Cyprus & Long-Term Care Systems

An excerpt from the Joint Report on Health Care and Long-Term Care Systems & Fiscal Sustainability, published in June 2019 as Institutional Paper 105 Country Documents - 2019 Update

Economic and Financial Affairs Economic Policy Committee

Cyprus Health care systems

From: Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability, prepared by the Commission Services (Directorate-General for Economic and Financial Affairs), and the Economic Policy Committee (Ageing Working Group), Country Documents – 2019 Update 2.5. CYPRUS

to the risk for long-term sustainability of public General context: Expenditure, fiscal finances (107). sustainability and demographic trends

General statistics: GDP, GDP per capita; Health status population Life expectancy at birth (83.7 years for women and GDP per capita in Cyprus was, in 2015, below EU 79.9 years for men) was above EU average levels average with 23,818 PPS (EU: 29,610). The of 83.3 and 77.9 years in 2015. The same is true population was estimated at 0.85 million in 2016. for healthy life years, with 63.4 years for women According to Eurostat projections, total population and 63.1 years for men in Cyprus compared with, is projected to increase from around 0.85 million respectively, 63.3 and 62.6 for the EU in 2015. in 2016 to 1.0 million in 2070. Similarly, the infant mortality rate of 2.7‰ was, in the same year, below the EU average of 3.6‰, having fallen throughout the last decade from a Total and public expenditure on health as % of value of 4.6‰ in 2005. GDP Total expenditure on health has relatively stable in As for the lifestyle of the Cypriot population, data the past decade. However expenditure as a indicates a high proportion of regular smokers percentage of GDP (6.8% in 2015) was relatively (25.2% in 2014), being above the EU average of moderate and well below the EU average of 10.2% 21.0 (value in 2015). Conversely, the proportion of in 2015. When expressed in per capita terms, also obese population was below the EU level at 13.9% total spending on health, at 1,564 PPS in 2015, (EU: 15.4%), and the latest available figure on was less than half of the EU average of 3,305 for alcohol consumption is below the EU level for the the same year. The gap is more marked for the same year (9.0 vs. 10.1 for the EU in 2013) and GDP share of public spending on health care: 2.9% below the 10.2 value for 2015. Based on available of GDP in Cyprus in 2015 vs. 8.0% of GDP in the data, over the last decade the proportion of EU; and 674 PPS in Cyprus vs. an EU average of population smoking seems relatively unchanged 2,609 PPS in 2015. Looking at health care without and the average alcohol consumption has slightly long-term care (105) reveals a similar picture, with decreased. public spending markedly below the EU average, but it reduces the relative gap (2.8% vs 6.8% in System characteristics 2015).

Overall description of the system Expenditure projections and fiscal sustainability The Cypriot health system is made up of two As a consequence of population ageing, health care uncoordinated sub-systems of similar size: a public expenditure is projected to increase by 0.4 pps of one and a separate private one. The public system GDP, below the average growth level expected for is highly centralised and planning, organisation, the EU of 0.9 pps of GDP, according to the "AWG administration and regulation are the responsibility reference scenario" (106). When taking into account of the Ministry of Health (MoH). It is mainly the impact of non-demographic drivers on future financed by the state budget, as well as by spending growth ("AWG risk scenario"), health contributions to health insurance from civil care expenditure is expected to increase by 0.6 pps servants and civil servant pensioners, with services of GDP from now until 2070 (EU: 1.6). Overall, provided via a network of public hospitals and projected health care expenditure increase is health centres directly controlled by the MoH. expected to add to budgetary pressure, contributing Public providers’ employees have the status of civil servants and are salaried employees. (105) To derive this figure, the aggregate HC.3 is subtracted from total health spending. (106) The 2018 Ageing Report: The current system has led to an unequal https://ec.europa.eu/info/publications/economy- finance/2018-ageing-report-economic-and-budgetary- (107) , Fiscal Sustainability Report (2018) projections-eu-member-states-2016-2070_en. https://ec.europa.eu/info/sites/info/files/economy- finance/ip094_en_vol_2.pdf.

50 Health care systems 2.5. Cyprus

distribution of services and inequities in access to Health System (around 80% of the population), care. Also, prices, capacity, and care quality in the while the rest of the population (non-beneficiaries) private sector are not sufficiently regulated. There paid according to fee schedules by the MoH. As is no implemented coherent framework matching from 1 August 2013 new fees and co-payments separate provision of public and private healthcare were set that reduced the share of free health care services, leading to inadequate and ineffective beneficiaries to around 70% of the population. As coverage. There is an over-burdened public demand exceeds significantly the supply for free healthcare sector leading to high waiting times for public health care services, long waiting lists for selected consultations, surgical procedures and some specialties create barriers to access for those diagnostic tests, and potentially also leading to a services. For this reason, part of the population decrease in the quality of care. The over-capacity uses the private sector health care services for of private health care providers is exacerbated. outpatient consultations and routine procedures This has led to wasteful allocative inefficiencies in while, using the public sector health care services total health care resources in Cyprus. for more costly services. Overall, the recorded proportion of the population covered by public or To address these inefficiencies and to ensure primary private health insurance was reported at efficiency gains in the mid-term, the Cypriot 83% in 2015 vs. the EU average of 98%. authorities are pursuing to implement a dual strategic reform program. Firstly, it aims to raise The introduction of the NHIS is expected to resilience of the system and to improve the access increase the accessibility of the whole population to quality with the and will provide free access to the private and the autonomisation of public hospitals. Public public health care sectors. hospitals financial autonomy can facilitate the improvement of access to quality health care and Administrative organisation and revenue foster it, thereby administering their own budgets collection mechanism based on available resources. The public hospitals’ autonomisation should lead to normalisation of The public health care budget is financed by the admissions and length of stay as well as the state. In addition, a contribution-based health care appropriate utilisation of infrastructure, staff as scheme is implemented for civil servants, and there well as the efficient use of hospitals’ properties. are co-payments defined for beneficiaries and non- beneficiaries of public health care services. The Secondly Cyprus will implement a National Health public health sub-system as well as most decision- Insurance Scheme (NHIS). Both relevant making processes are centralised. Public hospitals legislations for hospital autonomisation and NHIS form part of an integrated system of civil service were enacted on the 216th of June 2017. The main and ministerial control management, such that goals of NHIS are: (i) ensuring universal managerial decisions are taken outside of the healthcare coverage; (ii) pooling the public and hospitals. private financing; (iii) overcoming the fragmentation of provision of uncoordinated Role of private insurance and out of pocket private and public care; (iv) improving system co-payments organisation and monitoring; (v) improving access to and quality of care. According to the enacted The public health care system has since long been legislation, NHIS will become operational on June criticised for failing to effectively cover the 1st 2020, with the first phase of NHIS (outpatient population leading to inadequate and ineffective health care: Family Doctors, Specialists for coverage. The latter is associated with the fact that outpatient care, Pharmaceuticals and Labs for around 50% of people eligible for free public outpatient care) are due to become operational a health care opt to visit the private sector and pay year earlier (1st June 2019). out-of-pocket (mostly for ambulatory care services) to avoid long waiting times. As a result, the combined share of private and out-of-pocket Coverage spending out of total health expenditure (56.9% in Citizens below a determined income level used to 2015, with 43.9% covered by out-of-pocket be free health care beneficiaries of the Public expenditure alone) is the largest in the EU (EU

