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The European voice for informal carers

GREECE

Towards carer-friendly societies
Demographic background

In the period 2019-2050 the share of people aged 65+ in the Greek population is expected to grow from 22% to 33.8% (EU-28: 20%-28.5%), with most of the growth happening before 2032. At the same time, the share of people 85+ will more than double from 3.3% to 7% (EU-28: 2.7%-6.1%).

Over the same period, the old age dependency ratio measured as the percentage of 65+ compared to the population of 15-64-year olds will rise from 34.1% (EU-28: 30.5%) to 67.1% (EU-28: 55.3%).

Life expectancy for men and women at age 65 is projected to rise from 18.6/21.4 years (EU-28: 18.1/21.4) in 2017 to 22.6/24.6 years (EU-28: 22.4/25.6) in 2060. From 2005 to 2012 healthy life expectancy for men and women decreased by 1.1 and 2.7 years, respectively. Recent trends (2013 to 2017) indicate a stagnation in healthy life expectancy for both women and men at age 65. Greek women spend about two thirds of their life expectancy (at 65) in bad health while men spend more than half of it in bad health.

According to EU-SILC data, the share of men aged 65+ experiencing severe limitations in daily activities increased from16% to 22% from 2005 to 2011 (EU 27 rose from 16% to 17%). Among women the share increased from 17% to 26% (EU-27: from 20% to 21%). This, combined with the medium to long-term effects of the crisis on public health due to harsh cuts in public health care expenditure, increasing fees and co-payments, together with a rapidly growing number of people with no access to health care may have a serious impact on future disability and the demand for LTC in Greece.

Under an assumption of no policy change the Ageing Report scenario suggests that public expenditure as share of GDP would rise from 1.4% to 2.8% (EU-27: 1.8%-3.6%) by 2070. The impact of a progressive shift from the informal to the formal sector of care in Greece would entail an estimated increase by 121% in the share of GDP devoted to public expenditure on long-term care (128% on average for the EU27).

Current Long-term care provision

There is no universal statutory scheme for Long-Term Care in Greece. Social insurance funds provide disability pensions and allowances. Other (non-contributory) disability benefits (in cash and in kind) are provided by social welfare institutions to persons who are in need of care because of a specific chronic illness or incapacity. According to 2011 administrative data (referred to in OECD 2013), about 60% of disability benefit recipients (either insurance or assistance-based) were above 50 years of age.

Depending on invalidity levels (of 50%, 67% or 80%) and the type of chronic illness, recipients are entitled to different levels of care provision. People with serious incapacity (e.g. quadriplegics) who are not in institutional care are entitled to non-residential care benefits that can be used to pay professional providers and informal carers. The degree of incapacity is evaluated by the Centres for Certifying Incapacity (KEPA). Legislation passed in 2011 disbanded all centres operating at the level of prefectures and brought the certification process under the authority of IKA (the Social Insurance Organization).

In 2010 public spending on institutional care was negligible (0.13% of GDP; EU-27 average: 0.80%), while spending on home care and cash benefits amounted to 1.27% (EU-27 average: 1%). The same year, 12% of people aged 15 years and over in need of long-term care were in institutional care, 28% in home care, and 60% either had no access to care or were looked after by informal carers.[1]

Public nursing homes for the chronically ill are financed by the state budget and by per diem fees paid by social insurance organizations. In addition, according to recent legislation, 40% to 80% of the pension income of the chronically ill in state residential care (including psychiatric hospitals) is withheld by social insurance organizations for funding care expenses. Although there are not clearly designated long-term care beds in public hospitals, it is estimated that the number of long-term care beds in Greece is very low (i.e. 27.7 per 100,000 population, including psychiatric care beds); or 1.4 per 1,000 people aged 65+). A number of private clinics under contract with EOPYY, the National Organization of Health Service, provide long-term care (mostly to the terminally ill), but no data are available for the number of long-term care beds in these clinics.

The state provides residential care to indigent, lonely aged people in need of care through the 25 Chronic Illness Nursing Homes. Yet only three of them (two in Northern Greece and one in Crete) have a geriatric section. Long-term care to frail, incapacitated (mostly lonely and indigent) elderly people is also provided by about 100 non-profit residential care homes. The majority of them are run by the Church of Greece, and the rest are run by specific endowments and some local authorities. There are also about 100 for-profit residential homes for the elderly. In total, non-profit and for-profit residential care homes for the elderly have a capacity of about 15,000 beds. The former are partly subsidized by the state and partly funded by donations (as well as by per diem fees paid by social insurance organization for those entitled to social insurance). For-profit residential homes are privately paid by the persons in care and their families. Interestingly, over the last few years occupancy has significantly fallen from 100% to about 80%. Due to the crisis and economic hardship, families opt to look after the elderly at home as pension benefits are a major source of income particularly among households with unemployed members.

Semi-residential, day-care to the elderly is provided by the 68 Day Care Centres for the Elderly (KIFI). They undertake the day care of old-aged people who cannot care for themselves, have serious economic and health problems and their family members cannot look after them because of their work. Since their establishment they have been funded mostly by EU resources. According to current regulations, they are co-funded by the European Social Fund and national/local budgets. KIFI cooperate with local social and health services as well as with the welfare directorates of the regional units (ex-prefectures) of the country.

