitzakis1, S. Domente2, N. Pallikarakis1

1 Institute of Biomedical Technology, Greece
2 Regional Office for Europe, World Health Organisation 

ABSTRACT

Biomedical engineering is playing a leading role in the development of medical technology which is one of the pillars of 
modern medicine, or as differently expressed at the European Economic and Social Committee (EESC) opinion paper: 
“Biomedical Engineering is not simply a subset of modern medicine. Modern medicine predominantly secures important 
advances through the use of the products of biomedical engineering.”1 Health technology, according to the World Health 
Organization (WHO), refers to the application of organized knowledge and skills in the form of devices, medicines, vac-
cines, procedures, and systems developed to solve a health problem and improve quality of life. Therefore, medical devices 
(MDs) belong to health technologies, and radiotherapy (RT) is an important subgroup.
RT refers to high-tech MDs that are of high capital value both in terms of initial investment and operation, requiring specially 
trained personnel for its use and needs regular quality control, preventive maintenance and management procedures, to 
function properly and safely. Clinical engineering plays a major role in facing of the aforementioned challenges.
The present paper provides an overview of the results of an assessment report under the WHO action on Strengthening 
Capacity for Universal Coverage Greece/Phase 2 (SCUC2)2 aiming to:

• Assess the sufficiency and equity in the distribution of RT and its use in Greece
• Identify eventual inequalities in terms of geographical coverage, specific needs and lack of RT
• Assess the current status of staffing in RT units 
• Estimate the costs for the use of high-value capital medical equipment (HVCME)

Since a country-wide medical equipment inventory for Greece does not exist, various sources were used to obtain a clear 
picture of the installed units in public Greek hospitals, and private clinics.
As a result, it came out that, in terms of the number of units per million population the number of RT units rose by 23% 
from 4.3 in 2009 to 5.3 in 2017. In terms of the number of acts, a general increasing trend is noticed, resulting in a total 
cost increase of 25% from 2013 to 2016. 
The analysis revealed that in Greece, there are quite pronounced inequalities in terms of availability of RT technologies 
in different regions. Long term strategic planning is needed based on evidence, such as updated inventory of MDs, acts 
performed, associated costs etc., which are unfortunately lacking in Greece. Additionally, the role of clinical engineers in 
effective management and safe use of this technology should be widely recognized and regulated.

Keywords – Radiotherapy Units, Inventory, Clinical Engineering, Distribution, Greece. 

Copyright © 2021. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY): Creative Commons - Attribu-
tion 4.0 International - CC BY 4.0. The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) 
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.

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29 J Global Clinical Engineering Vol.2 Issue 1: 28-35 ; 2019

Dermitzakis, Domente, Pallikarakis: Distribution and utilization of Radiotherapy Units in Greece

INTRODUCTION
Advances in biomedical research are leading to a storm 

of innovation and the development of new diagnostic 
and therapeutic devices has led to a radical change in 
current healthcare delivery. Modern medicine is strongly 
dependent on technology.

WHO has published a general approach for performing 
a needs assessment based on existing and available equip-
ment in a region or country, comparing it with what should 
be available, considering particular demands and needs, 
and taking account of epidemiological data, recognized 
standards, and Clinical Practice Guidelines. By consider-
ing this alongside with possible financial restrictions and 
the human resources available, the actual technological 
gap can be identified. 

The whole approach is depicted in the general needs 
assessment diagram shown in Figure1.

It is important to note that reliable baseline data on 
the existing situation and evidence-based assessment of 
needs are prerequisites for effective use of such a model. 
In addition to the international scientific and technical 
literature, the standards and best practices in use and 
the current trends on these technologies, the general in-
formation sources for this report are data available from 
international organizations such as WHO; Organisation 
for Economic Co-operation and Development (OECD), 

European Union (EU), National Institute for Health and 
Care Excellence (NICE), ECRI Institute (ECRI), and other 
reliable web sources. 

In Greece, there is no centralized national inven-
tory for installed HVCME, so the relevant information 
and data collected and used in this report are based on 
cross-referenced sources which creates several problems 
associated with data integrity, reliability, and (in some 
cases) compatibility. 

There are also no available data related to the actual 
use of these technologies, except for indirect information 
on those procedures that are reimbursed by the National 
Organization for Healthcare Provision (EOPYY). However, 
these data do not present the whole picture of actual use 
and the associated expenditures since the numbers of 
diagnostic or treatment procedures not reimbursed by 
EOPYY are not known. Furthermore, the rebate and claw-
back procedures applied in Greece due to the economic 
crisis, are resulting to partial cost estimation. 

