issue18

Κοινωνική Συνοχή
και ΑνάπτυξηΕξαμηνιαία Επιστημονική
Επιθεώρηση,
Φθινόπωρο 2014, τόμος 9ος, τεύχος 2
Social Cohesion and
DevelopmentBiannual Scientific
18 Review,
Autumn 2014, volume 9, issue 2
AΡΘΡΑ
Articles
ISSN 1790-9368
Charalampos Economou, Daphne Kaitelidou, Dimitris
Katsikas, Olga Siskou, Maria Zafiropoulou,
Impacts of the economic crisis on access to healthcare
services in Greece with a focus on the vulnerable groups
of the population
Ioannis Dendrinos,
Youth employment before and during the crisis.
Rethinking labour market institutions and work
attitudes in Greece
Sevaste Chatzifotiou, Eleni Fotou, Ignatios Moisides
Best practices in police handling and liaisons with social
services workers in domestic violence incidents.
Katerina Vassilikou, Elisabeth Ioannidi – Kapolou,
Sex Education and Sex Behaviour in Greek adolescents:
a research review
EUROMED Migration III, Legal Migration Meeting,
Contribution by Nasia Ioannou
Manos Spyridakis, The Liminal Worker. An Ethnography of
Work, Unemployment and Precariousness in Contemporary
Greece (Th. Sakellaropoulos),Nathalie Morel, Bruno Palier
and Joakim Palme (eds.), Towards a Social Investment
Welfare State? Ideas, Policies and Challenges, (M. Angelaki),
Kaufmann, F.X., European Foundations of the Welfare State
(Chr. Skamnakis)
ΒΙΒΛΙΟΚΡΙΤΙΚΕΣ
Book Reviews
ΣΥΝΈΔΡΙΑ
Conferences
KΣΑ
9|2
SCD

KΟΙΝΩΝΙΚΗ ΣΥΝΟΧΗ ΚΑΙ ΑΝΑΠΤΥΞΗ
Εξαμηνιαία Επιστημονική Επιθεώρηση
ΣΚΟΠOΣ. Η Κοινωνική Συνοχή και Ανάπτυξη (ΚΣΑ) είναι μια εξα-
μηνιαία επιστημονική επιθεώρηση για την έρευνα και συζήτηση
θεμάτων κοινωνικής πολιτικής, συνοχής και ανάπτυξης. Σκοπός
της είναι η καλύτερη κατανόηση του ρόλου της κοινωνικής συνο-
χής στη σύγχρονη ανάπτυξη και προώθηση της κοινωνικής δικαι-
οσύνης στο εσωτερικό και μεταξύ των εθνών. Τα άρθρα που δη-
μοσιεύονται καλύπτουν τα πεδία της ανάλυσης, του σχεδιασμού,
της εφαρμογής των πολιτικών, της αξιολόγησης των αποτελεσμά-
των τους, της συγκριτικής έρευνας, της ανάλυσης του ρόλου των
διεθνών οργανισμών, των εθελοντικών, κοινωνικών, ιδιωτικών
και τοπικών φορέων στην κοινωνική ανάπτυξη και πολιτική. Ει-
δικότερα, η Επιθεώρηση φιλοξενεί άρθρα που αντιπροσωπεύουν
ευρύ φάσμα γνωστικών πεδίων, όπως εργασιακές σχέσεις και
απασχόληση, φτώχεια και κοινωνικός αποκλεισμός, συντάξεις και
κοινωνική ασφάλιση, υγεία και κοινωνική φροντίδα, εκπαίδευση
και κατάρτιση, πολιτικές για το παιδί, την οικογένεια και τα φύλα,
μετανάστευση, εγκληματικότητα, εταιρική κοινωνική ευθύνη,
καθώς και δραστηριότητες του τρίτου τομέα και της κοινωνίας
πολιτών. Η Επιθεώρηση φιλοξενεί επιστημονικά άρθρα, βιβλιο-
κριτικές και βιβλιoπαρουσιάσεις, σύντομες εκθέσεις ερευνητικών
προγραμμάτων, είτε στα ελληνικά είτε στα αγγλικά. Ενθαρρύνει τη
διεπιστημονική, συγκριτική και ιστορική προσέγγιση.
ΙΔΡΥΤΗΣ-ΕΚΔΟΤΗΣ
Θεόδωρος Σακελλαρόπουλος, Πάντειο Πανεπιστήμιο
ΣΥΝΤΑΚΤΙΚΗ ΕΠΙΤΡΟΠΗ
Ναπολέων Μαραβέγιας, Πανεπιστήμιο Αθηνών
Ανδρέας Μοσχονάς, Πανεπιστήμιο Κρήτης
Θεόδωρος Σακελλαρόπουλος, Πάντειο Πανεπιστήμιο
ΕΠΙΣΤΗΜΟΝΙΚΟ ΣΥΜΒΟΥΛΙΟ
Jos Berghman, Catholic University of Louven
Eberhard Eichenhofer, University of Jena
Korel Goymen, Sabanci University, Istanbul
Ana Guillen, University of Oviedo
John Myles, University of Toronto
Κούλα Κασιμάτη, Πάντειο Πανεπιστήμιο
Θωμάς Κονιαβίτης, Πάντειο Πανεπιστήμιο
Σκεύος Παπαϊωάννου, Πανεπιστήμιο Κρήτης
Άγγελος Στεργίου, Αριστοτέλειο Πανεπιστήμιο Θεσσαλονίκης
Λευτέρης Τσουλφίδης, Πανεπιστήμιο Μακεδονίας
Δημήτρης Χαραλάμπης, Πανεπιστήμιο Αθηνών
Ιορδάνης Ψημμένος, Πάντειο Πανεπιστήμιο
John Veit-Wilson, University of Newcastle
ΕΠΙΣΤΗΜΟΝΙΚΗ ΓΡΑΜΜΑΤΕΙΑ
Χριστίνα Καρακιουλάφη, Πανεπιστήμιο Κρήτης
Χαράλαμπος Οικονόμου, Πάντειο Πανεπιστήμιο,
Μανόλης Σπυριδάκης, Πανεπιστήμιο Πελοποννήσου
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SOCIAL COHESION AND DEVELOPMENT
Biannual Scientific Review
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Κοινωνική Συνοχή
και Ανάπτυξη
Social Cohesion and
Development

Charalampos Economou, Daphne Kaitelidou, Dimitris
Katsikas, Olga Siskou, Maria Zafiropoulou,
Impacts of the economic crisis on access to healthcare
services in Greece with a focus on the vulnerable groups
of the population
Ioannis Dendrinos,
attitudes in Greece
Sevaste Chatzifotiou, Eleni Fotou, Ignatios Moisides
Best practices in police handling and liaisons with social
services workers in domestic violence incidents.
Katerina Vassilikou, Elisabeth Ioannidi – Kapolou,
Sex Education and Sex Behaviour in Greek adolescents:
a research review
EUROMED Migration III, Legal Migration Meeting,
Contribution by Nasia Ioannou
Manos Spyridakis, The Liminal Worker. An Ethnography of
Work, Unemployment and Precariousness in Contemporary
Greece (Th. Sakellaropoulos),Nathalie Morel, Bruno Palier
and Joakim Palme (eds.), Towards a Social Investment
Welfare State? Ideas, Policies and Challenges, (M. Angelaki),
Kaufmann, F.X., European Foundations of the Welfare State
(Chr. Skamnakis).
AΡΘΡΑ
Articles
ΒΙΒΛΙΟΚΡΙΤΙΚΕΣ
Book Reviews
Περιεχόμενα | Contents
Κοινωνική Συνοχή και Ανάπτυξη 2014 9 (2), 97
Social Cohesion and Development 2014 9 (2), 97
99-115
117-132
133-142
143-154
155-159
161-168
ΣΥΝΕΔΡΙΑ
Conferences

