Maria Karagiannidou (Care Policy and Evaluation Centre, London School of Economics and Political Science)

The Long-Term Care system in Greece is characterised by mostly reliance on family and other informal care. Although there are some publicly available services, these are underdeveloped, fragmented and are limited to community and home care and to very limited numbers of publicly funded care homes. The existing system cannot be characterised as a universal public LTC system. In addition, private (non-state) provision of aged care services and services offered by for profit and non-profit organisations are widespread in Greece. These include institutional, community-based and home-based services.  Community care for older adults, which is the core of LTC services in Greece, are decentralized in terms of governance and provision of services but the funding is coming from the central government. In general, there is a very low level of public investment. For instance, in 2014 and 2018, Greece allocated only 2% of overall health spending to LTC, which is far lower than the EU-27 average of 15% and only 0.2% of Gross Domestic Product (GDP) per capita, which is one of the lowest in the world[1].

Overall, governance and LTC system organisation in Greece is underdeveloped as there is a lack of a comprehensive legitimate framework of LTC and in addition integration of services is also inadequate and illegitimate.

More specifically, in Greece legislative responsibility for LTC at national level is split between three Ministries, that is the Ministry of Health, Ministry of Labour, Social Security and Solidarity and Ministry of Interior Affairs. In addition, Local Authorities are responsible for running the community services for older adults (including “KIFI” and “Help at Home programmes”) but are not entirely responsible for the state care homes. State care homes, which are extremely limited, are mainly regulated by the Ministry of Labour, Social Security and Solidarity. However, quality and accreditation standards for private and state care homes are set by the Ministry of Health. In addition, regulations and accreditation standards for community care for older adults are set by the Ministry of Interior Affairs, however there is no quality framework in place. The degree of integration and collaboration is extremely low and in some cases is non-existent.

In Greece publicly available LTC is financed by a mixed system, that is general taxation and social insurance. Although in some cases there are general income criteria for accessing publicly available services (for instance older adults with very low income or pensioners), there is no means-tested mechanism in place. Eligibility criteria are mainly based on the degree of need for help, similar to Activities of Daily Living (ADLs), however there are no official measurement/instrument or processes in place. Loneliness and overall living alone over 60 years old is another important element of having access to publicly available long-term care (which is mainly the Help at Home programme). There is a dedicated financing mechanism for LTC but there is different financing mechanism for health and social care under which LTC is covered. However, there is no clear available data on how the funding is split between health and other social care services and LTC. In addition, part of the funding regularly comes through EU programmes and funding schemes. Overall, public funding for LTC services is limited to only 2% of overall health spending, and only 0.2% of GDP per capita, which is one of the lowest in the world. Out-of-pocket payments for LTC in Greece are the main source of funding LTC for older adults. There is no private insurance for LTC[1].

Greece’s publicly available LTC system is oriented towards community-based care.

Public available community-based LTC in Greece includes home help via the “Help at home” programme, which includes services related to personal care, home nursing domestic help, prescription of medications, food supplies etc, day care centres for older adults, and a limited number of day care centres for people with dementia. Although there are no publicly available rehabilitation centres, the state covers fully the cost of rehabilitation when needed and under specific circumstances. There is also a form of support for social participation (including recreational group activities, artistic activities but also support groups and peer to peer support) offered by a structure called K.A.P.I. – these are widespread in Greece. There are also some semi-residential day-care centres for older people (KIFI). There is limited publicly available support to unpaid carers mainly provided by the Greek Alzheimer’s Association.

There are also private companies offering community care similar to the “Help at home” programme, however there are limited number of companies and services running, covering urban areas only.

There are also a number of non-profit and for-profit NGO’s that are running some day care centres for older adults.

However, informal care within the family which is offered either by relatives or by paid carers (mainly immigrant women who live in the country legally or illegally) plays a key role in meeting the needs of older adults in the community.

There is only a limited number of state care homes for older adults. In contrast, private (non-state) provision of aged care services is widespread in Greece.

There are four categories of private (non-state) providers in Greece. The first category covers not-for-profit companies that receive public contract for service provision, and/or are commissioned by various authorities (or large enterprises) for service provision and receive public funds for their operations. Their establishment and operation is governed by law and their income streams include funds from national and subnational budgets and insurance funds. They are typically not-for-profit. The second category are independent not-for-profit organizations or companies that are engaged in various activities, including advocacy and service provision. Their revenue mainly comes from private endowments and donations. The third category are a diverse set of companies that are licensed, but do not typically have contracts for service provision with authorities and do not receive public funds, instead working on a fee-for-service model. These could be for-profit or not-for-profit. These providers derive the majority of their revenue from out-of-pocket payments and in a few cases receive funds from private insurance companies or donations. The fourth category are providers that are in the “grey zone” and are neither licensed to provide care nor receive public funding. These derive their revenue from out-of-pocket payments.