Finally, several interviews/discussions with medi-
cal specialists in the fields of radiology, RT and nuclear 
medicine; medical physicists; biomedical engineers; tech-
nologists and other specialists provided valuable input. 

Radiotherapy planning and acts, require the collaboration 
of mainly medical doctors and medical physicists, which 
both have a recognized, distinguished, and established 
role in the field. Although RT unit’s state and quality of 
maintenance, play a crucial rule for the overall effective-
ness, safety and quality of the provided health service, 
the intervention of clinical engineers which is of utmost 
importance to achieve these goals, is not yet regulated.

The present assessment report aims to assess the 
sufficiency and equity in the distribution of RT and its 
use in Greece, to identify eventual inequalities in terms 
of geographical coverage, specific needs and lack of RT, 
estimate the associated costs of use and assess the cur-
rent status of staffing in RT units.

MATERIALS AND METHOD
In the present assessment report, due to the lack of a 

concrete set of reliable data, a great number of different 
sources had to be used. Since there is no centralized na-
tional inventory for installed HVCME in Greece, the relevant 

Source: WHO, 2011

FIGURE 1. WHO needs assessment diagram.



Dermitzakis, Domente, Pallikarakis: Distribution and utilization of Radiotherapy Units in Greece

J Global Clinical Engineering Vol.2 Issue 1: 28-35 ; 2019  30

information and data collected and used in this report are 
based on cross-referenced sources from the Greek Atomic 
Energy Commission (EEAE), National Evaluation Center 
of Quality and Technology in Health (EKAPTY), Hellenic 
Association of Medical Physicists (HAMP), Federation 
of Technologists Radiologists of Greece (OTAE) and the 
inventory for medical devices (MDs) performed in 2015 
by the Biomedical Technology Unit of the University of 
Patras under an ESPA [in english NSRF (National Strate-
gic Reference Framework)] project. This creates some 
problems associated with data integrity, reliability, and 
(in some cases) compatibility. 

The data available from international organizations 
(e.g., OECD, WHO) rely also on sources providing the 
information (e.g., EKAPTY, EEAE, professional societies) 
and therefore also present discrepancies in the numbers 
of equipment installed in Greece. These various sources 
were not set up to provide a continuously updated and 
reliable MDs inventory, but for other more specific reasons. 
For instance, the EEAE database (considered as the most 
reliable) focuses on licensing and radiation safety issues 
and does not gather information on the year of manu-
facture or of entry into service. As a result, the database 
does not reflect the actual situation of the installed base 
(i.e., number of units actually in use) of these technolo-
gies at any moment.

Additionally, there are no available data related to 
the actual use of these technologies except for indirect 
information on those procedures that are reimbursed 
by EOPYY. However, these data do not provide the whole 
picture of actual use and the associated expenditures 
since the numbers of diagnostic or treatment procedures 
not reimbursed by EOPYY are not known. Furthermore, 
the rebate and claw-back procedures applied mean that 
EOPYY’s data are also partial. 

Taking into account the various sources of information, 
this analysis focuses on the existing RT installed technol-
ogy as of November 2017. Existing online information 
available at the EEAE website was cross-checked against 
that obtained from the other sources mentioned previ-
ously, duplicate entries were deleted and any new data 
identified were added. 

Data are organized and presented per administrative 
region in which each unit is installed. The administrative 
regions and their populations are shown in Table 1. All 
data are based on the 2011 census.

RESULTS 
The distribution of RT units is very sparse in comparison 

with other modalities and only a few regional sectors have 
these facilities. The distribution of RT units in the different 
administrative regions is shown in Figure 2. Five of the 13 
regions have no RT units – Central Greece, North Aegean, 
Peloponnese, South Aegean, West Macedonia and Ionian 
Islands. Of the 7 regions that have RT units available, only 
3 have units in the private sector. This is expected since 
RT facilities are very expensive, need both dedicated 
infrastructures and specialized human resources, and 
should be linked to cancer diagnosis and treatment facili-
ties. Conversely, RT units in public hospitals are available 

TABLE 1. Populations of Greek Administrative Regions, 2011 
Census

Regions Population

Attica 3.833

Central Greece 547

Central Macedonia 1.882

Crete 623

East Macedonia and Thrace 608

Epirus 336

Ionian Islands 207

North Aegean 199

Peloponnese 577

South Aegean 306

Thessaly 732

West Greece 679

West Macedonia 283



31 J Global Clinical Engineering Vol.2 Issue 1: 28-35 ; 2019

Dermitzakis, Domente, Pallikarakis: Distribution and utilization of Radiotherapy Units in Greece

in all the other 7 regions. Athens (in the region of Attica) 
has the greatest number of RT units.