Άρθρα | Articles
Impacts of the economic crisis on access to
healthcare services in Greece with a focus on the
vulnerable groups of the population1
Economou Charalampos, Panteion University,
Kaitelidou Daphne, Katsikas Dimitris, Siskou Olga, National and Kapodostrian University of Athens,
Zafiropoulou Maria, European Commission
Οι επιπτώσεις της οικονομικής κρίσης στην
πρόσβαση στις υπηρεσίες υγείας στην Ελλάδα με
επίκεντρο τις ευάλωτες ομάδες του πληθυσμού
Οικονόμου Χαράλαμπος, Πάντειο Πανεπιστημίο,
Καϊτελίδου Δάφνη, Κάτσικας Δημήτρης, Σίσκου Όλγα, Εθνικό και Καποδιστριακό Πανεπιστήμιο Αθηνών,
Ζαφειροπούλου Μαρία, Ευρωπαϊκή Επιτροπή
ΠΕΡIΛΗΨΗ
Το 2010, η ελληνική οικονομία εισήλθε σε μια
βαθιά, δομική και πολύπλευρη κρίση, τα κύρια
χαρακτηριστικά της οποίας είναι το μεγάλο δημο-
σιονομικό έλλειμμα και το πολύ υψηλό δημόσιο
χρέος. Αρνητικές επιπτώσεις παρατηρούνται και
σε κοινωνικό επίπεδο, καθώς όλοι οι κοινωνικοί
δείκτες έχουν επιδεινωθεί. Το άρθρο αυτό εξε-
τάζει την επίπτωση της οικονομικής κρίσης στην
πρόσβαση των υπηρεσιών φροντίδας υγείας ιδι-
αίτερα των ευάλωτων ομάδων του πληθυσμού.
Οι ανασφάλιστοι, οι άνεργοι, οι ηλικιωμένοι, οι
μετανάστες, τα παιδιά και οι πάσχοντες από μα-
κροχρόνιες ασθένειες και ψυχικές διαταραχές εί-
ναι οι ομάδες που επλήγησαν περισσότερο από
την οικονομική κρίση στην Ελλάδα. Το υψηλό
κόστος, η χαμηλή εγγύτητα και οι μεγάλες λίστες
αναμονής είναι μερικά από τα εμπόδια στην πρό-
σβαση των υπηρεσιών υγείας που αντιμετωπί-
ζουν οι παραπάνω ομάδες.
ΛΕΞΕΙΣ-ΚΛΕΙΔΙΑ: Οικονομική κρίση, ευάλωτες
ομάδες, πρόσβαση στις υπηρεσίες φροντίδας
υγείας.
ABSTRACT
In 2010, the Greek economy entered a deep,
structural and multi-faceted crisis, the main
futures of which are a large fiscal deficit
and huge public debt. The negative effects
can also be observed at the societal level,
as all social indicators have deteriorated.
The present paper discusses the impact
of economic crisis on access to healthcare
services especially for the vulnerable groups.
Uninsured, unemployed, older people,
migrants, children and those suffering from
chronic disease and mental disorders are
among the groups most affected by the crisis
in Greece. High costs, low proximity and long
waiting lists are among the main barriers in
accessing health care services.
KEY WORDS: Economic crisis, vulnerable
groups, access to healthcare services.
Κοινωνική Συνοχή και Ανάπτυξη 2014 9 (2), 99-115
Social Cohesion and Development 2014 9 (2), 99-115

[100] Κοινωνικη Συνοχη και Αναπτυξη
1. Financial crisis and adjustment program in Greece: Eco-
nomic, social and health effects
In 2010, the Greek economy entered a deep, structural and multi-faceted crisis, the main
futures of which are a large fiscal deficit, huge public debt and the continuous erosion of
the country’s competitive position. In order to address the problem, the Greek government
requested from the EU and the IMF the activation of a support mechanism, adopted a strict
income policy, increased direct and indirect taxes, enhanced flexibility in the labour market and
cut public expenses.
Indicative of the situation are the figures of Table 1, which present data published by the
Hellenic Statistical Service (ELSTAT, 2014a). GDP declined at current prices from €242.1 bln in 2008
to €182.4 bln in 2013. The real economy has been in recession since 2009 and GDP contracted by
6.1 in 2013, mainly on account of a sharp drop in investment, but also because of falls in private
consumption. The debt-to-GDP ratio continued to rise and the deficit remains high. In addition,
compensation per employee has been declining at an increasing rate since 2010.
The negative effects can also be observed at the societal level, as all social indicators have
deteriorated (ELSTAT, 2014b). The recession spread across all sectors of activity negatively
impacted on employment and caused an increase in the rate of unemployment which climbed to
27.5% in 2013. The same year, 28% of the Greek population was at risk of poverty, 35.7% was
at risk of poverty or social exclusion and 37.3% faced financial burden with an enforced lack of
at least 3 out of 9 categories of basic goods and services. Inequality of income distribution also
increased as the income quintile share ratio (S80/S20) reached 6.6 in 2013 from 5.9 in 2008. The
population that can afford the adequate heating of the dwelling decreased from 76% in 2008 to
38.1% in 2013 (ELSTAT 2014b).
Table 1. Economic and social indicators, Greece, 2008-2013 (ESA 2010)
2008 2009 2010 2011 2012 2013
GDP at current prices (bln Euros) 242.1 237.4 226.2 207.8 194.2 182.4
GDP growth % (at current prices) 4.0 -1.9 -4.7 -8.2 -6.5 -6.1
Public consumption (% change) -2.1 1.6 -4.3 -6.6 -5.0 -6.5
Private consumption (% change) 3.0 -1.0 -7.1 -10.6 -7.8 -2.0
Gross fixed capital formation (% change) -6.6 -13.2 -20.9 -16.8 -28.7 -9.5
Government gross debt (% of GDP) 109.3 126.8 146.0 171.3 156.9* 174.9
Government deficit (% of GDP) -9.9 -15.2 -11.1 -10.1 -8.6 -12.2
Compensation per employee (% change) 3.3 3.2 -2.6 -2.3 -2.0 -7.1
Employment rate 48.9 48.3 46.7 43.3 39.5 37.7
Total unemployment rate (%) 7.8 9.6 12.7 17.9 24.4 27.5
Long-term unemployed % of unemployed 47.1 40.4 44.6 49.3 59.1 67.1
Population at-risk-of-poverty rate (%) before
social transfers
23.3 22.7 23.8 24.8 26.8 28.0

Social Cohesion and Development [101]
Population at-risk-of-poverty rate (%) after
social transfers
20.1 19.7 20.1 21.4 23.1 23.1
Population at-risk-of-poverty or social
exclusion rate (%)
28.1 27.6 27.7 31.0 34.6 35.7
Income quintile share ratio (S80/S20) 5.9 5.8 5.6 6.0 6.6 6.6
Material deprivation (% of the population) ** 21.8 23.0 24.1 28.4 33.7 37.3
Households (%) with central heating 76.0 73.5 73.1 72.1 55.7 38.1
Sources: ELSTAT, 2014a and 2014b.
*Includes debt reduction under the private sector involvement (PSI) initiative.
**Enforced incapacity to face unexpected financial expenses, to afford one week’s annual holiday away from
home, to have a meal with meat, chicken, fish -or vegetarian equivalent- every second day, to afford the
adequate heating of the dwelling, to purchase durable goods like a washing machine, colour TV, telephone,
mobile telephone or car, or being confronted with payment arrears, such as for mortgage or rent, utility
bills, hire purchase installments or other loan payment.
Although quantifying the health effects of the economic crisis and of the government
policies introduced in response to it in Greece is difficult due to lack of timely and relevant data,
some preliminary evidence of targeted studies concerning self-reported health, mental health and
infectious diseases indicate negative trends. In relation to self-reported health in Greece, studies
conclude that the probability of reporting poor self-rated health is higher at times of economic
crisis, especially for the vulnerable groups including older people, unemployed, pensioners,
housewives and those suffering from chronic disease (Zavras et al., 2013, Vandoros et al., 2013).
Mental health has also been deteriorated due to the economic crisis. Between 2008 and 2011
one-month prevalence rate of major depression increased from 3.3% to 8.2% (Economou et al.,
2012). Besides depression, between 2009 and 2011 there was also a substantial increase in the
prevalence of suicidal ideation and reported suicide attempts in Greece (Economou et al., 2013).
The economic crisis in Greece seems to impact the infectious disease dynamics too. Since
2010, Greece has been suffering a high burden of different large-scale epidemics including the
increased mortality of influenza during the pandemic and the first post-pandemic seasons, the
emergence and spread of West Nile virus, the appearance of clusters of non-imported malaria and
the outbreak of Human Immunodeficiency Virus infection among people who inject drugs (Bonovas
and Nikolopoulos, 2012). The increase of the reported number of HIV infections among injected
drug users from 15 in 2010 to 522 in 2012 (Hellenic Center for Disease Control and Prevention,
2012) suggests that the recent economic crisis through the increasing socioeconomic disparities
and difficulties such as unemployment, extreme poverty, homelessness, stigma, discrimination and
social isolation and through the budgetary constraints and poor policies for financing prevention
and treatment have been translated to heightened risk behaviors on the individual level and
impaired public health response on the population level (Paraskevis et al., 2013).
Children are one of the population groups that have been affected by the crisis. The stillbirth
rate from 3.31/1000 live births in 2008 increased to 4.28 in 2009 and 4.36 in 2010, that is
an increase of 32% between 2008 and 2010 (Vlachadis and Kornarou, 2013). Similarly, after a
continuously decreasing from 40.1 deaths per 1,000 live births in 1960 to a low of 2.7 deaths per
1,000 live births in 2008, infant mortality rate increased to 3.1 in 2009 and 3.8 in 2010 (Eurostat,
http://appsso.eurostat.ec.europa.eu/nui/submitViewTableAction.do, accessed 20/1/2014).