51 European Commission Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents

average: 21.6% for the two combined and 15.9% modern technologies at hospitals such as day-care for out-of-pocket alone in 2015, respectively). The and laparoscopic services, the availability of population non eligible for free public health care follow-up care and the availability of long-term services is to some degree covered by private care services. With the planned autonomisation the health insurance schemes, although the domestic public hospitals shall be turned into independent private health insurance industry is still at an infant and autonomous units that can compete with stage. private providers on an equal basis to establish contracts with the purchasing authority (Health Insurance Organisation - HIO). Types of providers, referral systems and patient choice Treatment options, covered health services As stated above, public and private provision coexist. Public primary care is provided in hospital The benefit package is explicitly defined and is outpatient departments, urban and rural health comprehensive. It covers family doctor and centres and sub-centres. Public dental care is specialist outpatient visits, pharmaceuticals, provided in dental clinics in hospital outpatient laboratory tests, inpatient care, allied health departments and PHCCs. Public general hospitals professional services, A&E, ambulance services, offer specialist outpatient care and district rehabilitation and palliative care. hospitals and Specialist Centres such as the Bank of Cyprus Oncology Centre, Cyprus Institute of Price of healthcare services, purchasing, Neurology and Genetics offer outpatient and contracting and remuneration mechanisms inpatient hospital care. Private health services include a variety of specialists and dentists who Currently, doctors in the public sector are paid a provide their services in their own facilities, salary, while in the private sector they are paid on typically in the largest urban areas. a fee-for-service basis. Public sector remuneration is determined by the central government. The The number of practising physicians per 100 000 private sector fees are determined by the free inhabitants has risen above the EU average in 2015 market and depend on reputation of each specific (358 vs. 344 for the EU), after steadily growing doctor, although an indicator of private sector fees over the past decade, though still below average is set by the Medical Council. At the moment there during that time. Also the number of general is no activity or performance related payment in practitioners (GPs) per 100 000 inhabitants in 2015 the public sector. With the implementation of the was above the EU average, with 87 vs. 78 for the NHIS, family doctors' (FDs) reimbursement shall EU in the same year. At the moment, besides some entail a 3-tier payment: (i) an age-adjusted form of referral in the case of public provision, capitation (per number of patients); (ii) an activity- there is no formal referral system from primary to based reimbursement, depending on doctor specialist and hospital care. A main feature of the activities regarding preventive medicine practices, NHIS is the concept of family doctors and the chronic disease management, and (iii) a mechanism of referral system from primary care to performance related reimbursement that will be specialist doctors and other providers. In other tied to, among others, referral and prescribing words, all citizens would register with a family behaviour. The details of how this will be doctor, who would act as a gatekeeper referring implemented are in the process of being finalised. patients to specialist and other providers. A uniform reimbursement policy is to be applied to both public and private sector providers. Cyprus has seen a reduction in the number of acute care beds per 100 000 inhabitants in the last Specialists’ outpatient services will be reimbursed decade (342 in 2015 vs. 375 in 2005) and their on a fee for service basis (per activity) adjusted number, remains below the EU average of 402. through a point system mechanism in order to About half of the beds are publicly owned. The achieve implementation of a hard global budget. future number of acute care beds will depend on As regards to the reimbursement of specialists' the combination of public hospitals’ reorganisation inpatient services in hospitals, these will be following autonomisation and the NHIS incorporated into the DRG to which each case will implementation with optimal use of effective be assigned. It is expected that with its

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introduction, the DRG system will promote the manufactured generics, the ex – factory price is set containment of inpatient expenditure through the on the basis of the production cost plus a mark-up increased transparency concerning clinical of 20%, in cases where the originator is not activities. In addition, as the HIO will treat the included in the price list. Along with the imported public and private sectors exactly the same, it is generics, local manufactured generics should not expected that, through the competitive exceed 80% of the original product included in the environment which will be created, an price list. Price revisions take place annually. A re- improvement in hospital efficiency and quality of calibration of the pricing method is performed service provided will occur. semi-annually.

Currently the annual MoH budget includes a Public spending on pharmaceuticals in Cyprus specific hospital budget allocated to each hospital looks low compared to the average for EU according to need, primarily on a historical basis countries, with 0.2% of GDP spent on the area in adjusted to inflation. As a result, there are no 2015 compared with an average of 1.0% of GDP incentives for cost-awareness and control from the for the same year. part of the public providers. Consistently, when looking at hospital activity, inpatient and day case There are no lists of medicines (positive or discharges ranked much lower than the EU negative) in the private sector as pharmaceutical average in 2015 (respectively 7 discharges per 100 care is not reimbursed. Prescribing habits of inhabitants vs. 16 in the EU and 1,584 day case private doctors are not monitored, although the discharges vs. 7,635 in the EU per 100 000 authorities often issue guidelines and inhabitants). This suggests that there is room to recommendations for the correct use of medicines increase hospital activity. It also suggests that as a to the prescribing physicians. result of hospital inefficiency patients waiting times may be higher than otherwise possible. In the public sector pharmaceutical care is provided through public pharmacies and currently falls under the Pharmaceutical Services of the The market for pharmaceutical products Ministry of Health. The procurement of medicinal In the private sector, pharmaceutical care is products is the responsibility of the Directorate of provided through registered private pharmacies Purchases and Procurement of the Ministry of and financed with out-of-pocket payments. The Health and is block-funded by the Ministry of prices of imported pharmaceuticals are set through Finance. For the supply of medicines a public external price referencing. A 3% mark-up is added procurement method is used. Pharmaceutical care to the external reference price (ERP) to cover the is provided to eligible patients, according to the cost of importing pharmaceuticals. The price set is Medical Institutions and Services General the wholesale price. The wholesale prices include Regulations. the wholesale margins and the distribution costs. Since early 2018, the Pharmacy margins have been Pharmaceuticals provided to the eligible patients set to be regressive, incorporating both percentage are included in the Hospital Formulary which and fee. They reach 37% on wholesale price for provides contemporary information about the medicines up to €10, 35% for the medicines medicines available from public hospitals and between €50.01 – 250, € 83 for the medicines health care centres. In the past years, a co-payment between €250.01-1500 and €100 for the medicines scheme has been implemented which enables above €150. Pharmacists also receive a flat fee of doctors to prescribe a limited number of drugs not €1 per prescription. A 5% VAT is added to the net included in the approved list, but available in the price. private sector. The medicines in the co-payment scheme are partly reimbursed by the Government. The external price referencing is also applied for The amount reimbursed is based on the price setting the prices of imported generics, in case the difference between the price of the co-payment corresponding originators are not included in the drug and the price of the corresponding available price list. In general, the price of the generics drug on the list of approved drugs. cannot exceed 80% of the price of the original branded product marketed in Cyprus. For locally