Overall, private licensed providers are a large and diverse group. The Panhellenic Union of Care Units for the Elderly estimates that there are 276 private licenced businesses that provide services to older people. They offer accommodation and care to older people who are either self-sufficient or have reduced autonomy or are not self-sufficient and are in need of constant nursing care or medical monitoring. The fee for the provided services of these units is covered out-of-pocket. The majority of these private enterprises are profit-making entities and are located in large urban areas.  Indicatively, from the 112 care units for the elderly (Care Homes) belonging to the Panhellenic Union of Care Units for the Elderly, 81 are in the Region of Attica, 6 in the Prefecture of Thessaloniki, and the rest 23 are in another region of Greece.  There are also prefectures where – at least officially – there are no care homes.

Important to note here that many older adults with care needs are placed in mental health residential homes (psychiatric clinics), however the number of older adults in these services is unclear.

Most of the providers are predominantly small providers often based on old buildings. However, there are also some larger providers offering their services on new and modern buildings. The Greek Foundation “TIMA” is preparing a new programme aiming to renovate and modernise some of the non-profit care homes.

The role of Greek Orthodox Church

The Greek Orthodox Church plays a vital role in care of older people in Greece by providing a well-established network of services (including care homes and day care centres) for older people and a range of services for older people, particularly those on a low income and who live alone. Currently, the Greek Orthodox Church is running overall 83 care homes for older people in Greece (42 in Athens and 41 in several other areas in Greece covering North Greece, some islands). These services free are all completely free of charge.

There are widespread “Healthy cities” programmes running by local authorities. These are funded by the European Union’s funds.  Healthy systems initiative for municipalities.

Overall, there are currently no publicly available policies or initiatives aiming to ensure access to assistive technologies (e.g. mobility, hearing, seeing, cognitive aids). There are an extremely limited number of private initiatives mainly offered by communication companies or/and hearing or mobility companies. In addition, there are some very limited programmes focusing on remote monitoring, including technologies like the alarm button. However, there are currently more initiatives assistive technologies comparing to five years ago. Local authorities are running and funding these services, however there is no formal integration with other publicly available services, for instance General Practitioners. There are no initiatives aiming to improve and/or adapt home environments for older adults with care needs.

In Greece the LTC workforce as a share of the entire workforce is the lowest among the EU countries (0.3% in Greece; 1.8% in Bulgaria; 3.1% EU average; 7.1% in Sweden)[1]. However, the unlicensed domestic LTC workforce appears to be more common in Greece and the second-best option for informal care[2]. There is no available data on the share of specialist nurses, personal care workers, social workers etc, however by law they need to have some qualifications (usually tertiary education or and a degree of training). There are limited programmes of continuing training offered mainly by the Panhellenic Alzheimer’s Association. Low payment (usually with the minimum or just above the minimum wage) is an obstacle in finding staff although working conditions are acceptable. There are currently no measures to increase workforce.

In Greece most of the care subsectors (domestic help and in particular live-in care) are almost exclusively based on migrant labour. Care provided by migrants is a socially accepted segment of care in Greece, however there are: (a). no formal skills/qualifications barriers for entering care work; (b). there are not in place policies for regulating this sector and (c) as it is an undeclared work there is a strong cost incentive for users (untaxed labour). Currently, there is a gradual decrease in migrant care workers (an increase in needs of care) but there are no measures in place to increase the number of available migrant workers especially in rural areas or overall to attract more foreign workers.

Data and information systems related to long-term care for older adults are currently underdeveloped in Greece.

As part of Greece’s National Dementia Plan, three end-of life care homes were created in 2022 for people living at the final stage of Alzheimer’s disease. Overall, the three end-of life care homes have 75 beds, and they are currently funded by the European Union (Enterprise Agreement for Development Framework). Eventually, the plan is for those services to be funded by the Greek Government.

At the moment there is very limited accessibility of publicly available LTC services. Based on an analysis of the SHARE data, as this is the only available data for Greece concerning use of LTC services, approximately only 10% of people are currently using the publicly available services (that is “Help at Home” community programme). In addition, there is no data concerning affordability and equity of services, as well as resilience and satisfaction[3].

In 2014 the Greek Government established the National Observatory for Alzheimer’s and Dementia and they adopted, two years later the National Action Plan, which includes the creation of special care units (day-care centres, etc.) and the provision of support for carers. As a result, the government established seven day-care centres, and they are planning to build six memory and cognitive disorders clinics and five palliative care hospices for people having dementia related issues.

In addition, in 2018 the Greek Government established an institutional setting for the provision of ‘Integrated Care for Older People’. One hundred and fifty ‘Integrated Care Centres for Older People’ were created, which operate as branches of the ‘Community Centres’ in various municipalities of the country aiming to integrate administratively the publicly available community services for older adults.