At the time, although the available morbidity and mortality data are few, given that the
effects of economic recessions on the population health are visible in the long run, we have to be
aware of even more negative trends in the Greek population health that we will have to confront
with in the future. This is suggested by the results of a small Greek study conducted in 2013
which found a significant increase in all-cause mortality and death from ischemic heart disease in
workers of a Greek bus company which closed in 1992 (Drivas et al., 2013).
2. Trends in the coverage, use and financing of health care
services
2.1 Increasing self-reported unmet needs for examinations
One way to measure problems of access to health care is by reported unmet health care needs.
Inequalities in unmet care needs may result in poorer health status and increase health
inequalities. The SILC conducted on an annual basis, provides information on the proportion of
people reporting having some unmet needs for medical examination for different reasons. Table
2 summarizes the situation in Greece.
Table 2. Self-reported unmet needs for medical examination
(too expensive or too far or extended waiting lists (2008-2012)
2008 2009 2010 2011 2012
Total population 5.4 5.5 5.5 7.5 8.0
By income quintile
1st quintile 8.7 11.2 9.2 11.6 11.6
2nd quintile 7.1 7.4 6.7 9.8 9.6
3rd quintile 6.1 4.6 5.9 7.6 9.2
4th quintile 3.4 2.7 3.2 4.8 4.7
5th quintile 1.8 1.7 2.2 3.6 4.8
By labour status
Employed 3.3 2.8 3.1 4.7 5.6
Unemployed 8.6 7.5 9.4 11.3 10.8
Retired 7.6 7.8 7.3 10.2 9.4
Other inactive 5.9 7.3 6.3 6.9 8.1
Source: EUROSTAT,http://epp.eurostat.ec.europa.eu/portal/page/portal/health/health_care/data/database,
(accessed 20/1/2014)
From the data presented three conclusions can be drawn for the Greek population. First,
during the period 2008-2012, the percentage of the population reporting unmet needs for
medical examination due to high costs, low proximity or long waiting lists increased from
5.4% to 8%. Second, people with low incomes are more likely to report unmet care needs than

people with high incomes. Although deterioration has been observed in the period 2008-2012
in relation to the situation of all income quintiles, the gap between the first and the fifth quintile
remains large. Third, labour status seems to be a significant determinant of access to health care
in Greece. The percentage of the unemployed who report problems with access is almost twice
the percentage corresponding to the employed. This raises serious questions for health care
coverage given the very high unemployment rate in the country.
2.2 Reductions in public health spending
Started in 2010, the Greek Government continues to implement a reform program with the
objective of keeping public health expenditure at or below 6% of GDP for 2012. In practice,
this health policy has led to the deepest depression of the health economy. While nominal gross
domestic product declined by 6.5% in 2012 (see Table 1), health expenditure dropped down by
12.1%. These cuts were driven by a reduction in public spending and especially social security
funds spending on health (Table 3).
Table 3. Total current health expenditures (in million euro)
2009 10/09
%
2010 11/10
%
2011 12/11
%
2012
General Government 6,271 -11.5 5,548 2.2 5,673 -10.5 5,077
Social Security Funds 9,836 -13.6 8,499 -4.8 8,089 -14.0 6,957
Total Public Current
Expenditures
16,107 -12.8 14,047 -2.0 13,762 -12.6 12,034
Private Insurance 434 23.7 537 -0.4 534 -1.6 526
Private Payments 6,593 -7.5 6,096 -4.7 5,809 -12.3 5,096
Total Private Current
Expenditures
7,027 -5.6 6,633 -4.4 6,343 -11.4 5,622
Other Expenditures
(Church, NGOs etc)
53 39.2 73 -28.4 52 2.1 54
Total Current Health
Expenditures
23,187 -10.5 20,753 -2.9 20,157 -12.1 17,710
Source: ELSTAT, 2013.
*Preliminary data
Private expenditures increased as a percentage of total health expenditure during the crisis
mainly due to an increase in private insurance. However, out of pocket payments remain the
major segment of private health expenditures (Table 4). Since informal payments, represent a
significant part of out-of-pocket payments (approximately 30%) there are serious concerns about
the barriers imposed to access to health care services. In a previous study it was shown that
more than 36% of people who were treated in a public hospital reported at least one informal
payment to a doctor mostly in order to have access or faster access to public inpatient health
care services (the probability of extra payments were 72% higher for patients aiming to jump

the queue compared to those admitted through normal procedures) (Liaropoulos et al., 2008).
Although these payments are very common in order to support insufficient health care budgets,
they represent a bad option for financing the health sector, as they cause several inequalities
affecting mostly the poor and vulnerable groups (Kaitelidou et al., 2013). It is very likely that
health sector staff salary cuts implemented after 2010 in Greece, in relation to increases in
waiting times analyzed in the next section, will result in increased informal payments.
Table 4. Current health expenditures (percentage contribution by sector)
2009 2010 2011 2012
General Government 27.0 26.7 28.1 28.7
Social Security Funds 42.4 41.0 40,1 39.3
Total Public Current Expenditures 69.5 67.7 68.3 68.0
Private Insurance 1.9 2.6 2.7 3.0
Private Payments 28.4 29.4 28.8 28.8
Total Private Current Expenditures 30.3 32.0 31.5 31.7
Other Expenditures (Church, NGOs etc) 0.2 0.4 0.3 0.3
Source: ELSTAT, 2013.
*Preliminary data
2.3 Increases in the use of publicly funded health care services
and NGOs facilities
A 35.6% increase in patient admission was recorded between 2009 and 2012 along with a 11%
increase in the hospital bed occupancy rate (from 64% in 2009 to 71% in 2012). There were also
6% and 18% increases in surgical interventions and laboratory examinations, respectively, from
2010 to 2011. Visits to public hospital dental services and obstetricians also increased as well as
emergency visits increased by 1.8% (from 2011 to 2012) (Ministry of Health and Social Solidarity,
2012a and 2012b).
Visits to afternoon surgeries of public hospitals (compulsory afternoon shifts) decreased by
6% in 2010 compared to 2009, by 19% in 2011 compared to 2010 and by a further 7% in 2012
(from 559,358 in 2009 to 527,602 in 2010, 429,903 in 2011 and 398,731 in 2012) (Ministry
of Health and Social Solidarity, 2012a and 2012b). In afternoon surgeries of public hospitals
patients are obliged to pay a predefined fee (from €45 to €90 untill August 2013 and from €24
to €72 since September 2013) and this maybe explain the decline of visits during the crisis.
However, increased utilization in a time at which funding of publicly funded services was
decreased may raise concerns. In particular, the Memoranda of Understandings (MoUs) between
the Greek Government and the Troika (IMF, European Central Bank and European Union) required
major cuts to hospital and pharmaceutical expenditure. Total public hospital sector expenditure
decreased by 26.4%, from €7 billion in 2009 to €5.15 billion in 2011 (OECD, 2013), with major
savings in hospitals supplies (medical supplies, orthopedics, pharmaceuticals etc.) and through
MoUs conditions stipulating cuts to health personnel salaries and benefits.

A consequence of the above situation is that according to limited evidence but also from
unofficial sources from public health services, waiting times to receive public health services have
increased. For example according the only available official data from the Greek Health Map
(National School of Public Health and KEELPNO, 2013) waiting times for the use of outpatient
services have been increased by more than 200%.
In a survey concerning chronically ill patients, it was found that 64% of respondents (N=1,496)
reported problems in accessing a physician or a primary care unit due to economic restrictions
and 60% of them due to long waiting lists. Access to health care services was associated with the
socioeconomic status. Chronically ill patients with higher income and educational level were less
likely to face accessibility problems due to economic constrains or waiting lists (National School
of Public Health, Department of Health Economics, 2013).
Increased demand by the Greek population has led some NGOs to develop a number of
activities and programs, intended to provide the local population not only with health services, but
also with a wider range of social care services (dormitory for homeless people, food distribution,
elderly care programme, etc.) which until recently were not typically part their activities. For
example Medicines du Monde established two new polyclinics, one in Perama, a low-income
district in the area of Athens in 2009 and one in the city of Patras in 2012 as a response to crisis.
Additionally, a vaccination programme was introduced for children of Greek uninsured citizens.
In 2012, only in the area of Perama 880 children were vaccinated.
According to a survey conducted by Medicines du Monde in seven European countries,
it was reported that approximately half (49.3%) of the patients seen in the four Greek clinics
in 2012 were Greek nationals. In Perama (wider Athens area) this figure reaches 88%, in
Thessaloniki 52.1% and in Athens 11.8% In the other countries, this proportion was less than
5% (except in Munich where 12% of patients were nationals) and was almost zero in Amsterdam,
Antwerp, Brussels and London (Chauvin and Simonnot 2013). The respective percentage of Greek
nationals visiting NGOs polyclinics before the economic turmoil (2007 data) did not exceed 3-4%
(Karatziou, 2011) while the Greek citizens visiting the MdM polyclinics in the area of Athens did
not exceed 1%.
2.4 Increased demand of emergency services
For the needs of the study, 19 emergency units of rural (9) and urban (10) Greek hospitals have
provided data in order to better understand the impact of crisis on access to healthcare services.
During the crisis, the number and the status of patients visiting emergency units has
considerably grown. In fact, 95% of the urban hospitals, participating in this survey face an
increase of the number of patients ranging from 10 to 35% when only 30% of rural hospitals face
an increase of 5 to 15% of the number of patients. One of the reasons for this situation may be
the deterioration of the affordability of patients to use private services.
It’s important to note that the majority of interviewed urban hospitals (90%) and of rural
hospitals (75%) reported greater use of ER services mostly during the afternoon and night shifts.
This may partly be explained of the absence of any co-payments at the use of ER, while for the
use of outpatient clinics the patient is charged by a €5 co-payment. It may also be linked with
barriers in accessing hospitals, associated with long waiting lists.
Regarding the use of ER, some of the emerging groups or the groups of patients which
increased the visits included: (a) persons with anxiety problems (depression and stressful

