Author
L 4368/2016, which provides free access to public health services and pharmaceutical treatment for persons without social insurance and vulnerable social groups[1] is also applicable for asylum seekers and members of their families.[2] However, in spite of the favourable legal framework, actual access to health care services has been consistently hindered in practice by significant shortages of resources and capacity for both foreigners and the local population, as the public health sector is under extreme pressure and lacks the capacity to cover all the needs for health care services. A 2019 research documents the impact of the ten years of financial crisis and the austerity measures on the Greek public Health System.[3]
Furthermore, challenges in accessing healthcare due to the lack of interpreters and cultural mediators in public healthcare facilities (hospitals, social clinics, etc.) also persisted in 2023. The language barrier was also flagged as by far the primary obstacle to accessing healthcare by asylum applicants (registered or pending registration) surveyed as part of an ongoing monitoring activity carried out between February 2022-March 2024, under the coordination of UNCHR in Greece, followed by challenges in acquiring necessary documentation (i.e., social security number).[4]
Article 55 IPA, subsequently replaced by article 59 (2) Asylum Code, introduced a new Foreigner’s Temporary Insurance and Health Coverage Number (Προσωρινός Αριθμός Ασφάλισης και Υγειονομικής Περίθαλψης Αλλοδαπού, PAAYPA) replacing the AMKA.
Article 59 (2) provides that PAAYPA is to be issued to asylum seekers together with their asylum seeker’s card.[5] With this number, asylum seekers are entitled free of charge to access the necessary health, pharmaceutical and hospital care, including the necessary psychiatric care where appropriate. The PAAYPA is deactivated if the applicant loses the right to remain on the territory.[6]
An October 2022 Joint Ministerial Decision (JMD) regarding access of international protection applicants to health care services, medical and pharmaceutical care, social security, the labour market, provides further clarifications on the acquisition of a PAAYPA number.[7] For every applicant for international protection, a PAAYPA number is issued. This number is unique and corresponds to the number of the applicant’s international protection card.[8] The competent service for the procedure of PAAYPA issuance is the Asylum Service. The latter proceeds with the issuance of the PAAYPA when registering the application for international protection and writes the PAAYPA number on the international protection applicant’s card.[9] PAAYPA holders benefit from primary and secondary health care upon presentation of their international protection applicant card.[10] The PAAYPA number remains active as long as there is an active international protection applicant’s card and is renewed automatically with the renewal of the applicant’s card. The validity of PAAYPA is equivalent to the duration of the applicant’s card, except for pregnant women, whose number remains valid for one year.[11] For UAM applicants for international protection, PAAYPA remains active even after the issuance or service of a decision rejecting their asylum application and its validity is extended until the execution of a return decision or until the UAM reaches adulthood.[12]
Following these developments, and despite initial delays in the operationalisation of the new system, issuance of the PAAYPA seems to have been increasingly streamlined since early 2021,[13] at least to the extent that GCR is aware. Notwithstanding, challenges do seem to persist as, indicatively, out of 61 registered asylum applicant households surveyed between 1 January 2023 and 31 December 2023 as part of an ongoing monitoring activity carried out under UNHCR in Greece, 5% of respondents still lacked a PAAYPA number.[14]
Furthermore, as the issuance of PAAYPA requires the full registration of an asylum application, delays in accessing asylum, particularly in mainland Greece, also lead to de facto delays with respect to applicants’ acquisition of this document and in turn delays in their actual ability to access healthcare. Amidst the marked increase in the number of sea arrivals, similar challenges were also reported on the islands, as for instance in Kos, where during November 2023 waiting periods for registration were reported at 2 months, diminished to 35 days by February 2024, resulting in unregistered applicants not having access to healthcare.[15]
Similarly in Lesvos, as noted by MsF in September 2023,[16] “[d]elays in the registration process prevents people from accessing medical services in a timely manner and forces patients to seek support outside of the state’s coverage. For example, a patient with a chronic heart condition and a history of heart attack, who lost his medication during the journey, had not been registered at the camp for approximately 4 weeks and was unable to access needed support, as determined by our medical teams. In addition, urgent appeals from our doctors on behalf of the patient were not given due attention”. At the time, MsF reported that 1,000 persons, including vulnerable ones, were still waiting to be registered.
Yet, even for those with an active PAYPA number, the isolated nature of accommodation (i.e., camps in remote areas) in the Greek reception system also hinders applicants effective access to healthcare, including psychosocial support, with the challenge being noted also by the UN High Commissioner for Refugees, Filippo Grandi, during a two-day visit to Greece in early 2024.[17]
Lastly, applicants’ access to healthcare stumbles upon shortages of competent staff in facilities of the Greek reception system and reported challenges since August 2023 with respect to the continuation of the Philos programme, implemented by EODY with AMIF and national funding, which is aimed at covering healthcare and psychosocial care needs for those residing in the reception system.[18]
For instance, as confirmed by GCR during an early 2024 mission to Chios,[19] since March 2021 the island CCAC has no permanent doctor. Moreover, though during 2023, the doctor of the Leros CCAC was conducting periodic visits to the facility in Chios, this was only for administrative purposes, and namely for the purposes of signing vulnerability assessment documents and medical cards. Shortages in the availability of medication and medical equipment, including for the measurement of diabetes, were also observed.