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In order for a new product to be added to the Hospitals (in Nicosia and Famagusta) and some Hospital Formulary, a formal pharmaceutical health centres. Furthermore, the Ministry is request form has to be submitted by a specialist exploring the conversion of the existing paper physician practising in a public hospital. Generics medical records into digital records that will and generic substitution are used widely in the complement the Electronic Health Records created public sector. The use of generics provides high by IHIS. At the same time, the Ministry is in the cost savings in the public sector. Conversely, the process of developing the National Contact Point use of generics in the private sector is limited. One for e-Health (under Connecting Europe Facility of the reasons for this is the fact that pharmacists funding), as part of the e-Health Network project are not allowed to substitute original to facilitate cross border healthcare between the pharmaceutical products for generic medicines. network’s member states. Additionally, it will Furthermore, the promotion of generic medicines abide to the requirement of the EU regulations, to is still limited, and the Cypriot government does provide by the end of 2019 a common secure not provide any incentives for doctors and framework that will facilitate the Electronic pharmacists. A draft legislation allowing for Exchange of Social Security Information (EESSI) generic substitution in private pharmacies as part between the corresponding institutions or the of the implementation of the NHS is currently liaison bodies of each EU Member State. undergoing legal vetting. The main objective is to provide a functional A general reform of the pricing and reimbursement interoperable solution that will ensure electronic system is expected due to the introduction of the data exchange of patient records with other EU NHIS. This reform will unify the pharmacy market countries, the extension, in the future, of services under common pricing and reimbursement rules. to the Cyprus private healthcare sector, implementation of the further National Health Insurance System (NHIS) reform and other major Use of Health Technology Assessments and Cyprus health care initiatives that involve cost-benefit analysis development of electronic data exchange. The government currently builds up its HTA capacity. For pharmaceuticals, the criteria for In view of the implementation of the NHIS, the inclusion of a pharmaceutical in the List of Health Insurance Organisation (HIO), on the 30th Approved Pharmaceuticals include: product- March 2017, has contracted the development, specific criteria (e.g. medical and therapeutic implementation, operation and support of a total value, safety, lack of alternative therapies); solution for the information technology system and economic criteria (e.g. cost effectiveness, budget other business processes of the NHIS. Health care impact); patient-specific criteria (e.g. age, sex, providers will have access to the system to submit chronically or terminally ill patients); and disease- claims and issue prescriptions, lab orders and specific criteria (e.g. severity of illness, special referrals. The system will store clinical patient data medical needs). The Drugs Committee assesses all as they emerge from the activities of the doctors of the above criteria. such as referring and prescribing and the submission of claims.

eHealth, Electronic Health Record Health promotion and disease prevention The Ministry, as part of its ambitious health sector policies reform program that requires universal access for all public sector health providers to an Integrated Though total expenditure on prevention and public Health Information System (IHIS) and their health services as a share of GDP and as share of routine use of it, is in the process of a tendering total current health expenditure were below the EU procedure to obtain a new enhanced IHIS that will average in 2015 (0.1% of GDP and 1.7% of total incorporate the enhancements and/or amendments current health expenditure in Cyprus versus 0.3% required to support the reform process, as well as and 3.2% in the EU, respectively), based on a self- to expand in all the public hospitals and health assessment of the country’s public health capacity centres all over Cyprus, complementing the and services, using the WHO tool for 10 Essential existing IHIS that is currently used in 2 Public Public Health Operations, Cyprus obtained a

54 Health care systems 2.5. Cyprus

positive score in this area (108). The assessment Based upon the MOU a number of initiatives have report forms the basis for national planning and been implemented: the development and policy in the area as well as to monitor progress implementation of the information technology and further enhance the delivery of public health infrastructure for the NHΙS, the review of income services. Prevention is expected to increase further thresholds for free access to health care, the with the introduction of the NHIS and the concept creation of evidence-based protocols for laboratory of the Family Doctor since the design includes the tests and prescribing medicines, the establishment provision of incentives for specific preventive and of a system for health technology assessment screening activities. (HTA), the preparation of new clinical guidelines for the management of high-cost diseases, the introduction of coding for diagnosis-related groups Recently legislated and/or planned policy (DRGs) in both public and private hospitals to reforms provide the basis for a future payment mechanism, Health sector reforms gained some momentum shadow-budgeting for public hospitals, and under the Economic Adjustment Programme. A periodic reviews of various other measures (using Memorandum of Understanding on Specific HTA to define the scope of publicly covered Economic Policy Conditionality (MOU) attached services, user charges policy and the introduction to this economic adjustment programme included of income-related contributions earmarked for the fiscal and structural measures intended to “control NHIS), introduction of working time flexibility, the growth of healthcare spending, strengthen the definition of a basket of publicly covered sustainability of the health sector's funding (reimbursable) medical services and establishment structure and improve the efficiency of public of a system of family doctors to refer patients to healthcare provision”. other levels of care, etc.

Specific measures were intended to increase the The current planning of the comprehensive reform availability of publicly financed health services, to of the healthcare sector is soon to be completed initiate processes to improve the quality of care in and besides the Autonomisation of Public public provision of health services and to increase Hospitals, will include the modernisation of revenue for the health sector. These included: (a) a Primary Healthcare, the eHealth, the establishment revision of exemptions from user charges and the of University Clinics, the setup of National introduction of a new contribution of 1.5% on the Medicines Organisation and the introduction of gross salary or pension for active and retired civil National Health Insurance System that will be key servants; (b) a 30% increase in user charges for for accelerating reforms and provide citizens with publicly provided health services for ‘non- high level healthcare services, in a single market, beneficiaries’ and the introduction of new user without public – private boundaries, with the charges (co-payments) and increased user charges patient in the centre, able to choose healthcare for higher levels of care; (c) financial disincentives provider. The NHIS will be developed and for using emergency care in non-urgent situations; implemented based on the fundamental principles financial disincentives in the form of co-payments of free choice of provider, social equality and to minimise medically unnecessary laboratory tests solidarity, financial sustainability and universal and use of pharmaceuticals; (d) MOU measures coverage. The NHIS will be based on a single provided for the restructuring and autonomisation payer system. of public hospitals, the restructuring of the Ministry of Health, Associated Facilities/ Challenges Organisations and the Health Insurance Organisation (HIO). They provided also for the The analysis above demonstrates the various implementation of the National Health Insurance challenges that the health system faces and that Scheme. health reforms have to tackle. The highlighted intrinsic distortions in the system cause inequality, inefficiencies and prevent access to health care. (108) The assessment was based on the revised 2014 version of The reforms planned by the MoH in the next two the WHO tool for 10 Essential Public Health Operations. years have the potential to tackle many of these issues, but given the anticipated resistance on the

55 European Commission Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents

side of stakeholders, a strong political commitment • To define a comprehensive human resources is of the essence and will be a key driver of strategy to ensure a balanced skill-mix that success in responding to the challenges. These allows a strong primary care sector to develop. following can currently be identified: • To continue to improve data collection and data • To achieve the full implementation of the exchange by monitoring of inputs, processes, NHIS with the aim to ensure equal access, outputs and outcomes including putting financial sustainability and quality health care. interoperable IT-systems into place in every This, in turn, would ensure universal coverage public hospital. Accessibility and and the pooling of financing to the sector, interoperability should be extended to allow, currently non-existent. The full implementation with the consent of the patient and/or health of the NHIS would also address the professional, access and exchange of data with inefficiencies related to the fragmentation of private sector ehealth systems as well as with care provision characterised by separate public the patient, to eventually achieve a patient- and private provision that do not make part of a centred eHealth system. whole coherent framework. • To make systematic use of cost-effectiveness • To continue increasing the efficiency of health information, as planned, in determining the care spending in order to adequately respond to basket of goods and the extent of cost-sharing. the increasing health care expenditure over the coming decades that is a risk to the long-term • To foster health promotion and disease sustainability of public finances. prevention activities, promoting healthy life styles and disease screening given the pattern • To implement a comprehensive reform of the of risk factors (smoking, alcohol, obesity, public hospital sector increasing their circulatory system diseases). managerial capacity and legal ability for autonomous decision making within a strategic framework of public health policies aiming at: an increase of hospital output, an improvement of the provision of after-hours primary care services, and the creation of integrated networks of public primary health care centres working in a coordinated fashion with public hospitals.

• To reorganise and promote public hospitals autonomy so as to ensure equal competition between private and public health providers and ease failure of coordination between the public and the private sector leading to duplication and waste of resources.