situations), (b) young people uninsured and (c) retired persons with small pensions More than
68% of the respondents confirmed the finding.
In order to face this large demand of emergency services, the hospitals participating to
this survey stated the implementation of various mitigating measures, including triage system,
intensive education and professionalization of staff, use of volunteers and restricted use of health
materials.
2.5 Reductions in coverage
In 2011, the healthcare sector of all major social insurance funds covering salaried employees,
agricultural workers, the self-employed, civil servants, sailors and merchant seamen, and banking
and utilities employees formed a single healthcare insurance fund (EOPYY) which act as a unique
buyer of medicines and health care services for all those insured, thus acquiring higher bargaining
power against suppliers. The benefit packages of the various social health insurance funds merged
in EOPYY, were standardized and unified to provide the same reimbursable services.
A basic characteristic of the unified package is the reduction in benefits to which the insured
are entitled. For example, some expensive examinations including polymerase chain reaction
(PCR) tests and thrombophilia that used to be covered, even partially, were removed from the
EOPYY benefit package and have to be compensated on an out-of-pocket basis. In addition,
restrictions in entitlement were introduced in relation to childbirth, air therapy, balneotherapy,
thalassemia, logotherapy and nephropathy.
Moreover, the introduction of a negative list for medicines in 2012 resulted in the withdrawal
of reimbursement status of various drugs that were previously reimbursed. Under the terms of the
MOU, this negative list should be updated twice a year. In parallel, an over-the-counter drug list
has been in place since 2012, comprising many medicines that until then had been reimbursed
(eg. some pain relief medicines) but which now must be paid for out-of-pocket.
In 2011 an increase in user charges from €3 to €5 was imposed in outpatient departments
of public hospitals and health centres. From 2014 onward an extra €1 for each prescription
issued by ESY has been introduced. A €25 patient fee for admission to a state hospital from 1st
January 2014 was applied however the measure was soon revoked due to strong reaction by the
health care professionals and the opposition party and it is planned to be replaced by an extra
tax of 10 cents on cigarettes.
An increase in co-payments for pharmaceuticals for specific diseases also took place in
2013, including Alzheimer, Dementia, Epilepsy, Diabetes II (from 0 to 10%), Coronary Heart
Disease, Hyperlipidemia, Rheumatoid Arthritis and Psoriatic Arthritis, Chronic Obstructive
Pulmonary Disease (COPD), Osteoporosis and Paget, Crohn Disease and Liver Cirrhosis (from
10 to 25%). Furthermore, in 2013 the total number of medicines for which a 25% cost-sharing
arrangement was imposed has been increased. As a result of these increases, the average co-
payment rate for medicines increased from 13.3% in the first and second month of 2012 to 18%
in the corresponding period of 2013 while monthly expenditure for households was increased on
average from €36.3 mil. in 2012 to €38.2 mil in 2013 (for the same periods over the two years),
despite the price reductions (Siskou et al., 2014)
In an effort to further cut costs and combat excessive prescription among doctors, a ceiling
to the monthly amount prescribed by a doctor was set in January 2014 (at 80% of the last years’
prescription budget). The measure caused a number of reactions as the measure exacerbated the

patients’ discomfort, having to refer to a number of doctors in order to get the prescription from
a doctor who didn’t reach the prescription limit. As a result some exceptions were introduced
and doctors who work at public hospitals, as well as those who work for retirement homes and
nongovernmental organizations, are among those who are excluded from the measure.
Since the Greek health care system was characterized as inequitable in access even before
crisis (Economou and Giorno, 2009, Economou, 2010, Liaropoulos et al., 2008, Siskou et al.,
2008), it seems that the crisis has exacerbated existing problems, and many of the policy measures
introduced under pressure from bailout conditions have made the financing of the health sector
more inequitable. Most of the above mentioned measures are horizontal, not means-tested and
as a consequence they impose higher burden to the least well off. The imposition of public health
spending restrictions (to no more than 6% of GDP in 2012) and the simultaneous decline in GDP
(since 2009, with further decreases forecast in the next few years) means that the public health
sector is called upon to meet the increasing needs of the population with decreasing financial
resources. This has negative effects, especially for the middle and the low-income households
that do not have the disposable income to buy private health services (Economou et al., 2014).
3. The access of vulnerable groups to health care services
3.1 The unemployed and the uninsured
In 2013 the number of employed amounted to 3.5 million persons while the number of
unemployed amounted to 1.3 million. The unemployment rate was 27.5% and long-term
unemployment raised to 67.1% of all unemployed (ELSTAT, 2014b). Those who are unemployed
for less than 12 months, they continue to have access to sickness benefits in kind for 1 year after
the commencement of unemployment with the prerequisite proof to be given of at least 50
working days in the year prior to the commencement of unemployment.
After the expiry of the one year, OAED provides for health coverage in the following three
cases: (a) Long-term unemployed aged over 55 years with the prerequisite to have completed at
least 3000 daily wages (Article 10, Law No. 2434/1996). (b) Long-term unemployed aged 29 to
55 years old are covered for a period of up to two years with the prerequisite to have completed
600 working days, to be increased by 100 days per year on completion of 30 to 54 years of age
(§4, Article 5, Law No. 2768/1999). (c) Unemployed aged up to 29 years are covered for 6 months
with the prerequisite to have been registered in OAED as unemployed for a period of at least 2
months (Article 18, Law No. 2639/1998).
After a person has exhausted its insurance right for sickness benefits, and its eligibility for
OAED programmes and health voucher, an option is to request for a poverty booklet. Since 2006
(ministerial decision 139491/2006) a special mechanism has been developed in the framework
of protecting the vulnerable population with the provision of the “poverty booklet”. It addresses
poor and uninsured population that have exhausted their social insurance right and it provides
them with free access to public hospital, medical services and pharmaceuticals. The basic
eligibility criteria are the lack of insurance, low income (the annual family income not to exceed
6,000 euros, increased by 20% for the spouse and every under age or dependent child, provided
that this income does not come from employment giving access to insurance) and permanent and
legal residency in Greece. Beneficiaries who are eligible for the uninsured booklet are registered
in the Registry for the Uninsured and Financially Weak kept by the Health or Welfare Directorate

