Cyprus

In 2019, the total population in Cyprus was 0.9 million. According to Eurostat projections it is projected to increase to 1.0 million in 2070, a 20% increase which is well above the average EU value of 2%.

Demographic forecasts project a near doubling of the share of older persons aged 65 and over, making up 16.7% of the population in 2020 to 31.7% in 2060.

Based on the Ageing Report 2018, total public expenditure on long-term care (health and social part) is, with 0.3% of GDP in 2015, below the EU average in the same year (1.6%).

Cyprus displays all the characteristics of an ageing western society with increasing needs and alarming projections, particularly with respect to dependency ratios. In the period 2019 to 2070, the old-age dependency ratio i.e. the share of the population aged 65 and above as a % of the population aged 20-64 is projected to rise from 243.8% (EU-28: 32.2%) to 65.5% (EU-28: 56.4%), signalling a growing demand for LTC services for people aged over 65.

Life expectancy in Cyprus at 65 for men and women is projected to reach in 2070, 23.8/26.3 years (EU-28: 23.4/26.6) compared to 16.3/19.9 years (EU-28: 18.1/21.5) in 2016. In terms of healthy life years at birth, Cyprus is broadly in line with the EU average with 62.4 years for women and 62 years for men (vs. 64.2 and 62.6 in 2018 in the EU).

Under an assumption of no policy change (and base case scenario), according to the EU Ageing Report 2018, the projected public expenditure for long-term care (LTC) as a share of GDP would rise from 0.3% to 0.6% in the period 2020-2070 (EU-28: 1.7%-3.0%).

Cyprus has still to develop a comprehensive and integrated system of long-term care (LTC). LTC expenditure as a percentage of GDP is among the lowest in the EU member states, resulting in high out-of-pocket payments.

The total LTC expenditure for 2019 accounted for only 0.3 % of GDP, which was far below the EU-27 average of 1.7 %.

More than half of this spending i.e. 54%, was spent on in-kind benefits, which is a much lower share than for the EU as a whole (EU 2016: 84.4%), while 46%, far above the EU average of 15.6% for 2016, was provided as cash-benefits. Thus Cyprus appears to have a stronger focus on cash benefits, which is a consequence of the lack of a formal public long-term care scheme. It is not clear which role private co-payments for formal in-kind care play in the financing of long-term care services. Moreover, the expenditure for institutional (in-kind) services makes up 12.7% of public expenditure on long-term care in-kind (EU: 66.3%) whereas the remaining 87.3% are being spent for long-term services provided at home (EU: 33.7%).

Long-term care (LTC) services consist of long-term health care and long-term social care. Long-term health care is administered by the Ministry of Health (MoH) through the organisation of a system of community nursing, which provides home-based health services to patients with chronic health problems or disabilities. Long-term social care is administered by the Social Welfare Services (SWS) of the Ministry of Labour, Welfare and Social Insurance (MLWSI) through the operation of the Guaranteed Minimum Income (GMI) scheme. In parallel, a wide array of cash or in-kind benefits are provided by the Department for Social Inclusion of Persons with Disabilities of the MLWSI.

In July 2014, the GMI and Social Benefits legislation was adopted and the competent Ministry is MLWSI.

The GMI (Guaranteed Minimum Income) scheme and, in particular, the Social Benefits (Emergency Needs and Care Needs) Decree of 2014, incorporates the Scheme for the Subsidisation of Care Services – which was revised in 2015 (N.353/2015) and in 2016 (162/2016). The new Scheme subsidises the social care needs of GMI recipients, including the members of their family unit. Entitlement to long-term social care is based upon need, i.e. based on the person’s ability to carry out his/her daily home and personal care and his/her ability to meet his/her frequent activities outside of his/her home i.e. shopping, doctor visits, social activities.

This scheme mainly provides cash benefits and, in justified cases, in-kind services. In addition, the SWS operate community nursing homes and provide full-time residential care for the elderly and persons with mental and physical disabilities. It is explicit that only GMI recipients are entitled to long-term social care subsidies, with the only exception being individuals with a severe disability (motor/paraplegia/quadriplegia/blindness) who are entitled to subsidised LTC regardless of their income. The whole system is characterised not only by heterogeneity, but also by lack of comprehensiveness. The subsidisation of LTC is highly targeted, as its recipients are assessed in the context of the GMI scheme

Subsidisation of care services under the Decree covers home care, day care, respite care and residential care in approved and registered care services (natural or legal persons) under the relevant legislative framework of the SWS. Long-term social care services are provided by the government, local authorities, non-governmental organisations (NGOs) and the private sector (private for profit enterprises)

The level of the subsidisation for the various LTC in-kind services i.e. home care, day care, residential care, respite care, is defined by an automated analysis of the specific assessment tools used by the SWS. On the other hand, the provision of public long-term health care is quasi-universal, in the sense that the overwhelming majority of the population is entitled to it, albeit certain population groups remain uncovered.

In addition, two new Decrees were adopted in 2017 (365/2017) and 2018 (158/2018), covering in particular the subsidisation of home care services to persons with disabilities and persons aged 80 years old and above, respectively.