• To focus on enhancing primary health care services and to implement a comprehensive reform of the primary health care centres to improve efficiency and care coordination between types of care and to encourage patients to first make use of primary care vs. specialist care vs. hospital care.

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0.2 2.4 4.1 2.0 9.9 0.3 8.0 7.8 3.6 2.7 0.3 1.4 0.4 0.3 0.4 2.5 0.3 1.8 1.0 0.2 0.3 0.3 127 29.6 78.4 98.0 15.9 83.3 77.9 63.3 62.6 10.2 15.0 2015 2015 2015 2015 3,305 2,609 508.5 14,447 0.2 2.4 0.2 0.1 9.9 0.2 7.8 7.6 3.7 2.7 0.3 1.5 0.4 0.3 0.4 2.5 0.3 1.7 1.0 0.2 0.2 0.3 131 28.0 79.4 98.9 15.9 83.3 77.7 61.5 61.4 10.1 15.2 2013 2013 2013 2013 2,975 2,324 505.2 13,559 0.2 2.5 0.2 1.5 9.4 0.6 7.8 7.6 3.9 2.6 0.2 1.2 0.3 0.2 0.4 2.5 0.2 1.8 0.9 0.1 0.2 0.3 138 28.1 77.5 99.1 14.9 83.1 77.3 62.1 61.7 10.1 14.8 2011 2011 2011 2011 2,895 2,263 503.0 13,213 EU- latest national data EU- latest national data 64 0.2 2.5 3.7 9.3 0.9 8.0 7.7 4.2 2.7 0.2 1.2 0.3 0.3 0.4 2.6 0.1 1.8 0.9 0.1 0.2 0.3 -4.7 26.8 78.1 99.6 14.6 82.6 76.6 62.0 61.3 10.2 14.8 2009 2009 2009 2009 2,745 2,153 502.1 12,451 18 98 2.1 2.6 6.8 6.8 0.1 2.9 2.9 6.3 0.8 2.7 2.0 0.2 1.2 0.2 0.1 0.1 1.3 0.1 0.7 0.2 0.0 0.1 0.1 674 -4.9 23.8 0.06 43.1 83.0 43.9 83.7 79.9 63.4 63.1 2015 2015 2015 2015 1,564 : 18 93 2.1 7.4 6.8 0.6 3.1 3.0 5.4 0.9 1.4 2.0 0.2 1.1 0.2 0.0 0.1 1.4 0.1 0.7 0.2 0.0 0.0 0.1 686 -1.5 -0.3 22.1 0.08 41.5 44.8 84.7 80.9 66.3 66.1 2014 2014 2014 2014 1,653 18 92 2.1 7.5 6.9 0.6 3.3 3.2 6.1 0.9 1.6 2.1 0.2 1.2 0.1 0.1 0.1 1.5 0.1 0.7 0.3 0.0 0.0 0.1 747 -4.9 -5.7 21.9 0.07 43.8 83.0 43.1 85.0 80.1 65.0 64.3 2013 2013 2013 2013 1,708 19 2.1 7.4 6.7 0.7 3.1 3.0 6.7 0.9 3.5 2.0 0.2 1.1 0.1 0.1 0.1 1.4 0.1 0.7 0.2 0.0 0.0 0.1 767 107 -6.8 -4.5 23.2 0.06 41.9 83.0 44.0 83.4 78.9 64.0 63.4 2012 2012 2012 2012 1,829 20 2.0 1.8 7.6 6.6 1.0 3.2 3.1 6.9 0.8 3.1 2.1 0.2 1.1 0.1 0.1 0.1 1.5 0.1 0.7 0.2 0.0 0.0 0.1 815 103 -2.2 24.6 0.07 41.9 83.0 42.8 83.1 79.3 61.0 61.6 2011 2011 2011 2011 1,947 : : 19 46 7.3 6.3 1.0 3.1 3.0 7.4 0.8 3.2 2.0 0.2 1.0 0.1 0.1 0.1 1.5 0.1 0.7 0.2 0.0 0.1 0.1 795 -2.9 -1.3 25.4 0.06 42.4 41.0 83.9 79.2 64.2 65.1 2010 2010 2010 2010 1,875 : : 19 45 2.7 7.4 7.4 0.0 3.1 3.1 7.3 0.8 3.3 2.6 0.2 1.3 0.1 0.0 0.1 1.9 0.0 0.4 0.3 0.0 0.0 0.3 804 -4.4 26.3 0.06 42.4 49.9 83.5 78.5 65.3 64.8 2009 2009 2009 2009 1,895 : : 19 49 1.3 6.9 6.9 0.0 2.8 2.8 7.5 0.8 3.5 2.3 0.2 1.2 0.2 0.0 0.1 1.7 0.0 0.4 0.3 0.0 0.0 0.2 761 28.1 0.05 41.3 51.3 82.9 78.2 64.5 63.9 15.4 2008 2008 2008 2008 1,844 : : 18 54 2.6 6.1 6.1 0.0 2.6 2.6 7.7 0.8 3.7 1.8 0.1 1.2 0.1 0.0 0.1 1.4 0.0 0.3 0.3 0.0 0.0 0.2 669 -1.2 28.9 0.09 43.6 49.1 82.1 77.6 62.8 63.1 2007 2007 2007 2007 1,535 : : 16 63 1.3 2.8 6.3 6.3 0.0 2.9 2.6 7.3 0.7 3.1 1.8 0.1 1.3 0.1 0.0 0.1 1.4 0.0 0.3 0.3 0.0 0.0 0.2 683 27.6 0.27 45.5 48.6 82.0 78.1 63.4 64.2 2006 2006 2006 2006 1,500 : : : 15 55 2.2 6.4 6.4 0.0 2.8 2.5 7.7 0.7 4.6 1.8 0.1 1.3 0.1 0.0 0.1 1.4 0.0 0.3 0.3 0.0 0.0 0.2 617 27.1 0.27 43.2 50.1 80.8 76.5 58.2 59.8 2005 2005 2005 2005 1,428

Cyprus – Statistical AnnexStatistical

EUROSTAT, and WHO. OECD EUROSTAT,

2.5.1:

General context GDP GDP, in billion Euro, currentprices GDP capita per PPS (thousands) Real capita GDPper (% growth year-on-year) Real total health capitaper (% growth year-on-year) expenditure health* on Expenditure Total as %of GDP Total current as % of GDP Total capitalinvestment as% of GDP Total capita per PPS Public total as % of GDP Public current as %of GDP Public totalcapita per PPS Public capital investment as % of GDP Public as % total on health expenditure Publichealth on expenditure in %of total governmentexpenditure Proportion of the population covered public by primaryor private health insurance Out-of-pocket on health expenditure as % of total currenthealth on expenditure Note: *Including also on medical expenditure long-term carecomponent, as reported in standardinternation databases, such as in the System of HealthAccounts. Total includes expenditure current plus expenditure capital investment. status health Population and Population, current (millions) Life expectancy at birth for females Life expectancy at birth for males Healthy life years at birth females Healthy life years at birth males Amenable mortalityrates 100 000 inhabitants* per Infant mortalityrate 1 000 liveper births Notes: Amenable mortality rates break in series in 2011. characteristicsSystem GDP of % as expenditure current total of Composition Inpatient curative and rehabilitative care casesDay curative and rehabilitative care Out-patient curative and rehabilitativecare Pharmaceuticals and other medical non-durables Therapeutic appliances and other medical durables Prevention and public health services Health administration and health insurance GDP of % as expenditure public current of Composition Inpatient curative and rehabilitative care casesDay curative and rehabilitative care Out-patient curative and rehabilitative care Pharmaceuticals and other medical non-durables Therapeutic appliances and other medical durables Prevention and public health services Health administration and health insurance Table Source:

57 European Commission Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents

78 16 1.9 7.6 1.0 2.3 0.2 6.3 2.0 EU 0.9 1.6 EU 344 833 402 20.9 10.2 76.8 15.4 32.3 2015 2015 2015 2015 3.1% 4.1% 3.1% 3.8% 3.5% 2.1% 3.2% 3.4% 7,635 27.0% 24.0% 14.6% 31.9% 22.5% 12.7% 78 16 1.5 7.7 0.9 2.1 0.2 6.2 0.4 0.6 338 825 407 21.8 10.1 76.5 15.5 30.9 20.2 2013 2013 2013 2013 3.0% 4.1% 3.0% 3.9% 3.4% 2.0% 3.2% 3.6% 7,143 27.1% 23.7% 14.7% 32.1% 22.2% 12.6% Cyprus Cyprus Change 2016-2070, in % Change 2016-2070, in pps. 78 16 1.4 7.8 0.9 1.9 0.1 6.2 330 835 408 22.3 10.3 76.4 15.1 29.1 2011 2011 2011 2011 1.7% 3.6% 2.5% 4.3% 2.0% 1.9% 2.5% 4.0% 6,584 27.9% 26.3% 12.8% 33.6% 23.5% 11.9% EU- latest national data EU- latest national data 77 17 1.0 8.0 0.9 2.1 0.1 6.2 3.2 3.4 1.0 324 837 416 23.2 10.4 77.1 15.0 28.0 2070 2009 2009 2009 2009 2070 1.7% 3.6% 2.8% 4.5% 1.9% 1.8% 2.9% 4.1% 6,362 29.1% 26.8% 13.1% 33.9% 22.9% 11.8% : : : 7 87 6.2 0.8 3.4 0.0 2.2 3.2 3.4 1.0 358 523 518 2.01 72.2 16.7 2065 2015 2015 2015 2015 2065 3.4% 2.2% 0.7% 1.5% 4.2% 7.6% 0.3% 1.7% 3.5% 1,584 29.2% 30.6% 17.1% 46.2% 22.6%

: 8 80 6.4 0.8 3.3 0.0 2.2 3.1 3.4 1.0 338 501 524 1.99 25.2 74.7 13.9 18.2 2060 2014 2014 2014 2014 2060 3.4% 2.2% 0.6% 1.5% 4.0% 7.7% 0.3% 1.3% 3.4% 1,737 29.6% 31.1% 16.8% 46.3% 23.8% 2070). : : : 8 9.0 6.1 0.8 3.3 0.0 2.4 3.1 3.3 1.0 320 492 523 1.97 74.4 17.7 2055 2013 2013 2013 2013 2055 3.3% 2.0% 0.7% 1.6% 4.1% 8.2% 0.3% 1.3% 3.4% 1,672 30.4% 30.4% 16.6% 46.4% 22.9% : : : 8 6.0 0.8 3.2 0.0 2.4 3.1 3.3 1.0 302 475 528 1.97 10.6 75.8 15.7 2050 2012 2012 2012 2012 2050 3.3% 2.1% 0.7% 1.5% 3.9% 7.6% 0.3% 1.3% 3.3% 1,505 30.5% 30.6% 16.4% 47.4% 23.0% : : : : 8 0.8 3.2 0.0 2.3 3.1 3.2 1.0 297 487 535 2.00 10.7 90.9 15.3 2045 2011 2011 2011 2011 2045 3.3% 2.0% 0.8% 1.5% 3.9% 7.7% 0.3% 1.3% 3.2% 1,437 31.6% 30.0% 16.2% 48.4% 22.6% : : : : : 8 0.7 3.3 0.0 2.3 3.0 3.2 1.0 289 476 546 1.93 11.3 84.2 16.9 2040 2010 2010 2010 2010 2040 3.3% 1.9% 0.8% 1.3% 4.0% 7.6% 0.3% 1.7% 2.6% 1,574 31.8% 15.9% 48.5% 22.8% : : : : : 8 0.7 3.3 0.0 2.3 3.0 3.1 0.9 281 471 553 935 1.86 10.8 84.7 11.1 2035 2009 2009 2009 2009 2035 2.3% 1.9% 0.5% 1.5% 1.0% 0.0% 1.0% 8.4% 34.5% 17.3% 61.0% 13.6% 10.4% : : : : 7 0.8 3.5 0.0 2.1 9.7 2.9 3.0 0.9 276 450 559 701 1.64 12.0 88.2 25.9 2030 2008 2008 2008 2008 2030 2.3% 2.3% 0.6% 1.6% 0.7% 0.0% 1.1% 8.6% 33.7% 18.0% 61.1% 13.2% 10.7% EPC (AWG) 2018 Ageing Report projections (2016 - - : : : : : 7 0.8 3.6 0.0 2.1 9.1 2.9 3.0 0.9 270 458 608 749 0.89 11.6 76.0 2025 2007 2007 2007 2007 2025 1.5% 2.1% 0.7% 1.5% 0.8% 0.0% 1.2% 8.2% 29.6% 20.5% 54.9% 12.9% 11.0% : : : : 7 0.8 1.9 0.0 2.0 5.8 9.7 2.9 2.9 0.9 249 450 617 701 0.65 11.5 79.0 2020 2006 2006 2006 2006 2020 1.6% 2.1% 0.6% 1.6% 1.2% 0.0% 1.2% 8.1% 29.3% 20.4% 55.6% 13.1% 10.8% : : : : 7 0.8 2.0 0.0 2.1 6.0 8.7 2.8 2.8 0.8 257 409 690 632 0.66 11.4 84.0 2016 2005 2005 2005 2005 2016 1.4% 2.2% 0.5% 1.6% 0.8% 0.0% 1.2% 8.1% 27.6% 20.6% 54.4% 12.9% 12.1%

Cyprus – continued

- Statistical AnnexStatistical

EUROSTAT, OECD, WHO and European Commission (DG ECFIN)

2.5.2:

Population projections Composition of total as % of total current health expenditure health current total of % as total of Composition Inpatient curative and rehabilitative care casesDay curative and rehabilitative care Out-patient curative and rehabilitative care Pharmaceuticals and other medical non-durables Therapeutic appliances and other medical durables Prevention and public health services Health administration and health insurance expenditure health public current of % public as of Composition Inpatient curative and rehabilitative care casesDay curative and rehabilitative care Out-patient curative and rehabilitative care Pharmaceuticals and other medical non-durables Therapeutic appliances and other medical durables Prevention and public health services Health administration and health insurance Expenditure drivers life (technology, style) unitsMRI 100 000 inhabitants per Angiography unitsinhabitants 100 000 per CTS 100 000 inhabitants per PET scanners 100 000 inhabitants per Proportion of the population that isobese Proportion of the population that isa regular smoker Alcoholconsumption litres capita per Providers Practisingphysicians 100 000 inhabitants per Practisingnurses 100 000 inhabitants per General practitioners 100 000 inhabitants per Acutehospital beds100 000 inhabitants per Outputs Doctors consultations capitaper Hospital inpatient discharges 100 inhabitants per casesDay discharges 100 000 inhabitants per Acutecare bed occupancy rates Hospital length average of stay casesDay as % of all hospital discharges projections Expenditure Population and Projected public expenditureon healthcare of GDP*as % AWG referencescenario scenario AWGrisk Note: *Excluding on medical expenditure long-term care component. Population projections until 2070 (millions) Table Source:

58

Cyprus Long-term care systems

3.5. CYPRUS

increase of 73%, well above the EU-average General context: expenditure, fiscal increase of 21%. sustainability and demographic trends GDP per capita is below EU average based on the Expenditure projections and fiscal sustainability most recent figures, with 23,820 PPS in 2015(EU: 29,610). Population was estimated at 0.9 million in With the demographic changes, the projected 2016 (456). According to Eurostat projections, the public expenditure on long-term care as a total population is projected to increase from that percentage of GDP is projected to steadily level to 1.0 million in 2070, a 20% increase which increase. In the "AWG reference scenario", public is well above the average EU value of 2%. Based long-term expenditure is driven by the on the Ageing Report 2018, total public combination of changes in the population structure expenditure on long-term care (health and social and by a moderately positive evolution of the part) (457) is, with 0.3 % of GDP in 2015, below health (non-disability) status. The joint impact of above the EU average in the same year (1.6%). those factors is a projected increase in spending of The health component however, with 0.2% in 2015 about 0.3 pps of GDP by 2070(458), an increase of is lower than the EU average of 1.2% in the same 84% which stands above the average EU value of year. 73%. The "AWG risk scenario", which also captures the impact of additional cost drivers to demography and health status, i.e. the possible Health status effect of a cost and coverage convergence, projects Life expectancy at birth, 83.7 years for women and an increase in spending of 2.9 pps of GDP by 79.9 years for men, was above EU average levels 2070. This reflects the fact that coverage and unit of 83.3 and 77.9years in 2015. However, in terms costs of care are relatively low in Cyprus, and may of healthy life years, Cyprus is broadly in line with experience an upward trend in future, driven by the average with 63.4 years for women and 63.1 demand side factors. Overall, the projected long- years for men (vs.63.3 and 62.6 in 2015 in the term care expenditure increase is expected to add EU). The percentage of the population having a to budgetary pressure, contributing to the risk for long-standing illness or health problem is below long-term sustainability of public finances (459). the value for the Union as a whole (32.7% in Cyprus versus 34.2% in the EU in 2015). The

percentage of the population indicating a self- perceived severe limitation in daily activities for System Characteristics the same year stands at 7.9%, which is only slightly lower than the EU-average of 8.1%. Policies and measures that fall within the spectrum of long-term care are administered by the Ministry of Health (long-term health care) and the Ministry Dependency trends of Labour, Welfare and Social Insurance (MLWSI) The number of people depending on others to carry (long-term social care, sensory, cognitive) through out activities of daily living is projected to increase the Welfare Benefits Administration Service, the, significantly over the coming 50 years. From 70 Social Welfare Services (SWS) and the thousand residents living with strong limitations Department for Social Inclusion of Persons with due to health problems in 2016, an increase of Disabilities (DSID). 107% is envisaged up to 2070, to slightly less than 140 thousand. That is a steeper increase than in the In July 2014, the Guaranteed Minimum Income EU as a whole (25% in the EU). Also as a share of (GMI) and Social Benefits legislation was adopted the population the dependents are projected to and the competent Ministry is MLWSI. become a bigger group, from 7.8% to 13.4%, an

(458) The 2018 Ageing Report: (456) Based on Eurostat projections. https://ec.europa.eu/info/publications/economy- (457) Long-term care benefits can be disaggregated into health finance/2018-ageing-report-economic-and-budgetary- related long-term care (including both nursing care and projections-eu-member-states-2016-2070_en. personal care services) and social long-term care (relating (459) European Commission, Fiscal Sustainability Report (2018) primarily to assistance with tasks linked with Activities https://ec.europa.eu/info/sites/info/files/economy- with Daily Living). finance/ip094_en_vol_2.pdf.

326 Long-term care systems 3.5. Cyprus

The Guaranteed Minimum Income and in general These benefits cover the cost for the purchase of the Social Benefits (Emergency Needs and Care care services but also rehabilitation services Needs) Decree of 2015 N.353/2015, which was (physiotherapy, occupational therapy, speech revised in 2016 (N. 162/2016), incorporates the therapy etc). Due to the absence of a National “Scheme for the Subsidisation of Care Services” Health System and an integrated rehabilitation which covers social care needs of recipients of policy, persons with disabilities often use DSID guaranteed minimum income and members of their cash benefits for purchasing rehabilitation services family unit. The Scheme mainly covers cash from the private sector. benefits and in justified cases it may provide for in-kind services (from state home carers who are Long-term care constitutes a minor share of total employed under a contract with the government to government expenditure. In 2015, per capita provide their services – benefits in kind–to the spending for this item was at the level of 38.5 beneficiaries). million PPS (EU: 373.6 PPS). In terms of total government spending, this accounted for only Subsidisation of care services under the Decree, 0.4% (EU: 2.5%). covers home care, day care, respite care and residential care in approved and registered care Public spending on long-term care in Cyprus services (natural and/or legal persons) under the reached 0.2% of GDP in 2013 and remained stable relevant legislative framework of the SWS. Long- at that level until 2015, well below EU average of term social care services are provided by the 1.2% of GDP. Only more than half of this government, local authorities, non-governmental spending, (54%) was spent on in-kind benefits, organisations (NGOs), and the private sector which is a much lower share than for the EU as a (private for profit enterprises). whole (EU 2016: 84.4%), while 46%, far above the EU average of 15.6% for 2016, was provided In addition, two new Decrees were adopted in as cash-benefits. Based on available figures, 2017 (365/2017) and 2018 (158/2018), covering in Cyprus appears to have a stronger focus on cash particular the subsidisation of home care services benefits, which is a consequence of the lack of a to persons with disabilities and persons aged 80 formal public long-term care scheme. It is not clear years old and above, respectively. which role private co-payments for formal in-kind care play in the financing of long-term care Furthermore, the MLWSI subsidise social care services. programmes at local level run by NGO’s and Local Authorities [State Aid Scheme, under the Types of care Regulation 360/2012 for the provision of services of general economic interest (De minimis)]. These The expenditure for institutional (in-kind) services programmes (day-care, residential care, home care makes up 12.7% of public expenditure on long- and child care) cover the social care needs of older term care in-kind (EU: 66.3%), 87.3% are being people, people with disabilities and children at spent for long-term care services provided at home local level. (EU: 33.7%). However, as discussed above, Cyprus spends most of its long-term care resources The State (SWS) provides full time care in via cash benefits, thus with a greater focus on residential homes for older persons and persons home care. with mental and physical disabilities and it operates Houses in the Community for persons According to the Decree 162/2016 the following with mental and physical multiple disabilities. types of care (formal care), are covered:

Moreover, additional cash benefits are regulated Home care may include personal and household by the DSID for persons with disabilities, care. To cover the needs of home care either by an irrespective of their income level, targeting to approved natural and/or legal person, or by cover the cost of disability. In particular, under two Domestic Worker the maximum amount granted as special laws and two schemes, persons with severe a subsidy is €400/month per family unit. For motor disability, paraplegia, quadriplegia or extraordinary and justified cases a larger amount blindness are entitled to monthly cash benefits. can be covered for instance, when additional care

327 European Commission Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents

attendants are required. According to the Decree assessed and certified by the Disability Assessment 158/2018, for persons aged 80 years old and above Center of the Department for Social Inclusion of the amount of subsidisation for home care services Persons with Disabilities. is €200 or €400, according to their needs.