of each municipality. The duration of the poverty booklet is 1 year with the possibility of annual
renewal for as long as the eligible remains under the status of being poor.
A certificate of social protection is issued for foreign nationals with residence permit
for health reasons, nationals of member-states of the European Social Charter, expatriates
applying for the expatriate identification card or for Greek nationality. For recognized refugees
or immigrants that their application for refugee status is being processed and, beneficiaries
of subsidiary protection, immigrants with residence permit for health reasons, free access to
healthcare services, identical to the ones available for Greek citizens, is provided on condition
that they are uninsured and poor.
Since June 2014, according to new law amendments (Government Gazettes 1465
05/06/2014 and 1753 of 28/06/2014) the uninsured and their families are entitled to primary
and inhospital health services as well as pharmaceutical care. The ATLAS plan was completed
in June and therefore the provision of insurance to those recorded with no coverage (which
currently exceed 2.5 million) started officially in June. Eligible to participate to this program are
the uninsured Greek citizens, the legally residing Greek expatriates, the nationals of EU member
states and national of third countries who legally and permanently reside in Greece. In order to
receive free access, they should not fulfill conditions to issue a “booklet for uninsured” and they
shouldn’t be insured in any public or private fund. However, the fact that the beneficiaries have
access to pharmaceutical care for acute and chronic disease, with the same terms, conditions,
and charges for prescribed medicine as for insured patients may impose obstacles in accessing
care (as mentioned earlier co-payments vary from 0% to 25% with the mean co-payment rate
increased to 18% for 2013).
3.2 Health vouchers
The “Health Voucher” programme launched in September 2013 mainly funded by the National
Strategic Reference Framework. It targeted people who had lost their insurance coverage (and
were either directly or indirectly insured) and their dependent family members and allowed them
access only to primary healthcare services (visits to contracted physicians, NHS facilities and
services provided by contracted diagnostic centres).
The health vouchers were divided in two categories: a) General Voucher for people of all
ages. It provided only for up to 3 visits to a doctor or a diagnostic center contracted with EOPYY.
The program did not cover pharmaceutical treatment or inpatient care. b) Health Voucher for
pregnant which provided up to 7 visits (with the prerequisite that the voucher was issued in the
first three months) to a doctor or a diagnostic center contracted with EOPYY. Again, the voucher
did not cover the cost for hospital care.
Health vouchers had duration for 4 months without a potential to be renewed. They intended
to cover unemployed and uninsured that were actually more than two years uninsured, since
OAED provided the right for the unemployed to extend their insurance status up to two years
after they lost their jobs (see section 3.1). The specific criteria set made it available to people
who were former insured in Social Security Funds which joined the EOPYY, with an individual
income up to 12,000 euros (for singles) or family income up to 25,000 euros (for married) (http://
www.healthvoucher.gr). The program was estimated to cover approximately 230.000 uninsured
citizens for 2013-2014 However, no more than 23,000 health vouchers had been issued until

March 2014 and applications didn’t exceed 85.000 (data provided by EOPYY). The small number
of vouchers issued and the very limited scope raised serious doubts about its effectiveness.
3.3 The migrants
Migrants legally residing in the Greece enjoy the same rights as citizens in terms of access to the
healthcare system (Cuadra, 2010). The requirement is however to have insurance, as they cannot
claim the welfare benefit, nor the card which allows persons with low income free access to
healthcare. Free (or subsidized) healthcare is strictly connected to affiliation to a social insurance.
Only legal aliens, namely those holding a residence and employment permit, have a right to
social insurance.
Until today, there hasn’t been a formed policy in Greece regarding the access and use
of health care services mainly due to a lack of sound data for the epidemiological profile of
immigrants and the use of health services by them. According to a recent study regarding the
access of migrants in health care services conducted in 2012 in Greece (Galanis et al., 2013), only
56.5% of participants had health insurance coverage, a proportion relatively small compared to
the natives. Interestingly, over half of the participants in the study (62.3%) expressed unmet needs
regarding health care services. The most important reasons according to the respondents were
long waiting times in hospitals, difficulties in communication with health professionals, high cost
of health care and system’s complexity, findings also confirmed by other studies. In a more recent
study contacted by the same authors in 2013, with a similar questionnaire and methodology,
both the respective percentages have been increased since 67,4% of the participants reported no
health insurance coverage (Kaitelidou et al., 2014).
The problem is even bigger for undocumented migrants who can only access public healthcare
services in cases of emergency or if there is a risk to the patient’s life. The most significant change
during the crisis, which is also true for all other categories of uninsured patients, is that hospitals
and other healthcare providers do not any more turn a blind eye, as they used to do often in the
past, since they are obliged to follow strictly the rules for uninsured people, who are only eligible
for treatment in cases of emergency. According to a new directive of 2014 from the ministry,
asylum seekers, who otherwise have the same rights as Greek citizens, can receive treatment in
hospital for free, provided that they can demonstrate to the management of the hospital that
they are in a poor economic position.
The Directive of 2 May 2012 issued by the Minister of Health provides that treatment for
undocumented migrants is provided by public services, public corporate bodies, local authorities
and social security institutions only until the patient’s health has been “stabilised”. This provision
poses a real problem because nothing in the law or other regulations defines clearly the concept
of “stabilisation”. Once again, the decision is left to the discretion of the medical professionals
who in most of the cases do not stop treatment. Moreover, an effort that started in 2009-10 to
introduce cultural intermediaries in hospitals has frozen, which makes the issues of language and
culture an additional obstacle to access.

3.5 The Roma
According to a study of the National School of Public Health (2013) 77% of Roma people are
completely uninsured. Also, 13% of their children don’t have vaccination card, and 78% of them
reported that they have not made any vaccines. It is noteworthy that an inadequate coverage
with two doses of vaccine MMR was reported among Roma children (8.7%) since the respective
percentages were 83% of the total population, 86% of children who do not belong to a specific
group and 75% of children of immigrants.
Also, findings from a small scale survey conducted in 2011 assessing the use of health
services by Roma people in rural districts in Greece (n=103), reported that the most frequent
barriers, according to the respondents, concerning access to health services were high waiting
time in hospitals, the attitude of health professionals and high cost of health care. The majority
of the participants (61.1%) reported that they don’t have the ability to cover the financial costs
of health services. A significant proportion of the participants (45%) reported that during the
last 12 months, needed at least one time to use health services but they cannot afford it. Also,
38.8% reported that during the last year they were in need for medication, but didn’t receive any
because of the high cost (70.8%) (Galanis et al., 2012).
The above mentioned studies indicate that Roma lack access to or do not use preventative
healthcare and they face inequalities in accessing health services in Greece. This is linked to a
lack of targeted information campaigns, limited access to quality healthcare and exposure to
higher health risks. Roma experience ill health in part because they are much more likely to be
poor. Data show that Roma have lower socio-economic status, and diseases such as TB, measles,
and hepatitis disproportionately affect the lowest socioeconomic strata. Roma are also likely to
be sicker than other poor people with the same income level. The few studies that have been
conducted in EU countries assessing both health and poverty among the Roma confirm this
assertion (European Centre for Disease Prevention and Control, 2013). Therefore, although there
are no sufficient data and research documentation, it could be argued that economic crisis has
negative effects on Roma health status not only due to restrictions in coverage and access to
health services posed on the population of Greece as a whole but mainly due to deterioration of
their living conditions.
3.6 The chronically ill patients
According to some preliminary results of a study conducted by the National School of Public
Health (2014), regarding chronically ill patients approximately 60% reported facing significant
economic limitations or extended waiting lists to their access to health services. According to
the respondents, they have reduced by 30% the number of visits to primary care services during
the period 2011 – 2013 and 20% have decreased the out of pocket health expenditures. Out of
pocket expenditures for primary health services has been reduced by more than 50% during 2011
– 2013. As a result, visits of people with chronic diseases (especially diabetes) have increased to
NGOs and other social clinics. According to Doctors of the World, visits by chronically ill patients
to their polyclinics have increased by 23%, mainly in order to receive their medication, since with
the increase in co-financing for medicines they are unable to afford them.

Cancer patients represent one of the most vulnerable groups as all changes described above
are particularly striking in cancer care, with its lengthy and expensive treatments. Cancer patients
are one of the most hit patient groups by the health care budget cuts and are facing serious
problems during the economic crisis regarding waiting times and access to appropriate medicines
(Apostolidis, 2013). During the last two years delays and discomfort have been reported by
patient organizations in receiving their drugs. Until recently, uninsured cancer papers didn’t
have access to health care coverage (including pharmaceuticals) having thus significant problem
in accessing their therapy. Extended waiting times in order to access the appropriate therapies
were also reported by patient associations. According to unofficial sources, the waiting times for
a cancer operation might be 6-8 months, and the waiting times for radiation therapy exceed two
to three months. Data derived from the Greek Health Map showed that waiting times for a visit
to outpatient oncological clinic have been increased from 2010 to 2012, however the data are
limited and only for a sample of hospitals.
4. Efforts to increase the accessibility of health care services
Recently, (6/2/2014) the Greek Parliament passed a new legislation for primary health care.
A National Primary Health Care Network (PEDY) is going to be established, coordinated by
the Regional Health Authorities (DYPE). All primary health care facilities of EOPYY, rural health
centers and their surgeries as well as the few urban health centers are going to be under the
jurisdiction of DYPEs. The aim is these structures to function for 24 hours a day, seven days a
week. In addition, the law provides for the establishment of a referral system based on family
general practitioners. In the first article of the law it is stated that “primary health care services
are provided to all citizens equally, independently of their economic, social and labor status, via
a universal, integrated and decentralized network”.
Furthermore, in June 2014 two joint ministerial decisions signed by the Ministers of Finance,
Health, and Labor, Social Insurance and Welfare were issued, according to which all uninsured
Greek citizens and legal residents of the country without social or private health insurance, not
eligible for poverty booklets, or having lost their insurance right due to inability to pay their
social insurance contributions, as well as their dependants, are covered for:
(a) Inpatient care, free of charge, at the expense of public hospital budgets, provided that
they have received a referral from a doctor of the National Primary Healthcare Network or an
outpatient department of a public hospital and the special three-member medical committee
which will be set up in each hospital, certifying the patient’s need for hospitalization.
(b) Pharmaceuticals, at the expense of the state budget, provided that they are prescribed by
a doctor of the National Primary Healthcare Network or a doctor of a public hospital. However,
beneficiaries are required to pay the same copayments that apply for the insured.
Although the above mentioned legislation is expected to have positive effects, four issues
have to be considered. The first is that the establishment of a referral system based on family
general practitioners has not yet been implemented. The second is the stigmatizing procedure of
getting access to hospital services for the uninsured, given that a specific committee is in charge
of certifying the patient’s need for hospitalization, a procedure that is not applied to the insured
population. Thirdly, the provision of the legislation for the uninsured to pay copayments may
have negative effects to the needy of pharmaceuticals, given their difficult economic situation.