The role of informal care is substantial, with care services provided by spouses/partners, other members of the household, relatives or neighbours − often substituting for inadequate state provision. In many cases, care for frail elderly people (along with other housework duties) is additionally provided by live-in migrant workers/ domestic helpers. Cash benefits are often used by recipients to partly cover the salary of domestic helpers and other care expenses or to make up for income lost as a result of absence from the labour market.

It appears that the very slow rate of development of formal LTC services, is compounded by the existing high degree and dependency on informal care, the relatively “low-cost” solution of live-in migrant workers, and overall  the public sector’s inadequacy. However, a recent reform has been the introduction of the new universal National Health System (NHS) , which entered the second phase of its implementation on 1 June 2020 with the provision of hospital care.

The new system will have a positive impact on long-term health care recipients as it is anticipated to increase access to health services and reduce the financial burden of out-of-pocket payments. The new system envisages universal coverage and an integrated service package that will provide home, rehabilitation, and palliative care, with particular focus on the inclusion of vulnerable groups. The full implementation of the new NHS will be a major step in the right direction. In parallel,  policies and infrastructures will need to be better organised and further developed in areas of LTC services that are currently lagging behind, such as rehabilitation and palliative care, as well as residential and nursing care.

 Two new pieces of legislation for home and community care and residential and day-care are being introduced and are expected to define more clearly the criteria for the registration as well as the qualifications of formal are-givers; the new laws will also address the problem of regular reporting of LTC-related data by all private providers, through a standard form.

Number of carers

There are no official statistics about the number of informal carers in Cyprus. Studies in the field of LTC in Cyprus are scant and subsequently there is little reliable data on the number of informal carers. Nevertheless, recent data show a significant share of informal carers providing care for more than 20 hours per week. By 2050 it is projected that the number of people aged 20-64 (potential informal carers) will fall, whereas the number of people aged 65 and over (potential dependents) will increase, thus posing a threat to the availability of potential informal carers.

Women are often the primary informal carers. Some recent empirical analysis on country-specific data has been able to show that:

• the presence of household members with disabilities appears to have a negative and statistically significant effect on female employment.
• a similarly strong and negative effect is estimated to be exerted on female employment by the existence of family members in bad health.
• the same cannot be said concerning the negative effect on female employment and the presence of very elderly people (over 80), which seems to be statistically insignificant.
• live-in domestic workers have a strong positive and statistically significant effect on female employment.

More generally, it appears that in Cyprus, live-in migrant domestic helpers/workers are included under the category of informal carers, despite the fact that they offer paid services to the households. The reason for including them in the informal care sector is that their services are more similar to the type of informal care provided by family members and less comparable to services provided by qualified LTC professionals.

Recognition and definition of carers

Overall, one of the main challenges in Cyprus is the need to establish policies that recognise and support informal carers. Under the GMI scheme which gives access to subsidised LTC services and cash benefits, informal carers needs are also recognised along that of the care recipients.

Multisectoral care partnerships

Ensuring coordination and continuity of care is one of the main challenges of the LTC sector in Cyprus. A future priority is to establish better coordination of care pathways along the continuum of care such as through a single point of access to information, the allocation of care coordination responsibilities to providers or to care managers, via dedicated governance structures for care co-ordination and the integration of health and care to facilitate care co-ordination. An important future goal will be to invest in ICT as an important enabler for care management and coordination.

Carers’ mental and physical health

As mentioned, the social protection system places more emphasis on cash benefits rather than on in-kind benefits. However, carers and, in general, families with dependent members may benefit from various services, such as community nursing provided by the MoH through the network of General Nursing Community Nurses and Mental Health Community Nurses, which provides home visits to mentally ill patients, disabled people, artificially ventilated patients, and elderly people who live alone and encounter severe health problems. In this context the main services offered, among others, which may also go some way in supporting carers’ mental and physical health, notably include:

• provision of care to ill or disabled people;
• provision of specialised interventions to vulnerable groups;
• precautionary measures for curbing the effects of an illness;
• psychological support to families under acute stress.

Access to respite care

Respite care is temporary/short-term care of a person which allows the informal carer to have a holiday/a break from their care responsibilities. The service supports informal carers in their valuable role and simultaneously helps the person stay in their home. Respite care can also be requested by people who live alone and occasionally feel unable to look after themselves and require help. Respite care is arranged depending on the needs and preferences of the people themselves and of their families as far as possible; and it is provided through the above types of care (home, institutional or day care).

In order to claim subsidisation of their care needs, interested persons should complete and submit an application for the Guaranteed Minimum Income with the supplementary forms for the care of GMI beneficiaries (EEE10.v2 and EEE11.v2). Persons who are already recipients of GMI and have care needs should complete and submit the supplementary form for the care of GMI beneficiaries (EEE10.v2 and EEE11.v2).

