Marios Kantaris, Health Services and Social Policy Research Centre, Cyprus

Cyprus has all the characteristics of an ageing western society, including an expected significant increase in Long-Term Care (LTC) needs in the coming decades. Expenditure on public long-term care is among the lowest in the EU-27. Only a small proportion of people in need of LTC receive it under formal arrangements, which means low coverage and/or inadequacies and a very high burden on informal carers [1]. Furthermore, Cyprus has yet to develop a comprehensive and integrated LTC system. Currently, LTC services are provided by the public, private and community sectors and non-profit organisations, with informal care playing a very important role. Within the framework of national social policy, LTC focuses on supporting persons who need assistance due to old age and physical or mental disability.

The current LTC system is highly fragmented and divided into two different areas, one under the Ministry of Health and the other under the Social Welfare Services under the Deputy Ministry of Social Welfare. The Ministry of Health is responsible for the administration of LTC policies and measures, while the Deputy Ministry of Social Welfare is responsible for the governance of the social protection system and the administration of most LTC benefits in cash and in kind by the Social Welfare Services. There is room for improvement in communication and coordination between the two ministries when it comes to identifying and meeting LTC needs, establishing effective monitoring and setting priorities to promote quality and improve the delivery of LTC services in general.

The introduction of the General Health System (GHS) with universal coverage in 2019 was a landmark reform for health and social care in Cyprus and can be seen as a good opportunity for LTC services, as this system currently includes home care (only general nursing care) and several services related to LTC, such as physiotherapy, occupational and speech therapy. However, these LTC related services are still part of the healthcare system and do not serve the purpose of a comprehensive LTC system and do not fully address the needs of persons seeking LTC [1].

Public LTC expenditure as a percentage of GDP is among the lowest in the EU Member States, resulting in high Out-Of-Pocket (OOP) payments. Total public expenditure on LTC (health) amounted to only 0.32% of GDP in 2021 (the EU-27 average is 1.74%) and public expenditure on LTC (social) amounted to 0.09% of GDP. Both long-term health and social care are financed by general taxation. In 2021, the share of total health expenditure on LTC (health) was 3.32%, which is also very low compared to the EU-27 average of 16.02%. In the same year, the share for home-based LTC (health) was 1.93% (EU-27, 5.96%) and for inpatient LTC (health) 1.06% (EU-27, 9.48%). Although the share of OOP payments in total LTC expenditure is unclear, given the low coverage, it can be expected to be quite high, and that informal care reaches a very high level.

The Guaranteed Minimum Income[1] (GMI) and, more generally, the Social Benefits Decree of 2014 – incorporates the Scheme for the Subsidisation of Care Services, which covers the social care needs of GMI recipients and their family members. The Scheme mainly covers cash benefits and, in justified cases, in- kind services. In 2022, approximately 10% of the dependent population (EU-27 approximately 32%) were covered by cash benefits, with a relatively small percentage of the estimated dependent population (approximately 25% in 2022; EU-27 approximately 35%) receiving LTC services (home and institutional) [4].

[1]The GMI provides a minimum income allowance to every low-income person or household that meets certain criteria, with the aim of guaranteeing a minimum standard of living.

Currently, the quality framework for LTC is weak and inadequate (insufficient inspection and auditing of infrastructure, providers, and quality of LTC), mainly due to the lack of a co-ordinated national strategy and action plan and the high share of informal care and private care with out-of-pocket payments. Complaints about the provision of LTC can be made to the Social Welfare Services and the police, while service users can also turn to independent bodies, such as the Commissioner for Administration and the Protection of Human Rights and, following the inclusion of home care and some aspects of rehabilitation care in the GHS, to the Commissioner for the Supervision of the GHS («Επίτροπος Εποπτείας του ΓεΣΥ»).