A last but not least issue is the fact that until now the Ministry of Health has not clarified to
the public hospitals how to implement the ministerial decision about the hospitalization of the
uninsured. As a consequence, the uninsured seeking for hospital services face serious unjustified
administrative barriers to access of health care due to their differentiated treatment by different
public hospitals.2
The role of NGOs and other health and social networks should also be mentioned. In Greece
there are few NGOs (up to seven), active in providing health services to migrants, uninsured
and other vulnerable groups, which have developed more than twelve clinics and diagnostic
centers, in Athens and other cities of the country. In these clinics and centers, patients mainly
receive primary healthcare, provided by all the basic medical specialties (GPs, pediatricians,
gynecologists), prevention medicine (diagnostic tests) and mental health services.
With the demand increasing and the public health system deteriorating, NGOs (through
their community clinics and pharmacies) and other unofficial networks of health professionals
and volunteers which were set up to help poor and uninsured patients, contribute significantly
to retain access of poor and unemployed to a basic set of medical services. A network of around
40 community clinics operates across Greece providing mostly primary health services and
medications free of charge to people not able or not eligible to use the public services. The
Metropolitan Community Clinic at Helliniko is an illustrative example, having offered services to
more than 20.000 people since December 2011 when it was established in a volunteer basis as a
response to a society operating in austerity and difficulty.
According to the report of the Social Mission Infirmary (2014), which operates since February
2012, a major problem was that 10% of the patients needed to receive systematic continuous
care or at least be hospitalized, but this was not possible unless their situation could be classified
as an emergency. Thus, 86% of people visiting the Social Mission Infirmary lost their social
insurance during the years 2010, 2011 and 2012. The organization has created a network of
support with a number of hospitals, which could provide care to2-3 cases each month.
However, since the number of uninsured and unemployed is constantly increasing such
initiatives should be under the umbrella of National Health System and Ministry of Health
should implement a coordinated policy. The establishment of mechanisms to ease the access of
vulnerable groups to the Public Health System is an imperative need and the last law amendments
are definitely towards the right direction. Yet, it is important that equal access should be re-
established along with the provision of integrated, qualitative and undifferentiated care.
Notes
1. The present paper is part of a research funded by Eurofound, in the context of Eurofound’s
Research Report on ‘the impacts of the crisis on access to healthcare services’, available at
http://eurofound.europa.eu/sites/default/files/ef_publication/field_ef_document/ef1442en.
pdf. Opinions expressed are those of the writers only and do not represent Eurofound’s of-
ficial position.
2. According to a newspaper article, a journalist contacted 7 public hospitals, pretending the
uninsured and asking information about the necessary supporting documents and the proce-
dure in order to be hospitalized free of charge. The answers he received were far from identi-
cal (Ta Nea, Friday 10/10/2014).

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Biographical Notes
Charalampos Economou is Associate Professor in Sociology of Health and Health Policy at
the Department of Sociology, Panteion University of Social and Political Sciences, Athens. His
teaching and research activities and publications concern social policy, supranational social
policies, European social policy, social exclusion, health policy, and sociology of health. He
has participated in many international and national projects and he has collaborated with
international organizations (OECD, WHO) and research centres (European Observatory on Health
Care Systems, LSE Centre for Civil Society). E-mail: chaecono@otenet.gr.
Daphne Kaitelidou is currently an Assistant Professor at the Public Health Division, School of
Health Sciences, Department of Nursing in University of Athens, on the field of Health Services
Management and Director of Center for Health Services Management and Evaluation, University
of Athens. Her research interests are in the fields of Health Services Management and Health
Policy, she has participated in many international and national projects on these areas and have
published more than 60 articles in peer reviewed international and national journals. E-mail:
dkaitelid@nurs.uoa.gr.
Dimitris Katsikas is Lecturer of International and European Political Economy, at the Department
of Political Science and Public Policy, University of Athens and Head of the Crisis Observatory
at the Hellenic Foundation for European and Foreign Policy (ELIAMEP). His research focuses on
international and European political economy and economic governance. In recent years, he
has participated as coordinator and/or researcher in a number of Greek and European research
programmes examining the European and Greek crises. E-mail: dkatsikas@eliamep.gr.
Olga Siskou RN, MSc, PhD is a Senior Researcher, in the Center for Health Services Management
and Evaluation in the Faculty of Nursing at the National and Kapodostrian University of Athens
(full time staff) since 12/2001. From 2008, she is Deputy National Representative to OECD Health
Committee. E-mail: olsiskou@nurs.uoa.gr.
Maria Zafiropoulou was awarded a Phd in Healthcare policies and Management by the Public
School of Health in France - in which she has been a fellow as well - and has studied Health law
and Political Sciences in France. She works as an expert in the European Commission and is a
scientific member of different faculties such as the Hellenic Open University, the Open University
of Cyprus, Université Libre de Bruxelles and the Institut of Administration of Entreprises in France.
Her research interests relate to hospital evaluation, crisis’ impacts and European healthcare and
social policies. E-mail: marozafir@gmail.com

attitudes in Greece
Ioannis Dendrinos, Greek National School of Public Administration
Η απασχόληση των νέων πριν και κατά τη
διάρκεια της κρίσης. Επανεξετάζοντας θεσμούς
και αντιλήψεις στην ελληνική αγορά εργασίας
Ιωάννης Δενδρινός, Εθνική Σχολή Δημόσιας Διοίκησης
ΠΕΡIΛΗΨΗ
Κατά τη διάρκεια της ελληνικής κρίσης, τα πολύ υψηλά
ποσοστά ανεργίας των νέων έχουν δημιουργήσει
σοβαρή ανησυχία για την επίδραση της ύφεσης στην
κοινωνική συνοχή και την ποιότητα του ανθρώπινου
δυναμικού. Ωστόσο, ακόμη και σε περιόδους ισχυρής
οικονομικής μεγέθυνσης, η ανεργία των νέων και
άλλοι σχετικοί δείκτες απασχόλησης ήταν συστηματικά
δυσμενέστεροι αυτών του ενήλικου πληθυσμού,
καθώς και του κοινοτικού μέσου όρου. Το άρθρο
διερευνά τη συνδυαστική επίδραση που έχουν στην
απασχόληση των νέων θεσμικές και κοινωνικές
παράμετροι, καθιστώντας την ανεργία των νέων ένα
σοβαρό διαρθρωτικό και διαχρονικό πρόβλημα
της ελληνικής αγοράς εργασίας. Σε αυτό το πλαίσιο,
οι προτάσεις πολιτικής του άρθρου εστιάζονται σε
αλλαγές και μεταρρυθμίσεις τόσο στους θεσμούς όσο
και στις στάσεις και αντιλήψεις έναντι της εργασίας.
ΛΕΞΕΙΣ-ΚΛΕΙΔΙΑ: ελληνική κρίση, ανεργία
νέων, θεσμοί αγοράς εργασίας, οικογενειακοί
δεσμοί
ABSTRACT
During the Greek crisis, the high and rising
youth unemployment rates have created
severe concerns about the impact of the
deep recession on human capital and
social cohesion. However, even in previous
times of significant economic growth,
both youth unemployment ratio and other
related employment indicators had been
systematically worse compared to those of
the general population, and even more so
compared to other European countries. This
article demonstrates how institutional and
social factors influence youth employment
performance, arguing that the youth
unemployment problem in Greece has
actually structural and persistent root causes.
The article concludes with policy proposals
towards changes both in labour market
institutions and social attitudes.
KEY WORDS: Greek crisis, youth
unemployment, labour market institutions,
family ties
Κοινωνική Συνοχή και Ανάπτυξη 2014 9 (2), 117-132
Social Cohesion and Development 2014 9 (2), 117-132