Training and recognition of carers’ skills

Since informal care occupies a dominant position in the provision of LTC in Cyprus, it is suggested that a scheme for the compulsory training or up-skilling of informal carers (family members, next of kin and migrant domestic helpers) should be introduced in order to ensure that this type of LTC (largely unregulated and hard to monitor) is provided by adequately qualified individuals. Currently appropriate and targeted training programmes are only provided on an ad hoc basis, and at the discretion of community nurses or SWS officers. Routine one-on-one training of informal carers is provided by nurses, social workers, and other healthcare and social care professionals during home visits, covering basic caring skills (personal care and hygiene, and specific medical care). Mental health and community mental health nurses provide education to family carers in managing symptoms of mental illness, medication, coping and psycho-education.

Service provision from community nurses may include training and counselling to patients and their carers in regard to health issues and for dealing with certain urgent situations (e.g. instructions for medical uptake, personal hygiene, nutrition and other specialised medical knowledge).

Identification of carers and assessment of their needs

Identification and assessment of carers’ needs are formally assessed in the context of the GMI scheme, which sets out concrete and measurable criteria regarding the eligibility of the benefits paid to GMI recipients (i.e. the care recipient), following a rights-based approach. LTC-related benefits in Cyprus are highly targeted, therefore only a rather small proportion of the population (i.e. families satisfying the income and asset criteria of the respective GMI legislation) are covered by them. Depending on the specific case and needs, care recipients who meet the scheme’s criteria are potentially entitled to the following types of care i.e.: home care, residential care, day care and respite care for the informal carer.

The Social Welfare Services (SWS) perform in situ visits to the accommodation of the applicants/beneficiaries to assess the need for care with the use of specific assessment tools. The SWS may ask for additional certificates/reports from other Services (including medical reports). Subsequently, the information collected is assessed by Specialised Assessment Teams of the SWS. In case of a positive evaluation of the care needs of the applicant/ beneficiary which corresponds to the approval of care provision, it includes the type, the extent and the duration of the care that will be provided as well as the amount of subsidisation. Between the beneficiary and the approved service provider an Agreement for the Provision of Social Care is signed, which should be notified to the SWS for the correctness of the content and for the future quality checks of the service provision. In case the beneficiaries prefer a different type of care than the one proposed, then they have the right to make their own arrangements, which will be subsidised up to the approved amount.

Access to information and advice

An unmet need in the LTC sector is to establish good information platforms for LTC users – be it for care recipients and/ or their informal carers. An important future goal will be to invest in ICT as an important source of information also for informal carers

Community nursing provided by the MoH through the network of General Nursing Community Nurses and Mental Health Community Nurses, which provides home visits to care dependent persons, offer services such as further information on benefits and services provided by the state and the community.

Social inclusion of carers, access to education and employment

Cyprus does not have care-specific leave schemes and flexible time arrangements for carers. Employment legislation provides very few special arrangements for employees with caring responsibilities. However, it should be clarified that the law defines a minimum threshold of rights to these employees: arrangements agreed on an individual or collective basis that are more generous to them are not excluded. Such arrangements include annual, maternity and parental leave.

Parental leave legislation has a special provision for parents of children with disabilities: leave is available to parents of children up to the age of 8 years, but this age threshold increases to 18 years if the child suffers from a disability.

Employees with dependent relatives can also make use of leave on the grounds of force majeure. According to this leave scheme, the employee is entitled to seven days of unpaid leave each year on the grounds of urgent family reasons that include sickness, accident or similar emergencies befalling a relative of the employee. The leave may be taken over a single or several time periods.

Cash benefits for carers

In July 2014, the Cyprus Government reformed the welfare system by introducing a Guaranteed Minimum Income (GMI). In the relevant Law (N. 109(I)/2014), article 10 (2) refers to the care needs of the GMI recipients and their family members, where additional assistance can be provided. In this direction, the Minister of Labour, Welfare and Social Insurance, issued in August 2014 a Decree that incorporates the “Scheme for the Subsidisation of Care Services”, which was revised in 2015 (N.353/2015) and in 2016 (162/2016). The new Scheme subsidises the social care needs of GMI recipients, including the members of their family unit.

Other than the LTC-related (subsidised) benefits provided in the context of the GMI scheme, and the possibility for accessing a non-means-tested disability benefits are given to the families of disabled people, women who have dropped out of the labour market, for whatever reason including caring responsibilities, may be entitled to a social pension. Although these LTC benefits are usually non-taxable, there are no special tax credits, tax incentives or reductions for families with caring responsibilities.

A challenge for the LTC system in Cyprus is to establish policies to support informal carers, such as through flexible working conditions, carer’s allowances replacing lost wages or covering expenses incurred due to caring, cash benefits paid to the care recipients, while ensuring that incentives for employment of carers are not diminished and women are not encouraged to withdraw from the labour market for caring reasons.

• The 2021 Long-Term Care Report, Trends, challenges and opportunities in an ageing society, EC 2021
• The 2018 Ageing Report, Economic and Budgetary Projections for the EU Member States (2016-2070), EC, 2018
• Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability, Cyprus EC, 2019
• ESPN Thematic Report on Challenges in long-term care – Cyprus, EC, 2018
• ESPN Thematic Report on work–life balance measures for persons of working age with dependent relatives, Cyprus, 2016
• European Commission, DG EMPL – Your social security rights in Cyprus, 2020, https://ec.europa.eu/social/main.jsp?catId=858 – Last accessed 25/09/2020