With a total of 57 RT units available, resulting in a ratio 
of 0.53 units per 100 000 inhabitants, Greece meets EU 
recommendations.3 Of these 57 units, 39 are in the public 
sector and 18 in the private. The exact number and tech-
nologies installed in each region are shown in Table 2. 
It is important to point out that technologies other than 
LINAC (Linear Accelerator) and Co-60 are available only 
in Athens.

FIGURE 2. Radiotherapy units: distribution per 100 000 in-
habitants in each administrative region, 2017.

Source for Fig.2 and Table 2: data from EEAE

TABLE 2. Radiotherapy units: absolute number and number of units per 100 000 inhabitants in each health region, 2017

Health region
Total radiotherapy units Private sector Public sector

Absolute no. Per 100K 
inhabitants Absolute no. Per 100K 

inhabitants Absolute no. Per 100K 
inhabitants

Attica (Athens) 34 0.89 15 0.39 19 0.50

Cyberknife 1 0.03 1 0.03 0.00

LINAC 22 0.57 11 0.29 11 0.29

Co-60 8 0.21 8 0.21

Tomotherapy 2 0.05 2 0.05

γ knife 1 0.03 1 0.03

Central Macedonia 
(Thessaloniki)

11 0.58 2 0.11 9 0.48

LINAC 9 0.48 2 0.11 7 0.37

Co-60 2 0.11 2 0.11

Crete (Heraklion) 2 0.32 0.00 2 0.32

LINAC 2 0.32 0.00 2 0.32

East Macedonia and 
Thrace (Alexandropolis)

2 0.33 0.00 2 0.33

LINAC 1 0.16 0.00 1 0.16

Co-60 1 0.16 0.00 1 0.16

Epirus (Ioannina) 2 0.59 0.00 2 0.59

LINAC 2 0.59 0.00 2 0.59

Thessaly (Larissa) 3 0.41 1 0.14 2 0.27

LINAC 3 0.41 1 0.14 2 0.27

West Greece (Patras) 3 0.44 0.00 3 0.44

LINAC 3 0.44 0.00 3 0.44

Total 57 0.53 18 0.17 39 0.36



Dermitzakis, Domente, Pallikarakis: Distribution and utilization of Radiotherapy Units in Greece

J Global Clinical Engineering Vol.2 Issue 1: 28-35 ; 2019  32

A comparison between Greece and other EU countries 
of similar population is shown in Figure 3. As can be seen, 
Northern EU countries, such as Finland and Denmark, have  
twice as high a ratio of units per 100 000 inhabitants. 
While Portugal and Austria have similar ratios to Greece.

Concerning use and cost, the evolution of the number 
of reimbursed RT acts and the associated reimbursement 
costs from 2013 to 2016 are presented in Table 3, based 
on data provided by EOPYY.

Despite a few fluctuations, the number of RT acts 
remains more or less steady between 2013 and 2016. 
The market share also appears to be almost evenly dis-
tributed between the public and the private sector, with 
a 57/43 ratio. 

The relative distribution of RT acts per 1000 inhabit-
ants per administrative region in 2016 is shown in Figure 
4. This graph shows only the regions where RT units are 
available. 

Central Macedonia and Attica have the highest per-
centages of acts because they compensate for the lack of 
RT facilities in surrounding regions. Some technologies 
(e.g., γ-knife, cyberknife, tomotherapy) are available only 
in Athens. The time evolution of the number of RT acts 
per 1000 inhabitants per region between 2013 and 2016 
is shown in Figure 5.

The number of acts shows an increasing trend in all 
regions where RT units are available, except for Attica 
(Athens) and Central Macedonia (Thessaloniki). These 2 
regions show a steady increase from 2013 to 2015 but a 
slight drop in the number of acts during 2016. This may 
indicate that fewer patients are moving to these cities 
from other regions.

FIGURE 3. Evolution of the number of radiotherapy units per 
million inhabitants: comparison with 4 EU countries, 2009–2016.

Source: data from OECD (other EU countries) and EEAE (Greece)

FIGURE 4. Relative distribution of radiotherapy acts per 1000 
inhabitants in each administrative region, 2016.

Note: regions without radiotherapy facilities are not shown. Source: data 
from EOPYY

TABLE 3. Radiotherapy acts: analytical data, evolution and 
comparison of number of acts, installed units and costs reim-
bursed by EOPYY, 2013–2016.