1. Introduction
In the midst of the unprecedented Greek crisis, youth unemployment rate of those aged 15-24
reached the level of 60% (young women: 65%), while those of the broader 15-29 age group
reached 46%. These alarming figures raised awareness of the unemployment’s long term effects
on the human resources quality and, hence, the economic growth prospects, as well as concerns
about the social cohesion.
The great increase in youth unemployment is considered to be a result of the current crisis
in Greece. Indeed, it has been acknowledged in the relevant literature that young people were
severely affected by recession, as in almost all the European countries. However, even in times of
significant economic growth in Greece, youth unemployment ratio as well as other performance
indicators had been systematically worse than those among adult population, even more compared
to the EU and OECD average. Since the beginning of the ‘90, youth unemployment rate has been
much higher than in adult workers, while the time lapse until the first «stable» job was in Greece
twice the figure in many other European countries. Under this perspective, youth (un)employment
in Greece is rather a permanent and structural feature of the Greek labor market.
A number of papers in recent years have looked at the factors driving youth employment (in
international and European level), focusing on the role of non economic factors such as labour
market institutions, the education system and the socio-cultural environment. In this context, the
present article highlights the structural features of youth unemployment in Greece. It examines
the impact labour market regulations, strong family ties and relevant work attitudes, undermining
the smooth transition of Greek youngsters from education to employment, have on it.
The main conclusion of this paper is that the youth employment problem in Greece is related
to distortions both in labour demand and supply side, which are driven by a strong insider-
outsider divide and a prevalent set of social beliefs. Therefore, policy proposals arising under this
perspective inevitably focus on drastic reforms and changes in labour market institutions, but
also on work attitudes.
This paper is structured as follows. Section 2 presents the main dimensions of youth
employment problem in Greece. Section 3 illustrates the theoretical framework about the crucial
role of institutional and cultural environment on youth employment. Sections 4 and 5 investigate
how this environment functions in the Greek case, through examining the implications of labour
market institutions and family ties, respectively. Section 6 contains a brief discussion of the
recent labour market reforms and section 7 concludes. The data used in this paper are drawn
mainly from the OECD and Eurostat databases.
2. Mapping the problem of youth employment in Greece
The public and scientific debate about the situation of young people in Greek labour market
has focused almost exclusively on the “youth unemployment” problem. Such a discussion
however is often misleading for at least two reasons. First, the numerical description, i.e.
unemployment rate may reflect or hide realities completely dissimilar in different labour markets
(Blanchard and Portugal, 2001). The same level of unemployment rate may result from a high job
destruction rate or may be an issue of low rates of flow from unemployment to employment (and
vice versa). The latter is trapping workers in a few but long-lasting and painful unemployment

episodes as is the case of Greek labour market. Second, such excessive figures make the youth
unemployment problem look worse than it really is, since only a small fraction of the population
aged 15-24 is included in the labour force, and most of it is either in education or training.
For these reasons, the difficult position of young employees in the Greek labour market
could be better described and explained as a transition problem, from (any level of) education
to employment (Mitrakos, Tsakloglou and Cholezas, 2010). This broader approach focuses its
analysis on any type of barriers to transitions that a worker is called upon to carry through his/
her life cycle: from education to the labour market, from unemployment to employment, from
domestic duties to work, from work to retirement, etc.
Already in the early ‘90s - i.e. long before the crisis commencement - young people in
Greece would after leaving full-time education remain for a long time unemployed or temporarily
employed in precarious jobs (Karamesini, 2006). Moreover, in contrast to other countries, long
transitions time in Greece (table 1) was the case for all educational levels (Quintini and Manfredi,
2009; OECD, 2010). This unfavorable picture is also confirmed by more recent empirical findings,
since according to ELSTAT (2009) approximately 43% of young people in Greece find their first
job at least three years after completion of their studies, while the average time until finding their
first significant job reaches to 36.6 months. During the crisis, the already long year transition
time for young people entering the labour market may have extended further.
Table 1. Time needed to find the first job in Europe and USA (months)
Medium Median 75ο percentile 90ο percentile
Europe 16,9 3 23,0 59,0
Austria 5,7 0 12,0 14,6
Belgium 17,5 3 23,0 67,4
Denmark 6,3 0 5,0 17,1
France 14,4 2 21,0 54,0
Germany 5,0 0 3,0 14,0
Greece 24,4 12 38,3 71,0
Ireland 8,3 0 6,0 25,8
Italy 33,1 24 53,0 95,0
Luxembourg 21,6 3 18,8 95,0
Portugal 15,6 3 17,0 61,8
Spain 22,1 12 31,0 73,4
United Kingdom 5,8 0 2,0 12,0
USA 5,6 0 4,4 18,8
Source: OECD estimates based on the European Community Household Survey (1994-2001) for European
countries, and the National Longitudinal Survey of Youth 1997 for the United States.
An overview of the youth employment situation in Greece as compared to EU-27 and OECD
countries is shown in table 2. It must be pointed out that we focus in the age group 15-24,

because in EU statistics “young people” are conventionally defined as being less than 25 years.
Obviously, the lengthening of transitions suggests that it would be more correct to set “youth
phase” below 29 years than 24 years of age. However, the statistical picture and trends are
similar in this wider age group, though less acute.
Table 2. Comparative employment performance, youth (15-24),
Greece, EU and OECD
2001 2011
Greece EU OECD Greece EU OECD
Employment rate (%) 26,0 40,2 43,3 16,3 33,4 37,8
Unemployment rate (%) 28,0 16,5 14,5 44,4 22,8 19,0
Relative unemployment rate
youth/adult (15-24/25-54)
3,2 2,5 2,6 2,6 2,7 2,7
Unemployed/population
15-24 (%)
10,1 7,3 6,7 13,0 9,0 8,1
Long-term unemployed
(% unemployed 15-24) 45,3 25,4 18,7 42,4 28,0 22,1
Temporary employment (%) 28,2 33,1 30,0 30,1 40,6 38,2
Part-time employment (%) 5,8 16,8 20,6 15,5 25,4 27,9
Not in employment,
education or training, ΝΕΕΤ
(%)
18,2 13,6 `13,2 `13,2 11,2 12,8
School drop-out (%) 25,0 19,9 22,7 17,3 15,1 19,6
Relative unemployment
rate low skills/high skills
(ISCED3/ISCED3)
0,7 2,6 2,5 0,7 2,3 2,2
Source: National Labour Force Surveys, OECD Education Database
Although this condensed picture needs further analysis, it is remarkable that in almost all
indicators Greece has had worse performance than the EU or OECD average - before and during
the crisis. The unemployment rate for young people in all advanced countries is higher than
the adult population. In the Greek case, however, the problem lies not only in the high youth
unemployment rate (15-24) but also in its long-term characteristics, since one in two youngsters
remain unemployed for a time longer than one year. Of particular interest is the fact that the
number of young unemployed persons, as a percentage of total population in this age group is
relatively low, although higher than the EU average. Yet, the low participation rate is a well stylized
fact of Greek labour market for youth and women. In this sense, employment rate (Figure 1) seems
to be the most representative – though equally disappointing - indicator of poor employment
outcomes of youth before and during the crisis, than the unemployment rate (Figure 2).

Figure 1. Youth employment rate (15-24), Greece, EU, OECD
0
5
10
15
20
25
30
35
40
45
50
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Employmentrate(%)
Greece EU OECD
Source: OECD, Employment Database
Figure 2. Youth unemployment rate (15-24) Greece, EU, OECD
0
5
10
15
20
25
30
35
40
45
50
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Unemploymentrate,15-24(%)
Greece E.U. OECD
Source: OECD, Employment Database
3. Some theoretical considerations
In a matching process - such as hiring a new employee - decisions of contracting actors (workers
and employers) are taken in a context of given preferences and available options. This could
be described schematically as follows:
Employers seek to hire applicants at the lowest possible cost and those they believe are
the most productive for the requirements of the job to be covered. In their decision, training
and experience act as “signals”, i.e. significant indicators of the workers’ potential productivity
(Mueller, 2005). On the other hand, workers tend to seek to take jobs that promise the highest
return (considering both income and non pecuniary rewards) for their education investment
(Becker, 1964). In any case, workers accept wages higher than the level they determine as
threshold to obtain a job, e.g. their own “reservation wage”.