Eligibility criteria and user choices: Day care: is offered during the day at Day Care dependency, care needs, income Centers for the Elderly and Persons with Disabilities covering personal care services, meals, GMI recipients may be entitled to subsidisation of social and creative activities. The State may pay a their long-term social care needs, except for cash benefit to recipients of long-term care of up to persons with severe disability €137 per month for day care provided by approved (motor/paraplegia/quadriplegia/blindness), who are physical and/or legal persons. In some cases the entitled to this irrespective of their income level. transportation/accompanying costs especially for Subsidisation for long-term social care may also be persons with disabilities are also covered. provided to persons that are not eligible for GMI, if their income is not sufficient to cover for their Residential care: provides for a 24 hour care, long term social care needs, provided that they where the person requires continuous support and meet all the other conditions specified in the GMI their needs cannot be covered by family members legislation. or other supportive services in their environment. Residential care is provided by the public, private No qualifying period is defined for long-term or non-governmental. In addition to free residential social care eligibility. Entitlement to long-term care in public institutions, the state may pay social care is based upon need, i.e. based on the monthly cash benefit for residential care provided person’s ability to carry out his/her daily home and by approved natural and/or legal persons. Cash personal care and his/her ability to meet his/her benefits vary from €625 to €745 per month frequent activities outside of his/her home (i.e. depending on the care needs of the beneficiary shopping, doctor visits, social activities). In (e.g. bedridden, mobility difficulties or not). addition, the Decree (N.162/2016) does not provide for any element of duration/degree of Respite Care: is for short periods of time in order dependency. Only in the case of home care to give short spells of rest to the informal care- provided by Domestic Worker, the persons should giver and can take the form of the above types of be deprived of their ability for self-care. care (home, residential or day care). Informal carers are supported in their valuable role and GMI applications are evaluated by the Welfare simultaneously the person concerned is supported Benefits Administration Service, which informs for staying in their home environment. Respite the SWS whether the applicant fits in the category care is arranged depending on the needs and of people who can be assessed for the provision of preferences of the people themselves and of their care services based on the legislation and whether families as far as possible. the applicant receives care benefit from any other Service. Subsequently, the SWS assess the social The level of the subsidisation for the above types care need of applicants and then communicate the of care is defined by an automated analysis of the results of their assessment to the Welfare Benefits specific assessment tools used by the SWS. Administration Service for their decision on the application according to the results of the In the case of DSID cash benefits can be used by assessment. the beneficiaries at their choice of care services either formal or informal. The SWS perform in situ visits to the accommodation of the applicants/beneficiaries to In addition, as from November 2017 a new Decree assess the need for care with the use of specific 365/2017 was issued according to which home assessment tools. The SWS may ask for additional care for persons with disabilities in the framework certificates/reports from other Services (including of the Guarantee Minimum Income Law has four medical reports). Subsequently, the information level subsidy being €100, €200, €300 or €400. The collected is assessed by Specialised Assessment needs for care at home and the level of subsidy are Teams of the SWS. In case of a positive evaluation

328 Long-term care systems 3.5. Cyprus

of the care needs of the applicant/ beneficiary Long-term care includes health, personal, and which corresponds to the approval of care support services, aiming at helping people to provision, it includes the type, the extent and the remain at home and live as independently as duration of the care that will be provided as well as possible. Long-term care is mainly provided either the amount of subsidisation. Between the in the home of the person receiving services or at a beneficiary and the approved service provider an family member's home. In-home services may be Agreement for the Provision of Social Care is short-term -for someone who is recovering from signed, which should be notified to the SWS for surgery, for example -or long-term, for people who the correctness of the content and for the future need help continuously. quality checks of the service provision. Long-term care Services are provided mainly to In case the beneficiaries prefer a different type of people with a high level of dependency, often care than the one proposed, then they have the elderly people, those with chronic diseases and right to make their own arrangements, which will people with physical, learning and mental be subsidised up to the approved amount. disabilities. The Nursing Services of the Ministry of Health facilitate the long-term care provided by In the case of persons with disabilities, in order to a network of Community Nurses (General Nursing become entitled of disability cash benefits by Community Nurses and Mental Health Community DSID or the GMI-Disability additional benefit Nurses) through home visits to mentally ill they have to follow a disability assessment and patients, disabled people, artificially ventilated certification through the DSID Disability patients at home and elderly people who live alone Assessment Centre. The disability assessment and encounter severe health problems. methodology is based on the International Classification of Functioning, Disability and The long-term care provided by the Mental Health Health (ICF) issued by the World Health Services, is being ensured by monitoring chronic Organisation (WHO). mental patients in the community (at their homes or at rehabilitation units, such as Day Centers and According to Decree 365/2017 as from November Occupational Rehabilitation Units). These services 2017, the Disability Assessment Centers of the are provided by a multi-disciplinary team of Department for Social Inclusion of Persons with mental health professionals – psychiatrists, clinical Disabilities also assess and certify, based on the psychologists, ergo therapists, nursing officers. ICF classification, the needs of persons with disabilities for care at home. Dental Services have a wide network of clinics geographically distributed to provide access in remote areas populated predominantly by elderly Prevention and rehabilitation measures people. These clinics in the rural and urban areas In Cyprus the health care system for the elderly offered primary and secondary oral care services. people is strongly acute-care oriented. Hospital Alongside the four large hospitals operate and specialist care is a priority over other models prosthetic clinics for construction of partial and of care. Elderly patients have the opportunity to full dentures. Beneficiaries as third age patients, visit the primary health care services either at the have to pay a small amount of 100 euro per item out patients surgeries or at the health care centers (denture). all over the districts. The GPs do not function as gatekeepers for medical care, as hospitals and Formal/informal caregiving private specialists are directly accessible to patients. Nursing homes as such do not exist, but In the case of DSID cash benefits can be used by elderly and very elderly people in need of complex the beneficiaries at their choice of care services care stay in hospitals or in special care wards in either formal or informal. retirement homes. Health care provision is also offered in hospital physiotherapy services, according to their needs.

329 European Commission Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents

Recently legislated and/or planned policy providers; to share data within government reforms administrations to facilitate the management of potential interactions between LTC financing, In July 2014, the Cyprus Government has targeted personal-income tax measures and reformed the welfare system by introducing a transfers (e.g. pensions), and existing social- Guaranteed Minimum Income (GMI). In the assistance or housing subsidy programmes. relevant Law (N. 109(I)/2014), article 10 (2) refers to the care needs of the GMI recipients and their • Improving financing arrangements: to face family members, where additional assistance can the increased LTC costs in the future e.g. by be provided. In this direction, the Minister of tax-broadening, which means financing beyond Labour, Welfare and Social Insurance, issued in revenues earned by the working-age August 2014 a Decree that incorporates the population; to foster pre-funding elements, “Scheme for the Subsidisation of Care Services”, which implies setting aside some funds to pay which was revised in 2015 (N.353/2015) and in for future obligations; to explore the potential 2016 (162/2016). The new Scheme subsidises the of private LTC insurance as a supplementary social care needs of GMI recipients, including the financing tool. members of their family unit, as described in section “LTC System Characteristics”. • Providing adequate levels of care to those in need of care: to reduce the risk of In addition, two new Decrees were adopted in impoverishment of recipients and informal 2017 (365/2017) and 2018 (158/2018), covering in carers. particular the subsidisation of home care services to persons with disabilities and persons aged 80 • Ensuring availability of formal carers: to years old and above, respectively. determine current and future needs for qualified human resources and facilities for In addition, the SWS, as the competent authority long-term care. for the inspection of the minimum quality standards of care structures, have determined in • to establish 2016 Terms and Conditions for the Provision of Supporting family carers: policies for supporting informal carers, such as Home Care Services, pending the drafting of a new through flexible working conditions, , carer’s law which will regulate home care provision. allowances replacing lost wages or covering expenses incurred due to caring, cash benefits Challenges paid to the care recipients, while ensuring that incentives for employment of carers are not Cyprus has recently reformed and clearly defined diminished and women are not encouraged to eligibility for long-term care benefits, but the withdraw from the labour market for caring financing of the system is relatively fragmented reasons. and overall governance seems improvable. The main challenges of the system appear to be: • Ensuring coordination and continuity of care: to establish better coordination of care • Improving the governance framework: to set pathways and along the care continuum, such the public and private financing mix and as through a single point of access to organise formal workforce supply to face the information, the allocation of care co- growing number of dependents, and provide a ordination responsibilities to providers or to strategy to deliver high-performing long-term care managers, via dedicated governance care services to face the growing demand for structures for care co-ordination and the LTC services; to strategically integrate medical integration of health and care to facilitate care and social services via such a legal framework; co-ordination. to define a comprehensive approach covering both policies for informal (family and friends) • carers, and policies on the formal provision of To facilitate appropriate utilisation across LTC services and its financing; to establish health and long-term care: to steer LTC users good information platforms for LTC users and towards appropriate settings.

