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 the majority of public healthcare facilities (hospitals, social clinics etc.) also continued to persist in 2022 In addition to the limited capacity of the public Health system, applicants’ access to healthcare was further hindered as far back as 2016,[4] due to the reported ‘generalised refusal of the competent public servants to provide asylum seekers with an AMKA’ [5] (i.e. social security number), which up to the entry into force of article 55 IPA (as replaced by article 59 par. 2 of L. 4939/2022) served as the de facto requirement for accessing the public healthcare system. This was further aggravated following a Circular issued on 11 July 2019, which in practice revoked asylum seekers’ access to the AMKA. As noted by Amnesty International in October 2019, ‘the administrative obstacles faced by many asylum seekers and unaccompanied children in issuing an AMKA have significantly deteriorated following 11 July 2019, when the Ministry of Labour revoked the circular which regulated the issuance of AMKA to non-Greek citizens. Following the circular’s revocation, no procedure was put in place for the issuance of AMKA to asylum seekers and unaccompanied minors’.[6]
Article 55 of the IPA (as replaced by article 59 par. 2 of L. 4939/2022), introduced a new a Foreigner’s Temporary Insurance and Health Coverage Number (Προσωρινός Αριθμός Ασφάλισης και Υγειονομικής Περίθαλψης Αλλοδαπού, PAAYPA), replacing the previous Social Security Number (AMKA). PAAYPA is to be issued to asylum seekers together with their asylum seeker’s card.[7] 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.[8] Said provisions of the IPA entered into force on 1 November 2019. However, the necessary mechanism for their implementation was not activated until the start of 2020.
In a welcome development, the publication of the Joint Ministerial Decision for the issuance of the PAAYPA was issued on 31 January 2020,[9] officially triggering the mechanism. The activation of the PAAYPA number was announced in April 2020.[10] Acquisition of the PAAYPA by its beneficiaries (i.e. applicants) was recorded as slow up to the end of the year. Indicatively, by 7 December 2020, out of the 14,392 asylum applicants residing in the ESTIA II accommodation scheme, only 35% (approx. 5,037) had acquired the PAAYPA.[11] It needs to be pointed out that another 39% (approx. 5,612) of asylum seekers residing in ESTIA II were recorded as holding an AMKA during the same time,[12] potentially due to having arrived in Greece before the issuance of the July 2019 Circular, which, nevertheless still means that 36% of beneficiaries did not have access to Greece’s healthcare system, apart from in emergency cases. By the end of the year (31 December), the number of PAAYPA and/or AMKA holders in ESTIA II (asylum seekers & beneficiaries of international protection) was recorded at 45%, highlighting the ongoing challenges.[13] Relevant data for residents of the camps are not available, at least, to GCR’s awareness. Also, relevant data for those residing under the ESTIA II accommodation scheme has not been published in the project’s updates issued by MoMA in the most recent available statistics for 2022.[14]
Furthermore, throughout 2020 challenges were also observed due to the automatic extension of documents, amid measures aimed at restricting the spread of the COVID-19 pandemic, i.e. the suspension of GAS services towards the public. This created delays in the ability of applicants to receive and/or renew their PAAYPA during the foreseen renewal of their documents, since no similar automatic extension of the PAAYPA was foreseen. Delays with the renewal of the PAAYPA were also observed in 2021.
By February 2021, even though challenges persist, the issue of PAAYPA seemed to have been almost completely solved as far as GCR is aware, with 80% of eligible beneficiaries holding a PAAYPA and efforts being made to cover the rest of the population. Nevertheless, as access to PAAYPA is inter alia dependent on the full registration of a claim, and considering ongoing relevant delays particularly on the mainland, the time it takes for unregistered asylum seekers or applicants with police notes and/or only an initial registration of their claim to enjoy access to Greece’s healthcare system should be further assessed.
GCR is also aware of a limited number of cases where individuals have remained without either an AMKA or a PAAYPA for up to 2 years or more, as they had arrived in Greece during the gap that followed the issuance of the 2019 Circular and seem to have fallen through the cracks, also due to the aforementioned challenges that ensued in the context of the pandemic.
In a case handled by GCR’s Social Unit, the beneficiary, a vulnerable applicant with a chronic and serious health conditions and holder of an active asylum seeker’s card since October 2019, had been unable to obtain a PAAYPA by March 2021 and as a result has been unable to access the necessary medication for his condition, as prescribed by his doctor. Following multiple yet unfruitful attempts to resolve the issue by referring the case to the competent service (GAS), GCR’s social worker intervened to the Ombudsperson requesting their intervention. In the relevant March 2021 intervention,[15] the Ombudsperson inter alia recalls their previously submitted proposal to the GAS to ‘move forward with the necessary arrangements…for the extension of the validity of PAAYPA for all active cards up to 31/3/2021 – and obviously, until the [expiry] of each potential subsequent extension…’, while also recalling the institution’s proposal to also enable this for ‘potential applicants that have not received the PAAYPA, even though they have a valid card’. As noted by the Ombudsperson, ‘[s]uch a holistic regulation of the issue seems to be able resolve the serious obstacles in accessing healthcare services that arise in various individual cases of applicants’.
