Author
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 applicants 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[3] 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.
Moreover, 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 for asylum seekers.[4]
Article 59 (2) provides that PAAYPA is to be issued to asylum applicants together with their asylum applicant’s card.[5] With this number, asylum applicants 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]
As explained above (see Access to the Labour Market), a recent legislative development automatically excludes from access to public healthcare beneficiaries of international protection (when one becomes a recognised refugee a PAAYPA needs to be converted to AMKA) who are not yet working or are not able to work because of their health condition or age (e.g. the elderly). Also, the possession of an active AMKA is necessary for access to the benefits of the Agency for Welfare Benefits and Social Solidarity (OPEKA).
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. Based on GCR’s observations, after the deployment of EUAA personnel in Kos.
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 hinders applicants’ effective access to healthcare, including psychosocial support.[15] This challenge was also noted by the UN High Commissioner for Refugees, Filippo Grandi, during a two-day visit to Greece in early 2024.[16]
In 2024, asylum seekers in Greece faced serious challenges in accessing medical care, given that on the one hand there was not adequate nor full-time medical staff available in all facilities nor available interpretation for most of the year. Well documented issues[17] of “on and off” healthcare service provision with PHILOS II (project implemented by EODY) persisted until July, when officially IPPOKRATIS project started with MoMA’s implementing partner being IOM.[18] In July 2024, IPPOKRATIS started with the former EODY as a transition personnel and by September 1st 2024, it was implemented by a private sector entity (Omilos Iatrikou Athinon) and Doctors without Borders NGO.
According to MoMA’s Minister’s answer to the Greek parliament, this programme concerns the provision of medical and psychosocial services, including prevention, health education, diagnosis and treatment to third-country nationals who live in RICs, CCACs, CAFTAAS and includes: (a) the treatment of urgent cases – screening, (b) the identification of vulnerable persons, and (c) the provision of a comprehensive approach to the provision of health care services c) taking a medical history – registration, d) clinical physical examination, e) referral to a medical service, f) identification of vulnerable groups (e) referral to further care (secondary/tertiary) and also, the provision of psychosocial care to residents within the facilities by specialised staff. This programme has been included in the new multiannual programme of the Asylum, Migration and Integration Fund (AMIF) 2021-2027.[19]
IPPOKRATIS project is designed to offer both medical and psychosocial support services together with child protection case management, although in its initial stage of implementation it was challenged by the lack of interpretation services and the difficulty in staffing medical services (especially doctors) in the islands of Dodecanese.[20]
More specifically, challenges in accessing healthcare due to the lack of interpreters and cultural mediators in public healthcare facilities (mainly hospitals and health centers) also persisted in 2024. 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. This was followed by challenges in acquiring necessary documentation (i.e., social security number).[21] Especially in 2024, though, this lack of interpretation services from May till the end of 2024 and thus the obstruction communication between asylum seekers and medical staff was at a point that in many cases resulted per se in people being excluded from effective medical care, exposing them to serious risks and significantly impacting their physical and mental health.[22] As already mentioned, interpretation services during 2025 continued to be extremely limited as well as the number of available doctors depending on the region of the accommodation facility. Therefore, the obstacles in accessing health care persisted throughout 2025 as well.
As per GCR’s observations in the field,[23] in Lesvos CCAC the situation was dire when transitioning from PHILOS II to IPPOKRATIS medical care project. In the middle of June 2024, organisations reported that there were no doctors for registrations and screenings, referrals to the hospital could not be made, and no vulnerability assessments were taking place.[24] Until the end of August 2024 there was a “bridge” project with severe limitations, such as the working shift and interpretation supported by RIS.[25]
Regarding mental health support in particular, access to medical care was even more restricted, as interpretation is pivotal in treating such cases. Even after IPPOKRATIS commenced, referrals to public hospitals were not implemented if an interpreter was not physically available for the case.[26] “Almost all of them talk about suicidal thoughts, lack of support, and sleeping problems” shared an MSF psychologist when talking of his recent experience on the field and further added on unaccompanied children that reach adulthood: “Once they are no longer minors, they are sent to camps, where there is little to no follow-up”[27] highlighting the gaps in mental health without sufficient support.
[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 Article 33 L. 4368/16.
[3] For the impact of the ten years of financial crisis and the austerity measures on the Greek public Health System, see Amnesty International, Greece: resuscitation required – the Greek health system after a decade of austerity, April 2020, available at: https://bit.ly/3cAKeG0.
[4] See Content of international protection.
[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] MSF, Greece: The impact of living in limbo on asylum seekers’ mental health, 17 June 2024, available here.
[16] 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.
[17] See Greek Ombudsperson, The Challenge of Migratory Flows and Refugee Protection, April 2024, available here; and European Commission, Letter to civil society organisations, Ares(2024)613054, 26 January 2024 (available upon request), replying to the Joint CSOs Letter “Human Rights, But Not for All: Open Letter on Access to Food and Medical Care in Lesvos Closed Controlled Access Center”, available here. It is noted that in the Commission’s view chronic gaps of PHILOS II are identified “mostly due to the absence of doctors”.
[18] See MoMA’s announcement here.
[19] Answer to parliamentary question provided on 09 August 2024, available in Greek here.
[20] Information shared at a special meeting of IOM and Child Rights Advocacy Network (CRAN) Members in November 2024.
[21] UNHCR, Inter-Agency Protection Monitoring for Refugees in Greece: Key findings, available at: https://tinyurl.com/3z6t3y9f, relevant section on health.
[22] See more on this: Voices from the Camps: Living Conditions and Access to Services in Refugee Camps on the Greek Mainland, Mobile Info Team, 2024, available here and GCR and Save the Children joint report “It does not feel like real life”: Children’s everyday life in Greek refugee camps, available here, 19 and “Refugee camps in mainland Greece”, Refugee Support Aegean, 2024, available here, 13.
[23] GCR maintains a permanent presence on the island.
[24] Lesvos Legal Aid Sub Working Group minutes of 18 June 2024 are available upon request
[25] Only one shift from 07:00 to 15:00, information shared among Lesvos Legan Aid Sub Working Group, 23 July 2024, minutes available upon request.
[26] Information shared at an IOM and CRAN special meeting in November 2024.
[27] MSF, A mental health crisis among refugees and migrants in Greece, 10 October 2024, available here.