330 Long-term care systems 3.5. Cyprus

• Improving value for money: to invest in ICT as an important source of information, care management and coordination.

• Prevention: to promote healthy ageing and preventing physical and mental deterioration of people with chronic care; to employ prevention and health-promotion policies and identify risk groups and detect morbidity patterns earlier.

331 European Commission Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents

: : 8.1 2.2 1.2 2.5 509 34.2 29.6 83.3 77.9 63.3 62.6 373.6 4,313 6,905 14,447 EU 2015 EU 2015 : : 8.7 2.2 1.2 2.5 505 32.5 28.0 83.3 77.7 61.5 61.4 352.1 4,183 6,700 13,559 EU 2013 EU 2013 : : 8.3 2.2 1.2 1.8 503 31.7 28.1 83.1 77.3 62.1 61.7 283.2 3,851 7,444 13,213 EU 2011 EU 2011 : : 8.3 2.0 1.1 1.6 502 31.3 26.8 82.6 76.6 62.0 61.3 264.1 3,433 6,442 12,451 EU 2009 EU 2009 : : 3 3 18 7.9 0.8 0.8 0.2 0.4 38.5 32.7 23.8 83.7 79.9 63.4 63.1 2015 2015 : : 3 3 18 7.3 0.8 0.9 0.2 0.3 35.2 32.2 22.1 84.7 80.9 66.3 66.1 2014 2014 : : 3 3 18 8.0 0.7 0.9 0.2 0.4 33.9 33.2 21.9 85.0 80.1 65.0 64.3 2013 2013 : : : 5 19 7.9 0.5 0.9 0.1 0.3 33.5 32.6 23.2 83.4 78.9 64.0 63.4 2012 2012 : : : 4 20 0.5 0.8 0.1 0.3 10.3 34.6 32.7 24.6 83.1 79.3 61.0 61.6 2011 2011 : : : 4 19 7.6 0.5 0.8 0.1 0.3 33.0 34.0 25.4 83.9 79.2 64.2 65.1 2010 2010 : : : : 4 19 6.7 0.5 0.8 0.0 0.0 28.4 26.3 83.5 78.5 65.3 64.8 2009 2009 : : : : 3 19 6.9 0.4 0.8 0.0 0.0 25.9 28.1 82.9 78.2 64.5 63.9 2008 2008 : : : : 3 18 8.2 0.4 0.8 0.0 0.0 28.7 28.9 82.1 77.6 62.8 63.1 2007 2007 : : : : : : 16 8.5 0.7 0.0 0.0 29.1 27.6 82.0 78.1 63.4 64.2 2006 2006 : : : : : : : : 15 0.7 0.0 0.0 27.1 80.8 76.5 58.2 59.8 2005 2005

Cyprus – Statistical AnnexStatistical

EUROSTAT, and WHO. OECD EUROSTAT,

3.5.1:

GENERAL CONTEXT GENERAL GDP Population and GDP, in billion euro, current prices GDP per capita, PPS Population, in millions long-term on expenditure care (health) Public As GDP % of Per capita PPS As % total government of expenditure Note: Based on OECD, Eurostat - System Health of Accounts Health status Life expectancy at birth females for Life expectancy at birth males for Healthy years life at birth females for Healthy years life at birth males for havingPeople a long-standing problem, pop. % health in of or illness People having self-perceived severe limitations in daily activities (% pop.) of CHARACTERISTICS SYSTEM Reports) Ageing from data on (Based Coverage thousands in an institution, in care receiving people Number of Number people of receiving care at home, in thousands % pop. of receiving formal LTC in-kind Note: in Break series in 2010 and 2013 due methodological to changes in estimating number care of recipients Providers Number informal of carers, in thousands Number formal of carers, in thousands Table Source:

332 Long-term care systems 3.5. Cyprus

5% 0% 1% 2% -1% 25% 21% 73% 72% 86% 52% 61% 33% 10% -27% -14% 170% EU 2016-2070 Change 9% 1% 0% -5% -9% -9% 20% 73% 84% 96% 13% -11% 2070 107% 947% 157% 164% 117% MS 2016- Change 1.0 0.6 3.2 9.0 2.0 4.7 0.14 13.4 67.2 58.9 41.1 12.9 87.1 14.1 2070 21,528 20,603 49,959 1.0 0.5 1.8 7.9 2.0 4.8 0.12 12.3 64.3 57.2 42.8 12.9 87.1 14.2 2060 18,538 17,497 44,046

2070). - 1.0 0.4 1.1 7.2 1.9 4.9 0.11 11.4 62.9 55.6 44.4 12.8 87.2 13.7 2050 16,224 15,187 39,108 1.0 0.4 0.7 6.4 1.9 4.9 0.10 10.4 61.9 54.6 45.4 12.7 87.3 13.7 2040 13,967 13,066 34,564 0.9 9.3 0.4 0.5 5.6 1.9 5.1 0.09 60.5 46.3 12.7 87.3 14.1 53.7 2030 11,530 10,753 29,588 0.9 8.2 0.3 0.3 4.9 2.1 5.1 0.07 59.4 54.2 45.8 12.7 87.3 15.3 2020 9,186 8,530 24,654 EPC EPC (AWG) 2018 Ageing Report projections (2016 - 0.9 7.8 0.3 0.3 4.6 2.1 5.1 0.07 59.3 54.0 46.0 12.7 87.3 15.5 2016 8,390 7,798 23,009

Cyprus – continued

- Statistical AnnexStatistical

EUROSTAT, OECD, WHO and European Commission (DG ECFIN)

3.5.2:

PROJECTIONS Population Population projection in millions Dependency millions in dependents Number of % in dependents, Share of GDP as % of LTC on expenditure Projected public AWG scenario reference AWG scenario risk Coverage Number people of receiving care in an institution Number people of receiving care at home Number people of receiving cash benefits % pop. of receiving formal LTC in-kind and/or cash benefits formal LTC receiving dependents % in-kind and/or of benefits cash costs unit and expenditure public of Composition Public spending formal on LTC publ. spending in-kindtot. % ( LTC) of publ. spending tot. % ( LTC) of Public spending LTC on benefits cash related publ. spending tot. % ( LTC of care in-kind)Public spending institutional on publ.Public spending spending tot. % home ( on LTC of care in-kind) Unit costs institutional of care per recipient, as % GDP of per capita Unit costs home of care per recipient, as % GDP of per capita Unit costs cash of benefits per recipient, as % GDP of per capita Table Source:

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