Year
Number of reimbursed RT acts per year No of 

unitsPublic Private Total

2013 232 574 64% 132 986 36% 365 560 49

2014 248 409 61% 160 617 39% 409 026 50

2015 245 393 58% 174 443 42% 419 836 51

2016 233 892 57% 176 549 43% 410 441 53

Year
Total EOPYY expenditure per year (€)

Public Private Total

2013 18 564 495 50% 18 630 985 50% 37 195 480

2014 19 373 735 47% 21 625 454 53% 40 999 189

2015 19 416 459 44% 24 896 716 56% 44 313 175

2016 18 616 010 40% 27 935 467 60% 46 551 477

RT = radiotherapy; EOPYY = National Organization for Healthcare Provision
Source: data from EOPYY



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Dermitzakis, Domente, Pallikarakis: Distribution and utilization of Radiotherapy Units in Greece

DISCUSSION
In both private and public health sectors, all RT depart-

ments in Greece are licensed according to the national law 
on radiation protection.4 In addition, the EEAE closely su-
pervises the terms of radiation protection and compliance 
with quality and safety regulations for RT treatments. A 
common practice for the lifetime of RT treatment machines 
(8–15 years) does not appear to have changed over the 
last decade. However, in Greece until 2016, the vast ma-
jority of RT equipment (mainly LINACs and Co-60 units) 
in the public sector was more than 15 years old. In 2017, 
this situation changed radically as a result of the Stavros 
Niarchos Foundation donating 10 new LINACs to replace 
old equipment in 7 public hospitals. 

European directive guidance on the important issues 
of accessibility and availability of RT equipment5  is based 
on the corresponding European Society for Radiotherapy 
& Oncology (ESTRO) and European Federation of Orga-
nizations for Medical Physics (EFOMP) guidelines. These 
guidelines, recommend a ratio of at least one RT equipment 
available for every 200 000 to 250 000 inhabitants. Given 
the population of 11.4 million, Greece should have at least 
45 to 50 RT machines and therefore it can be concluded 
that it meets the guidelines on the number of units.

Staff levels in both private and public health sectors fall 
far below European standards and guidelines. The Hel-
lenic Association of Medical Physicists (HAMP) reported 

that the New European Directive 2013/59/EURATOM on 
basic safety standards for protection against the dangers 
arising from exposure to ionizing radiation, includes 
several articles related to the medical physics profession 
and competency requirements (articles 14 and 18). It also 
details the tasks required of experts in medical exposures 
and radiation protection that are pertinent to the roles 
and responsibilities of the medical physicist – namely 
the medical physics expert and the radiation protection 
expert (RPE)6. 

On the contrary, no regulation and guidelines are 
existing concerning the role of clinical engineers inside 
the RT departments. It is well known that maintenance is 
assigned to private companies under maintenance con-
tracts. Although maintenance is crucial for the quality of 
provided health service, unfortunately, no data are avail-
able on the quality of repair or preventive maintenance 
acts, safety checks etc. As for the case of medical physi-
cists, which have a clearly stated role with well-defined 
rules and guidelines, the same should apply for clinical 
engineers, which should be responsible to closely inspect 
and supervise the maintenance procedure and the safety 
status of the RT units.

As reported by HAMP, under-staffing is one reason 
why RT, as the primary treatment for more than 60% of 
cancer patients in Europe and the United States, is used 
to only 30% of cancer patients in Greece.7 As a result, 
health system in Greece is forced to pay for less effec-
tive and more expensive treatments such as surgery and 
extensive chemotherapy.

A structural problem should also be mentioned. The 
fact that most centers have only one or 2 RT units results 
in high overhead costs for the accompanying equipment 
and eventually staff. At the same time, the widespread 
of equipment critically affects a patient’s treatment. 
Currently, 28 LINACs are installed in 15 public-sector 
RT departments in 7 large Greek cities. Of these, 4 have 
only one unit, 10 have two units and only one has 3 units. 
In cities with other public RT departments, single-unit 
RT departments are ineffective in both organization and 
service provided. Reorganization into bigger RT centers 
could produce serious resource savings and improvements 
in the treatment provided. 

FIGURE 5. Time evolution of number of radiotherapy acts per 
1000 inhabitants in each administrative region, 2013–2016.