The lack of a national body responsible for LTC and the quality of services provided (promoting person-centred and integrated approaches) and the fragmentation of services between the Ministry of Health and the Social Welfare Services is also a problem that needs to be addressed to improve the current situation. The inclusion of rehabilitation and palliative cancer care services in the GHS in January 2023 has set the stage for better monitoring of the delivery of these LTC-related services, through the financing monitoring mechanisms and policies, and quality-of-service delivery monitoring frameworks, established by the Health Insurance Organisation. The lack of a law regulating the operation of rehabilitation centres is an additional significant obstacle, as it already affects the rehabilitation services provided under the GHS: the Health Insurance Organisation cannot enter into agreements with all rehabilitation centres operating in Cyprus as they do not have the necessary permits. The lack of a basic legal framework for homecare and the outdated legal and regulatory framework that currently applies to residential care are not helpful in formulating clear criteria and drawing sound conclusions about the quality in LTC in Cyprus and how it could be explicitly defined. The current weaknesses and deficiencies of the existing system are expected to be addressed with the introduction of new, modernised legislation, incorporating quality criteria and indicators. However, 2024 marked the fourth year in which the aforementioned legislation was expected to be discussed in the Cypriot Parliament and to be approved and passed into national law. The long delay in modernising legislation allows for a state of weak regulation and poor monitoring.

Overall, the lack of an integrated LTC system in Cyprus and the fragmentation of services do not help to ensure quality at a satisfactory level. Therefore, under the current conditions, it is not only difficult to ensure quality but also to identify and record quality needs.

Finally, the lack of a general quality framework for health and social care is mainly because LTC services are provided by different public and private institutions, as well as non-governmental organisations and local authorities, between which there is insufficient coordination and cooperation. There are no other types of mandatory or voluntary accreditation and certification schemes for LTC providers [5].

For more than a decade, the Cypriot state has been committed to the deinstitutionalisation of long-term care services while strengthening and empowering community care and home care services. Prior to the introduction of the GHS, this was initially implemented by the community nursing services of the Ministry of Health and after 2020 with the inclusion of home care (basic nursing care) by contracted providers from the public and private sectors in the new healthcare system. Currently, the Deputy Ministry of Social Welfare and the Ministry of Health are overseeing this approach as part of the National Strategy and National Action Plan for the Third Age and the Social Policy Strategy 2022-2027.

Home care services are provided as part of the GHS but do not fully meet the needs of people who require LTC. These home care services cover basic care, such as personal hygiene and care for bedsores. In addition, the scope of services is limited to the number of visits, which in turn does not meet the needs of long-term care and burdens households with increased private payments. At the same time, home care and day care services are also provided by organised patient groups of a non-profit/charitable nature (e.g. cancer patients) and by local municipal and community authorities. In addition to basic care, these services also include psychological support, physiotherapy and occupational therapy and are generally affordable for recipients. Informal care plays a dominant role in Cyprus, with the family structure remaining the main source of support and care, especially from spouses and children. An important role in the provision of informal care has also been played for almost four decades by female migrant domestic workers, who are employed on special contracts and whose main tasks also include cleaning and organising the household.

The national strategy for disability for 2018-2028 recognises that there is much room for improvement in services for persons with disabilities in Cyprus [2]. The department responsible for monitoring progress in the implementation of this strategy is the Department of Social Inclusion for Persons with Disabilities. In November 2022, the Deputy Ministry of Social Welfare announced the allocation of €13 million as the implementing body for axis 5 (labour market, social protection, social welfare and inclusion) of the Cyprus’s 2021-2026 Recovery and Resilience Plan. This Plan investment concerns the creation of housing structures for persons with disabilities and those in need of care. The aim is to strengthen assisted living in the community for persons with disabilities as part of the implementation of the already established goal of gradual deinstitutionalisation and social integration. The implementing agency is the Department of Social Inclusion for Persons with Disabilities, and the targets announced are for the creation of at least 18 structures, with the first nine by the end of 2024 (total completion is scheduled for the end of 2026). The investment includes financing of the construction and equipment costs.

The role of residential rehabilitative care has for many years been assigned to care homes which function primarily as a place of residence and care for people of advanced age, but also for a number of people who require long-term care either due to rehabilitation or due to an inability to care for themselves. Most care homes/older people homes are private/for-profit, but there is a small number of municipal or non-profit and charitable institutions subsidised partially by the state. There is only one residential rehabilitation centre in Cyprus, which is accredited as such by the Health Insurance Organisation and therefore can be contracted with the GHS.