The “Home Help” programme, which provides access to social workers, nurses, physiotherapists and home helps, was introduced as a pilot in 1998 and was later on expanded to cover most of the country. As with the day care centres, it has been mostly funded thanks to EU funding. There are currently about 879 “Home Help” schemes providing services to about 76,000 beneficiaries.

Competition between providers is encouraged as, apart from the schemes operated by municipal enterprises, non-profit and for-profit “Home Help” units are invited to submit bids to be included in the registry of certified services administered by the Social Insurance Organization (IKA). Beneficiaries can then choose a provider from that list. It is nevertheless expected that state funding to municipal “Home Help” will be discontinued. The option offered to those working in municipal schemes is to form “social cooperatives” and submit a bid to be recognised as an accredited provider under the new, competitive system.

Accreditation of institutions providing care to elderly chronically ill and incapacitated persons is carried out for non-profit and for-profit elderly nursing homes and care centres by the Directorate of Welfare of the Ministry of Labour, Social Insurance and Welfare. Regular inspections of both state and non-state institutions also take place by the health inspectorate services of the Ministry of Health.

Access to residential care (care centres for the chronically ill and nursing homes for the elderly) is means-tested, but criteria are applied in a more flexible way than for “Home Help”. Admission to state-operated care centres for the chronically ill and to contracted non-profit and for-profit clinics are subject to referral by the social services of local authorities, of “regional units” (ex-prefecture level social welfare directorates), and of the NHS hospitals. However, existing legislation does not define a specific income threshold. It rather stresses that economic hardship is a crucial criterion, but other factors defining the severity of need should be taken into account too in the evaluation of each specific case.

Prevention measures and promotion of independent living among the elderly are rather neglected policy areas (as are also public health and health promotion). Moreover, over the last few years the combined effect of cuts to benefits and rapid increases in co-payments for medical devices and materials of vital importance for the chronically ill place a heavy burden on low-income pensioners.

In a nutshell, there are currently no comprehensive universal formal LTC services in Greece. Existing services are addressed to the neediest, poorest people. Care for the chronically ill (either in state residential units or contracted non-profit and for-profit care centres and clinics) hardly covers the demand due to an insufficient number of beds, the low rates paid by social insurance organizations, and a rapidly shrinking public budget. Private insurance for LTC is negligible and the cost of private residential care, by those who can afford it, is met by out-of-pocket payments.

[1] By 2060 it is projected that a little over 50% of the population 15+ will have no access to formal “Home Care” or institutional care.

Carer-friendly policy environment

Number of carers

34% of the Greek population, more than 3,600,000 people

Although official data about the prevalence of informal care in Greece is scarce, the number of informal carers as estimated by Eurofound (EQLS 2016) amounts to 34% of the Greek population, or more than 3,600,000 people.

Identification of carers and assessment of their needs

Greece continues to suffer from a lack a clearly formulated strategy and policies regarding the regulation of informal care and the support of informal carers. Indeed, there are currently no provisions concerning in-kind benefits and in-cash support for carers. There are no benefits such as cash, pension credits/rights or allowances to compensate informal carers for the care services they provide. By and large, family carers in Greece are primarily viewed by the state as a resource and their own needs are hardly considered.

The only support services available to carers are those provided by a small number of NGOs, operating mainly in Athens and other big cities and offering – among other things – information, practical advice, psychological/emotional support and training. Most of these services target informal carers of persons suffering from specific diseases, such as dementia or Alzheimer’s disease and – to a lesser extent – blindness and cancer. It is rather evident that the capacity of such services can hardly meet the numerous needs of carers across the country (although no actual data is available to support this).

Recognition and definition of carers

None of the relevant laws includes a definition of the ‘informal carer’ as a distinct category. Instead, the first work-life balance law in Greece (L.1483/19849) provided an indirect definition of carers by describing four categories of dependent relative (Ntalaka, 2014):

  • Children up to 16 years old,
  • Children more than 16 years old who suffer from a serious or long-term illness or disability
  • Husbands/wives who suffer from a serious or long-term illness or disability and are unable to care of themselves; and
  • Parents or non-married brothers/sisters who suffer from a serious or long-term illness or disability, are unable to care of themselves, and whose annual income does not exceed that of an unskilled worker (whose monthly income equals to 25 times the minimum daily wage).

Multisectoral care partnerships

As already noted, there is a shortage of public long-term care services, which implies that the number of personnel engaged in the provision of formal long-term care is likely to be very limited (though relevant official data are not available). Apart from the fact that long-term care in Greece relies heavily on informal care services, it appears that the job of professional carer has received any recognition yet. Due to the traditional central role of the family as a provider of elderly care, and to financial hardship and the lack of supporting private provision, families are increasingly resorting to the use of migrant carers. These are typically hired to look-after the elderly and often live with them, providing 24-hour care, and they are entirely financed by the patient or his network (undeclared work).

References
  • The 2018 Ageing Report, Economic and Budgetary Projections for the EU Member States (2016-2070), EC, 2018
  • ESPN Thematic Report on Challenges in long-term care – Greece, EC, 2018
  • Informal care in Europe – Exploring Formalisation, Availability and Quality, LSE consulting, 2018
  • ESPN Thematic Report on work–life balance measures for persons of working age with dependent relatives, Greece, 2016
  • Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability, EC, 2016
  • Adequate social protection for long-term care needs in an ageing society, European Commission, 2014
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