As per GCR’s observations in the field,[20] the situation was similar in Kos, where by December 2023, the island CCAC similarly lacked a permanent doctor and a psychologist. As in the case of Chios, efforts to cover the gap were made via missions of medical personnel from the Leros CCAC, as well as a military doctor.[21] As per similar observations made by GCR, in December 2023, severe shortages in the medical and psychosocial division of the RIS were also identified in Lesvos CCAC, while in Samos CCAC, which since its operationalization has lacked a permanent doctor, the situation remained up to the end of 2023, with only one state-appointed doctor being present in the facility for a period of a month, between October and November 2023.[22]
Between July and November 2023, at least three parliamentary questions were tabled to the competent Ministries regarding the continuation of the Philos programme, and specifically the fate of the programme’s more than 400 remaining staff, whose contracts were approaching their August 2023 expiry date.[23] In its relevant replies, MoMA highlighted that the programme had received an extension up to 15 March 2024, covered via AMIF 2021-2027 funds, after which the programme is scheduled to be replaced by a new programme, called “IPOCRATES – Provision of health services to residents in the accommodation facilities under the responsibility of the Reception and Identification Service”.[24] However, as denounced by the Union of Employees of EODY in October 2024,[25] the remaining 427 employees of the Philos programme would remain “indefinitely unpaid”, as, based on a notification they received from the President of the Board of Directors of EODY on 24 October 2023, “the procedures for the inclusion of the extension of the programme in the 2021-2027 AMIF ha[d] not been concluded, and, therefore, the institution [could] not receive appropriations for the payment of their September salary”. The delay in the programme’s extension was also reported in a November 2023 announcement made by EODY, which also noted that “persistent efforts were successful so that the previous month’s salary of the Philos Programme staff would be paid on 9 November”.[26] Nevertheless, the very existence of such gaps with respect to a critical programme aimed at covering health and psychosocial needs for residents of the camps, should be seen as cause of concern in itself.
[1] Article 33 L 4368/2016, as amended with article 38 par. 1 of L. 4865/2021.
[2] Article 59 (2) Asylum Code referring to art. 33 L. 4368/16.
[3] Amnesty International, Greece: resuscitation required – the Greek health system after a decade of austerity, April 2020, available at: https://bit.ly/3cAKeG0.
[4] UNHCR, Inter-Agency Protection Monitoring for Refugees in Greece: Key findings, available at: https://tinyurl.com/3z6t3y9f, relevant section on health.
[5] Article 59 (2) Asylum Code.
[6] Article 59 (2) Asylum Code.
[7] Ministerial Decision 605869 (Β’ 5392/18.10.2022).
[8] Article 1(3) of Ministerial Decision 605869/2022.
[9] Article 2(1) of Ministerial Decision 605869/2022.
[10] Article 3 of Ministerial Decision 605869/2022.
[11] Article 6(1), (2) of Ministerial Decision 605869/2022.
[12] Article 6(6) of Ministerial Decision 605869/2022.
[13] For more, see AIDA, Country Report Greece: 2022 Update, June 2023, op.cit, pp. 191-193 and previous relevant reports.
[14] UNHCR, Inter-Agency Protection Monitoring for Refugees in Greece: Key findings, available at: https://tinyurl.com/3z6t3y9f, relevant section 2 on documentation. For the data in this paragraph, filters have been used to only include registered asylum applicant households surveyed during 2023 alone.
[15] As reported in February 2024 by legal aid actors under the newly established Border Legal Aid sub-working group, which covers the islands of Lesvos, Samos and Kos. Information received on 12 March 2024.
[16] MsF, Greece: Amid increased arrivals, Médecins Sans Frontières records significant gaps in access to health services for asylum seekers on Lesvos, 1 September 2023, available in Greek at: https://tinyurl.com/bdmvxne2.
[17] UNHCR, UN High Commissioner for Refugees wraps up visit to Greece: welcomes progress on integration and urges continued efforts, 22 February 2024, available at: https://tinyurl.com/bdepjsbh.
[18] EODY, Integrated Emergency Health Intervention for the Refugee Crisis – Philos Programme, available in Greek at: https://bit.ly/3UzeF82.
[19] Information received on 26 February 2024.
[20] GCR maintains a permanent presence on the island.
[21] Also see, GCR, Absolutely inadequate conditions in the new Closed Controlled Access Center (CCAC) of Kos: The European Court of Human Rights has granted Interim Measures, 14 December 2023, available at: https://tinyurl.com/mr278p6f.
[22] For more on Samos, also see Joint NGO Statement, Not again in 2024: Call for upholding human rights in the Samos Closed Controlled Access Centre, 31 January 2024, available at: https://tinyurl.com/pekrp7rn.
[23] Parliamentary questions 107/17.07.2023; 490/30.08.2023 and 1491/01.11.2023.
[24] Relevant parliamentary replies by the MoMA of 15 September 2023 (protocol numbers: 422602 and 422540), respectively available in Greek at: https://bit.ly/3Weqfqk and https://bit.ly/4dakO1F, and of 11 December 2023 (protocol number: 537032) available in Greek at: https://bit.ly/3Jzt6Cz.
[25] Naftemporiki, Employees of EODY: 427 will remain indefinitely unpaid because the Ministry of Migration does not tend to their salaries”, 24 October 2023, available in Greek at: https://tinyurl.com/bdhwjktr.
[26] EODY, Information on the KOMY and PHILOS programmes and their staff, 2 November 2023, available (Greek) at: https://tinyurl.com/22t8azkt.