Note: regions without RT facilities are not shown. Source: data from EOPYY



Dermitzakis, Domente, Pallikarakis: Distribution and utilization of Radiotherapy Units in Greece

J Global Clinical Engineering Vol.2 Issue 1: 28-35 ; 2019  34

Whether used for diagnosis or therapy, a healthcare 
facility should ensure that the equipment is perform-
ing as intended by the manufacturer. Uncontrolled use 
of technology in medicine can result in increased costs 
for the delivery of healthcare services. Hence, it has 
become evident that there is a need to develop proper 
infrastructure for evaluating, supporting and managing 
biomedical technology. Greece lacks reliable information 
related to MDs, including the RT technologies addressed 
in this assessment. Data on the purchase price, annual 
maintenance costs, downtime, and actual use of devices 
are lacking. Evidence-based decisions are impossible 
without adequate data and information and it is impos-
sible to calculate the median age of the installed bases, 
their value, annual service costs and annual use; or to 
estimate potential underuse of the machines or calculate 
incremental costs of corrective actions. 

During the last 3 decades, computerized maintenance 
management systems (CMMSs) for medical equipment 
have been used worldwide, providing all necessary data 
for cost-effective management and evidence-based deci-
sions. Such systems these have been available since the 
late 1980s but installed in just a few Greek hospitals till 
today. CMMSs have multiple advantages, providing a com-
plete and updated inventory at any time, with at least the 
following essential information for each machine – make 
and model, value, annual maintenance costs, weekly op-
erating hours and number of uses. Such a system would 
have made the data collected within this assessment report 
available instantly to the Ministry of Health, avoiding a 
great deal of effort and enabling verification. Addition-
ally, such systems are essential for vigilance purposes, 
evidence-based decisions on replacement, and control 
of service providers (i.e., response time, cost, respect 
of service contract rules) amongst many others, which 
are under the responsibility of the clinical engineering 
departments.

Aggregated data on maintenance costs of RT units in 
the public sector are not available. Most hospitals have 
maintenance contracts with equipment providers but 
these are negotiated on a case-by-case basis and the 
actual costs are not known. As a general rough estimate, 
the assumption of an annual cost of 8–10% of the initial 
equipment purchase price could be used. Maintenance 

and repair issues are becoming more critical as the equip-
ment ages. After the initial few years period during which 
maintenance is usually well-defined in the procurement 
agreement, in many cases price negotiations are under 
the control of manufacturers. 

Additionally, rapid technological developments lead to 
the high-paced introduction of new or improved devices 
and require lifelong learning and continuous training for 
all healthcare professionals. Therefore, necessary means 
and facilitating conditions should be provided to guar-
antee the level of knowledge and skills of staff involved. 
Professional associations should play an important role 
in such procedures, and assessment should become a 
priority for all.

CONCLUSIONS
Lack of a continuously updated inventory means that 

there are no centrally available data concerning medical 
equipment information on maintenance, age and actual 
use of devices. The availability of such data is necessary for 
correct decisions on technology procurement, management, 
and replacement. This information is generally needed to 
estimate potential underuse, identify unjustifiably high 
management costs or calculate incremental costs of cor-
rective actions. Evidence-based decisions are impossible 
without adequate data and information.

Personnel issues are considered to be a problem in 
RT departments and there is a discrepancy between the 
actual number of staff employed (especially non-medical) 
and the number recommended by (already approved) 
EU guidelines. Staffing of RT departments should be 
regulated in line with best practices and guidelines, and 
in accordance with EU regulations and directives. The 
application of these regulations should become a priority. 
Adequate staffing could allow the available infrastructure 
to be fully exploited, resulting in economy of resources 
and better patient treatment, the presence of clinical 
engineers should be regulated. Continuing professional 
development should also be organized in collaboration 
with professional societies to assist personnel in keeping 
pace with recent technological developments.

Improvement of RT investment planning is a critical 
factor for ensuring that healthcare systems are more 



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Dermitzakis, Domente, Pallikarakis: Distribution and utilization of Radiotherapy Units in Greece

cost-effective and able to respond to patient needs in a 
most efficient way. Therefore, RT should be installed and 
used according to well-defined criteria, needs assessment 
analysis and priority settings. Greece should develop its 
Health Technology Assessment (HTA) capacity, as sug-
gested by a 2016 WHO mission on HTA in Greece7. 

The absence of biomedical/clinical engineering de-
partments in most Greek hospitals, is a great obstacle to 
effective and safe management of medical technology, 
resulting in incomplete records and no quality and cost 
control. Maintenance of RT and the relevant costs should 
be followed using modern computerized systems in all 
public-sector hospitals. 

ACKNOWLEDGEMENT
This work was performed under the World Health 

Organization action on “Strengthening Capacity for Uni-
versal Coverage Greece/Phase 2” (SCUC2), carried out 
with funding from the European Union through a grant 
agreement between the European Commission and WHO.

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