The recent Covid-19 pandemic has highlighted the need for more effective control and monitoring and modernisation of the legal framework. Since 2021, the passing of a bill is pending regarding the creation of a framework for the operation of rehabilitation centres and palliative care centres, which will define quality criteria for facilities and staff. The Deputy Ministry of Social Welfare is also planning the revision and modernising the legislation for care homes to improve the level of care in terms of both the facilities and the personnel who staff them.

In December 2024, the Republic of Cyprus launched a public consultation for the preparation of a National Strategy and Plan for Active Ageing 2025-2030, which lasted until January 2025. This strategy recognises, among other things, the great need for access to affordable and quality LTC services for the older people in Cyprus. The vision of the National Strategy for Active Ageing is social inclusion, healthy ageing, the activation of older people and the promotion of issues of diversity and inequality towards older people. At this stage and after the public consultation, it is being processed by the relevant Deputy Ministry of Social Welfare.

In recent years, significant progress has been made in promoting independent and assisted living for people with disabilities and care needs. The Department of Social Inclusion of Persons with Disabilities also operates the “Scheme for Financial Assistance for the Purchase of Technical Means, Instruments and other Aids of Persons with Disabilities” (e.g. personal computers, special or adapted software programmes, mobile phones, communication aids, mobility aids, etc.) to support persons with disabilities in various aspects of their daily lives. In addition, special monthly allowances are available for people to receive any type of personal care and assistance of their choice.

Most formal care providers are nurses and other rehabilitation professionals such as physiotherapists, speech, and occupational therapists. Several universities in Cyprus offer undergraduate and postgraduate courses in nursing and various specialisations such as community and mental health nursing, physiotherapy, speech therapy and occupational therapy. There is currently a severe shortage of qualified nurses in Cyprus.

The high level of informal care resulting from the lack of coverage and limited-service availability of the LTC system and the highly targeted subsidisation of LTC is leading to migrant domestic helpers providing informal care and, in many cases, spouses, family members, close relatives or next of kin who feel morally obliged to provide informal care. Moreover, it can be said that the norms of family obligation and reciprocity have, over time, created an anti-reform trap for the welfare state: The prevalence of informal in-kind or cash transfers within households prevents the decisive political mass that would be necessary to initiate far-reaching structural reforms in the field of LTC. In recent years and following the introduction of the European Pillar of Social Rights in 2017 (Principle 18 on LTC) and the reinforcement of the need for measures and actions by EU Member States, there has been a growing momentum in Cyprus towards much-needed LTC reforms (Cyprus Recovery and Resilience Plan 2021-26). Finally, unlike other EU countries, Cyprus has no specific leave arrangements for care and no flexible time arrangements for carers. The formal workforce providing LTC services covered by the GHS is well-qualified, with employment conditions that can be considered satisfactory.. However, this is not always the case for the private providers of residential care (care homes), which still operate under a weak legal framework. In the last ten years, more private providers of residential care have emerged. However, it is not known whether they employ sufficiently qualified formal carers. LTC professionals employed by public providers enjoy much better working conditions and salaries compared to LTC professionals employed by private providers (especially private residential care providers) [6].

The Cypriot government has repeatedly called for participation in training programmes to train the unemployed and provide them with the knowledge and skills to care for people with LTC needs. The Ministry of Health and local authorities have made similar attempts in the past to qualify and train informal carers. The draft law on the regulation of residential and palliative care, set to be passed, will define specific quality frameworks for providers by setting minimum quality standards, including staffing levels, professional composition, and qualification requirements.

Data information systems are very weak, data collection is fragmented and interoperability and communication between different stakeholders and providers is rather non-existent. Data related to long-term care is primarily collected and maintained by the social welfare services of the Deputy Ministry of Social Welfare, the Ministry of Health, the Health Insurance Organisation responsible for the administration of the GHS and private providers (residential care and specialists). The granularity of the data depends on the systems and operating procedures used by the providers. A positive development in this regard was the introduction of the electronic patient record in 2019 for beneficiaries receiving healthcare services from the GHS, which includes homecare (basic care) and some aspects of rehabilitation[1] medical care (neurological diseases, multiple traumas and cardiac surgery cases. This information system contains information on access to care and utilisation and can be used by beneficiaries, care providers and the health insurance organisation to evaluate the service provided by the GHS.