Concerning the impact of Covid-19, although there was a quick and effective response to contain the virus, there have been no new policy initiatives following from the pandemic.

Karagiannidou, M. (2023) Long-Term Care System Profile: Greece. Global Observatory of Long-Term Care, Care Policy & Evaluation Centre, London School of Economics and Political Science. https://goltc.org/system-profile/greece/

Brenda,Georgia, & Rompolas,Periklis. (2019). Long-term care: Greek reality. Perioperative nursing (GORNA), EISSN:2241-3634, 8(4), 238–254. http://doi.org/10.5281/zenodo.3692433

Colombo, F., et al. (2011), Help Wanted?: Providing and Paying for Long-Term Care, OECD Health Policy Studies, OECD Publishing, Paris, https://doi.org/10.1787/9789264097759-en.

Dubois, H., Leončikas, T., Molinuevo D., and Wilkens, M. ( 2020). Long-term care workforce: employment and working conditions. European Foundation for the Improvement of Living and Working Conditions.

ESPN Thematic Report on work–life balance measures for persons of working age with dependent relatives, Greece, 2016.

European Commission, Directorate-General for Employment, Social Affairs and Inclusion, Long-term care report – Trends, challenges and opportunities in an ageing society. Volume I, Country profiles, Publications Office, 2021, https://data.europa.eu/doi/10.2767/183997

European Commission, Directorate-General for Employment, Social Affairs and Inclusion, Long-term care report – Trends, challenges and opportunities in an ageing society. Volume II, Country profiles, Publications Office, 2021, https://data.europa.eu/doi/10.2767/183997

EU Report: the impact of demographic change in Europe https://ec.europa.eu/info/strategy/priorities-2019-2024/new-push-european-democracy/impact-demographic-change-europe_en

EU Ageing report 2021: Underlying Assumptions and Projection Methodologies. https://ec.europa.eu/info/publications/2021-ageing-report-underlying-assumptions-and-projection-methodologies_en

European Social Policy Network (ESPN): Thematic Report on Challenges in Long-Term Care: Greece; (February 2018).

Eurostat statistics https://ec.europa.eu/eurostat/web/products-eurostat-news/-/DDN-20200402-1#:~:text=Across%20the%20EU%20Member%20States,and%20in%20Luxembourg%20(14.4%25)

Lyberaki, A. and Tinios, P., 2018. Long-term care, ageing and gender in the Greek crisis.

McKim, C.A., 2017. The value of mixed methods research: A mixed methods study. Journal of Mixed Methods Research, 11(2), pp.202-222.

Waitzberg, R., Schmidt, A.E., Blümel, M., Penneau, A., Farmakas, A., Ljungvall, Å., Barbabella, F., Augusto, G.F., Marchildon, G.P., Saunes, I.S. and Vočanec, D., 2020. Mapping variability in allocation of Long-Term Care funds across payer agencies in OECD countries. Health Policy, 124(5), pp.491-500.

References in Greek:

Βακάλη, Ν. (2011). «Ασφάλιση μακροχρόνιας φροντίδας: Ρόλος της οικογένειας, κράτους και ιδιωτικού τομέα σε διεθνή προοπτική – Θεωρητικές και πρακτικές διαστάσεις», Διπλωματική Εργασία, Πανεπιστήμιο Πειραιώς.

Κολυζά, Α. (2019). «Βελτίωση ποιότητας και καλές πρακτικές σε δομές για άτομα τρίτης ηλικίας» – Διπλωματική Εργασία, Πανεπιστήμιο Πειραιώς.

(Petmetzidou et al., 2016): Πετμετζίδου, Μ., Παπαναστασίου, Σ., Πετμετζογλου, Μ., Παπαθεοδώρου, Χ., και Πολυζωίδης, Π (2016). «Υγεία και Μακροχρόνια Φροντίδα στην Ελλάδα». Μελέτη 35. Ινστιτούτο Εργασίας ΓΣΕΕ. Παρατηρητήριο Οικονομικών και Κοινωνικών Εξελίξεων (Οκτώβριος 2015).

Σαχιτζή, Ε. (2016). «Μονάδες Παροχής Υπηρεσιών στην 3^η Ηλικία. Μελέτη Περίπτωσης», Διπλωματική Εργασία, Πανεπιστήμιο Πειραιά.

[1] European Commission, Directorate-General for Employment, Social Affairs and Inclusion, Long-term care report: trends, challenges and opportunities in an ageing society. Volume I, Publications Office, 2021, https://data.europa.eu/doi/10.2767/677726

[2] Based on the author’s own survey, not yet published.

[3] Based on the author’s own analysis of SHARE data, not yet published.

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