In 2020, a seemingly welcome increase in the medical/ staff in the RICs was observed. Throughout 2020, though presumably during different time intervals depending on location, a total of 113 doctors were present in the island RICs, namely 4 in the RIC of Kos, 4 in the RIC of Leros, 5 in the Evros RIC, 3 in the RIC of Samos and 6 in the RIC of Chios. Another 17 doctors were present in the temporary Mavrovouni RIC, which is, however, 27 doctors less than the number of doctors that had been present in the Moria RIC during the year (44), and until the latter’s destruction in September 2020. Nevertheless, challenges remain, particularly with respect to residents’ access to mental healthcare services,[16] amid a recorded growing mental health crisis because of prolonged containment.[17]
As stated by the Minster of Migration and Asylum in a February 2021 interview, refugees and migrants in Greece would be vaccinated against COVID-19 in accordance with their age.[18] However, as of May 2021, information on when the vaccination of asylum seekers and refugees living in camps and RICs will start remain unavailable.[19] By the end of October 2021, it was estimated that slightly less than 25% of the population residing in reception facilities had been vaccinated.[20]
Lastly, in a positive development in November 2021, a procedure for issuing a temporary AMKA (PAMKA) for accessing vaccines was introduced for people in vulnerable conditions (e.g. homeless) that lack any type of social security number, irrespective of their legal status,[21] albeit the extent to which undocumented people have been able to issue the PAMKA and get vaccinated is unavailable as far as GCR is aware.
In October 2022, a new Ministerial Decision[22] was issued regarding access of international protection applicants to health care services, medical and pharmaceutical care, social security, the labour market, and the acquisition of a PAAYPA number.
For every applicant of international protection, a PAAYPA number is issued. This number is unique and corresponds to the number of the applicant’s international protection card.[23] 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.[24]
PAAYPA holders benefit from primary and secondary health care upon presentation of their international protection applicant card.[25] 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.[26]
For UAMs 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.[27]
[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] SolidarityNow, ‘Issues with the issuance of AMKA to international protection applicants’, 10 November 2016, available (in Greek) at: https://bit.ly/3bgttja.
[5] Joint Agency Briefing Paper, Transitioning to a Government-run Refugee and Migrant Response in Greece: A joint NGO roadmap for more fair and humane policies, December 2017, available at: https://bit.ly/2S3yiVn, 12.
[6] Amnesty International, ‘Greece must immediately secure the free access of asylum seekers, unaccompanied minors, and children of undocumented migrants to the public healthcare system’, 14 October 2019, available in Greek at: https://bit.ly/372T4sz.
[7] Article 59 (2) Asylum Code.
[8] Article 59 (2) Asylum Code.
[9] Joint Ministerial Decision 717/2020, Gov. Gazette 199/Β/31-1-2020 The said JMD is replaced by JMD 605869/ B΄ 5392/18.10.2022.
[10] Skai.gr, Προσωρινός αριθμός ασφάλισης – περίθαλψης: Από σήμερα σε όλους τους αιτούντες άσυλο, 1 April 2020, available at: https://bit.ly/3cjTyh4.
[11] UNHCR, Population breakdown in ESTIA II Accommodation Scheme (as of 7 December 2020), 12 December 2020, available at: https://bit.ly/2RM76NA.
[12] Ibid.
[13] UNHCR, Fact Sheet: Greece (1-31 December 2020), 27 January 2021, available at: https://bit.ly/34nI7Te.
[14] ESTIA updates can be found (in Greek) on the webpage of the MoMA, under ESTIA 2022 FACTSHEET – Σεπτέμβριος/Οκτώβριος/Νοέμβριος 2022, published 30 November 2022, available at: https://bit.ly/3qhEmxb.
[15] Greek Ombudsperson, Letter to the GAS on ‘The non-issuance of PAAYPA to an applicant of international protection with a serious health condition’, 26 March 2021, protocol no. 294463/16706/2021.
[16] For instance, GCR & Oxfam, Lesbos Bulletin (April 2021), 21 April 2021, available at: https://bit.ly/3wyyD3N.
[17] For more International Rescue Committee, The Cruelty of Containment: The Mental Health Toll of the EU’s ‘Hotspot’ Approach on the Greek Island, 2020, available at: https://bit.ly/2XWKyJA.
[18] Capital, ‘N. Mitarakis: refugees and migrants will be normally vaccinated against the coronavirus’ (‘Ν. Μηταράκης: Θα εμβολιαστούν κανονικά κατά του κορονοϊού πρόσφυγες και μετανάστες’), 15 February 2021, available in Greek at: https://bit.ly/3fLRMbM.
[19] As per information shared through the Greek advocacy working group on 26 May 2021.
[20] Data provided during the Health working group of 27 October 2021.
[21] JMD 5160/2021, Gov. Gazette 5247/Β/12-11-2021.
[22] Ministerial Decision 605869 (Β’ 5392/18.10.2022).
[23] Article 1(3) of Ministerial Decision 605869/2022.
[24] Article 2(1) of Ministerial Decision 605869/2022.
[25] Article 3 of Ministerial Decision 605869/2022.
[26] Article 6(1), (2) of Ministerial Decision 605869/2022.
[27] Article 6(6)vof Ministerial Decision 605869/2022.