[1] In the absence of legislation regulating the operation of rehabilitation centres and the provision of said services, the Health Insurance Organisation was forced to introduce residential (medical) rehabilitation services, allowing the conclusion of a relevant contract with providers who have a license to operate a hospital and satisfy the additional requirements/criteria set by the organisation for the services in question.

The introduction of the GHS, a health system with universal coverage, and the inclusion of homecare and, gradually, rehabilitation and palliative care are benefiting people in need of LTC. However, the coverage (number of visits and types of conditions) provided by the new national health system is limited as it is not designed as a long-term care system.

As part of the restructuring of the social welfare services of the Deputy Ministry of Social Welfare, the institution of the “neighbourhood social worker” was introduced in 2023, which aims, among other things, to facilitate citizens’ access to social care services, including long-term care, in cooperation between social care services and local authorities (municipalities and communities) by deploying frontline social workers to identify and assess the need and to facilitate the access and use of all forms of social support and thus contribute to the reduction of social exclusion and the early prevention of current social problems.

The current LTC system is rather fragmented and divided into two different areas, one of which is the responsibility of the Ministry of Health and the other that of the Deputy Ministry of Social Welfare. In addition, there is a need for enhanced communication and coordination between the two ministries regarding the identification and fulfilment of LTC requirements. This includes establishing effective monitoring mechanisms and prioritising initiatives to promote quality and improve the provision of LTC services in general.

With respect to the coverage, it is inadequate and problematic as there is no comprehensive LTC system in place. The introduction of GHS, a system of universal health coverage based solely on residence has improved the coverage of aspects of some LTC health services such as nursing homecare, physiotherapy, speech therapy and medical rehabilitation. Direct private payments (out-of-pocket) for LTC are, as might be expected, very high and not easy to quantify, and it is fair to say that LTC expenditure can place a significant financial burden on individuals and households. In addition, informal care from spouses and close relatives and friends takes up a considerable amount of time and expense, which in turn has a negative impact on them as carers [1]. The Guaranteed Minimum Income scheme, introduced in 2014 and overseen by the Deputy Ministry of Social Welfare, is the main framework that provides social protection in the form of cash and in-kind benefits for low-income beneficiaries and persons with disabilities, provided they fulfil certain criteria. There are complaints from organised patient groups about the effectiveness of the GMI scheme in meeting the needs of persons with disabilities and about the methods and procedures used in the assessment and reassessment of disabilities. Concerns are also expressed about the level of social protection (eligibility and adequacy) afforded to individuals and low-income households given the strict criteria that must be met to qualify for cash and in-kind benefits [1].

The COVID-19 pandemic has been a severe test of the resilience of the current system of long-term care, especially in care homes (residential care). In November 2020, during the second major wave of the pandemic in Cyprus, a significant increase in infections in care homes (mainly for older people) was observed among residents and staff. During this period, more than 50% of deaths from COVID-19 recorded nationally, occurred in these care homes and mainly affected older people and people with multiple comorbidities [7]. As a result, the Ministry of Health of the Republic of Cyprus, in collaboration with the appointed National Scientific Advisory Committee and in close cooperation with the Deputy Ministry of Social Welfare and the care home administrations, planned and implemented a policy response. The main objective of the policy response was to stop the spread of infections, improve epidemiological surveillance and control and enforce more comprehensive monitoring of LTC facilities that house and care for a particularly vulnerable population at high risk and susceptibility to COVID-19. Considering the fragmentation of LTC services, the weak oversight and monitoring of care home providers and the lack of coordination and cooperation between key stakeholders, this policy measure has proven to be a remarkable example of how the care and support system in Cyprus should be approached and managed, as it has managed to monitor, control and significantly reduce the number of deaths in care and support facilities. The mapping of needs and capacities fostered co-operation between the three stakeholders involved in the intervention and contributed to the creation of protocols and standard operating procedures that were implementable and considered the specificities of each care home in terms of buildings, staff and financial resources.

The fragmentation of LTC and the rather weak legal framework were two obstacles that were overcome due to the Ministry of Health and the Deputy Ministry of Social Welfare, under the leadership of the former, quickly joining forces and opening channels of communication. The care home administrations soon joined in and welcomed this initiative given the epidemiological situation at the time. The mapping of needs and capacity further developed the collaboration between the three actors involved in the measure and contributed to the creation of protocols and Standard Operation Procedures that were implementable and considered the specificities of each care home in terms of buildings, human and financial resources.

There are two fundamental bills to regulate and modernise the framework for homecare and residential care awaiting enactment since 2020. There is currently no other formal agenda or explicit reform plan for LTC to create a more coordinated and integrated system for high-quality LTC services. The lack of a basic legal framework for homecare and the outdated legal and regulatory framework that currently applies to residential care are not helpful in formulating clear criteria and drawing informed conclusions about the quality of LTC in Cyprus and how it could be explicitly defined. This long delay allows for a state of weak regulation and poor monitoring which in turn creates unfavourable conditions for qualified nurses and other health professionals to enter the sector, find employment and develop professionally. In addition, the bill on palliative care, that was prepared in 2020 and aims to regulate and monitor the treatment of the chronically ill and those in need of palliative care, is being pushed forward.

The Cyprus Recovery and Resilience Plan 2021-2026 recognised the need for investment in the LTC sector, particularly investment in modern structures for persons with disabilities and mental health problems, as well as for older people. With the new investments, the plan aims to improve the quality of life of these people and promote their social integration and participation in the community. In addition, the Plan recognises that spending on long-term care in Cyprus is very low and that a significantly lower percentage of the population in need of care receives long-term care compared to the EU-27 average [3].

The draft National Strategy for the Health of Older People 2022-27, prepared by the Technical Committee of the Ministry of Health for the Third Age, points to a serious gap in specialised care staff for older people. In addition, the following points were identified: Difficulties in synchronising government services dealing with the health of older people, the need to devote more time to older patients (especially in health centres and rural areas) and insufficient care at home. At the same time, the Ministry of Health has begun to map supply and demand in the field of long-term care and to identify other relevant measures for the development of a national action plan for long-term care.

Kantaris M. (2025) Long-Term Care System Profile: Cyprus. Global Observatory of Long-Term Care, Care Policy & Evaluation Centre, London School of Economics and Political Science. https://goltc.org/system-profile/cyprus/

Deputy Ministry of Social Welfare (2023), First National Strategy for Disability 2018-2028 (in Greek), Republic of Cyprus.

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European Commission, The European Pillar of Social Rights in 20 principles

Eurostat Data Browser 2024

Eurostat, Healthcare expenditure by function, HLTH_SHA11_HC.

Ministry of Health (2023), National Strategy for the Health of the Elderly people 2022-2027 (in Greek), Republic of Cyprus.

OECD/European Observatory on Health Systems and Policies, Cyprus: Country Health Profile 2023, State of Health in the EU, OECD Publishing, Paris/European Observatory on Health Systems and Policies, Brussels, 2023.

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1. Theodorou M., Kantaris M., Koutsampelas C., (2018), European Social Policy Network, Thematic Report on Challenges in Long-term care: Cyprus, European Commission.
2. Deputy Ministry of Social Welfare (2023), First National Strategy for Disability 2018-2028 (in Greek), Republic of Cyprus.
3. European Commission (2021), Directorate-General for Employment, Social Affairs and Inclusion, Long-term care report – Trends, challenges and opportunities in an ageing society. Volume II, Country profiles.
4. European Commission (2024), Ageing Report Economic & Budgetary Projections for the EU Member States (2022-2070) INSTITUTIONAL PAPER 279 | APRIL 2024.
5. Kantaris, M., (2022) ESPN Thematic Report on Social protection for people with disabilities – Cyprus, European Social Policy Network (ESPN), Brussels: European Commission.
6. Kantaris, M., and Theodorou, M., (2020), ESPN Thematic Report: Contribution to the 2021 SPC-COM report on long-term care for older people in the EU: Cyprus, European Commission.
7. Vogazianos, P., Argyropoulos, C. D., Haralambous, C., Mikellidou, C. V., Boustras, G., Andreou, M., … & Pana, Z. D., (2021). Impact assessment of COVID-19 non-pharmaceutical interventions in long term care facilities in Cyprus: Safety improvement strategy. Safety Science, 143, 105415.

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