Although this general matching mechanism between employer and employee is rather
common, the institutional and structural conditions on which decisions are made, significantly
differ (between countries, different time periods, etc.), thus highlighting the role of the
framework in which each pairing takes place. For example, regulations about dismissals and
severance payments are very important, since they determine how easily or at how a high cost an
employer could replace an employee who does not perform as expected.
Indeed, the integration of young people into the labour market considerably differs across
European countries. Some countries are characterized by very smooth school-to-work transitions,
while in other countries early career is a particularly turbulent and uncertain period for young
people, trapping them in unstable routes between unemployment and temporary job positions.
To some extent such a variation would reflect the state of the economy in different countries.
But this is far from being the whole story, because the ratio of youth to adult unemployment
rates also varies widely, suggesting that economic conditions have an effect on young people’s
unemployment rates in different manners in different countries. At this point the relevant
theoretical and empirical literature highlights the important role of other (non economic) factors,
especially national institutional settings such as labour market regulations, the education system,
social institutions as well as the quality of governance and the political system, cultural beliefs
and norms, etc. Even more crucial are the complementarities between the above mentioned
factors than the factors themselves (Kalleberg and Sorensen, 1979, Contini, 2012, Kawaguchi
and Tetsushi, 2012).
As Nicolitsas (2007:42) notes on the Greek case “…institutional as well as economic and
social factors shape participation, employment, unemployment and education enrolment rates”
without these factors being independent to each other. In this context, the present article
explores the effect that specific institutional and social factors have on youth employment in the
Greek labour market. Employment protection legislation and minimum wage as well as strong
family ties and the relevant work attitudes affect the labour demand and supply side respectively,
creating entry barriers and inertia conditions for Greek youngsters.
4. The role of labour market institutions
Employment protection
Much of the relative literature has studied the impact of strict employment protection -
namely restrictions on layoffs in the form of severance payment or procedural costs,
established through legislation, collective agreements or even via case law - on the employment
outcome. It is true that there is no theoretical conformity on how aggregate employment and
unemployment are affected from such regulations, while empirical evidence is rather ambiguous
and inconsistent, depending on the complementarities with other labour but also product market
regulations (Agell, 1999, Nickell and Layard, 1999, Boeri and van Ours, 2008).
However, greater agreement exists among researchers and stronger empirical evidence
is observed regarding the negative effect of employment protection on the demographic
composition but also on the duration of unemployment. Strict protective regulations enhance
the employment perspectives of those already securely placed in the labour market, while the
opposite stands for more vulnerable groups, especially the youth. As Skedinger (2011) notes, the

firm already incorporates potential future costs in a case of lay-off already at the hiring decision.
So, firing costs not only decrease the employer’s inclination to lay off an employee, but also his or
her willingness recruit new staff. The latter effect applies, obviously, on groups of workers whose
professional success depends on the existence of barriers in the entry or re-entry into the labour
market, such as youth and women (Esping-Andersen and Regini, 2000).
For this reason, countries with high rates of employment protection index (Employment
Protection Legislation, EPL), such as Greece, face low employment levels, high unemployment
rates as well as long-term unemployment spells in this age group. Obviously, the above mentioned
correlation is more complex. In specific, it appears that the lay-off restrictions undermine the new
entrant’s perspectives primarily in countries where employers can’t easily and reliably estimate
the potential productivity of job seekers by their educational credentials (Mueller, 2005). Thus,
in the Mediterranean countries (including Greece), where there are no ready-to-use and reliable
professional skills, the impact of employment protection legislation is more explicit and clear. In
Germany and Austria, i.e. countries that have developed training systems associated to production
needs, this effect is overturned by the strong signals sent by the educational credentials that job
seekers possess (Mueller and Gangl, 2003, Wolbers, 2007).
Even more problematic is the situation of youth in labour markets where employment
protection is designed in a way that it creates or stimulates dualism conditions (Boeri, 2011,
Scarpetta et al. 2010). It has been documented that the poorly integrated entry process - i.e.
trapping in shuttle routes between inactivity, unemployment and temporary or other atypical forms
of employment, even in periods of strong economic growth – affecting about 30% of young people
in OECD countries is due to dualistic labour market structures (Boeri, 2010, European Commission,
2010). The latter may be the result of a strong institutional asymmetry in the protection of open-
ended and temporary contracts as in the case of two tier labour market reforms in Spain, France
and other countries, where the reform process focused primarily at the margin of labour market.
However, this dualism may arise in labour markets with a strong insider-outsider divide and with
high segmentation along a range of divisions, namely public vs. private sector, large vs. small
firms, formal vs. informal economy and even divisions by age, gender and ethnicity as Karamesini
(2008) notes for Mediterranean countries. This is also the case of Greece, where youth are more
likely than to their adult counterparts to be “outsiders”, while they are overrepresented in flexible
employment arrangements and undeclared work (Lyberaki and Tinios, 2012).
Τhe involvement of young people in flexible or temporary contracts is not a problem per se.
The latter is applied, in more or less all European countries, often operating as “stepping stones”,
i.e. as an entry tool to the labour market or as transitional steps in the trajectory career (Booth
et al. 2002, Scherer, 2005). For this reason, the incidence of temporary arrangements is higher
among young people, e.g. in Germany (57.2%), France (51.2%), Spain (55.9%), Sweden (53.4%),
Portugal (53.5%) and Nederland (46.5%), much higher than among adult population (Eurostat,
2009). In Greece also, the share of temporary contracts among young people is more than twice
than in adults (28.4% compared to 11.9%)
The significance of temporary contracts as an “entry port” mechanism is further confirmed
by the Figure 3, which illustrates the types of first employment contract for new entrants. In the
case of Greece (and Italy), the share of self-employment is remarkable, mainly in the form of false
or “pseudo self-employment”. According to Karamesini (2010), 5-7 years after graduation the
59.6% of graduates were employed in stable employment positions in the private and public
sector, 19.7% had fixed-term contracts and 20.7% were self-employed in a unique employer.

Figure 3. Types of first employment contract (2004-2007)
0
20
40
60
80
100
D
enm
a
rk
IrelandH
ungary
C
yprous
B
elgiu
m
Sw
edenC
hech
R
ep
Austria
Finland
Italy
G
ree
ce
France
Poland
Spain
P
ortugal
FirstJobtype(%)
Self-employment Temporary permanent
Source: EU SILC longitudinal component (Employment in Europe, 2010)
The problem lies in the reluctance of employers to convert these forms or employment to
permanent job positions. This is more likely to happen in countries with strict employment regulations
against lay-offs, as employers prefer to rotate workers in temporary jobs than to bear the high cost
of potential dismissal of a permanent employee (Blanchard and Landier, 2002, Kahn, 2010). Indeed,
as shown by the Figure 4, entrapment in temporary employment for young people aged 15-24
(and for the whole population) is more likely in countries with strong insider-outsider divide such
as Greece, Spain, France, Italy, Portugal, etc. On the contrary, in countries with more deregulated
labour relations (e.g. UK, Ireland), temporary workers are 1.5 to 2 times more likely to move to
permanent jobs in the next year than to remain in the temporary job (Booth et al. 2002, E.C., 2010).
Figure 4. Probability of transition from temporary to permanent employment*
0
0,5
1
1,5
2
2,5
3
3,5
Ireland
U
n.K
ingdomH
ungary
AustriaSw
edenSloveniaBelgium
C
hech
rep.
Italy
Spain
Poland
FinlandG
reeceC
yprousPortugalFra
nce
Transitionpropability
15-64 15-24
Source: Employment in Europe, 2010
*
In axis y is measured the ration of the likelihood a person who worked temporary in the period t to have
acquired a permanent job in the t+1 period, to the likelihood to remain in the temporary job. The higher the
price of the unit, the higher the rate of conversion of temporary contracts into permanent.

The cost of employing youths - Minimum wage
Of particular interest in the Greek case is the way in which labour cost influences the
employment perspectives of particular groups of young workers. Indeed, young people with
working disadvantages (“youth left behind”), such as those to a low education level, immigration
background or those suffering some kind of disability, face high risk of remaining for a long time
outside the labour market (OECD, 2008, Boeri, 2010). A very useful comparative indicator for this
group of youngsters is the so-called NEET’s, i.e. young people who are out of work (unemployed
or inactive) and, simultaneously, out of any educational or training course. In the context of the
above mentioned matching model, the difficulty for this category of young people to enter the
labour market is closely related to the labour cost and, hence the minimum wage.
The theoretical and empirical assessment about the impact of minimum wage on total
employmentandunemploymentisambiguousandinconclusive,dependingonthecomplementarities
to other labour market institutions (Dolado et al. 1996). However, robust findings exist in the case of
youth employment. Both the level of the minimum wage (especially when it is determined at a level
higher the one corresponding to competitiveness equilibrium) and the sharp wage increases could
have adverse effects on youth and unskilled workers (Neumark and Wascher, 2004). Indeed, young
people have less professional experience and they exhibit higher labour turnover. Moreover, the
employer can’t immediately recognize the potential productivity of the young candidate, especially
in situations where the education system has weak connection with the labour market and the
production system, as in the case of Greece (Mueller and Gangl, 2003). Consequently, labour cost
is the only observable and measurable factor for the evaluation of youth labour.
It is well known that formal job positions in low productivity sectors are created only when
they are cheap or subsidized (Baumol, 1967). In Greece, the coexistence of the minimum wage
institution with a high tax wedge (due to social contributions), as well as the accumulated
distribution of wages at the levels of the sectoral minimum wages and slightly above them, made
it more attractive for employers to employ people with experience and skills than unskilled new
entrants (Mitsopoulos and Pelagidis, 2011). Although employers can transfer, to some extent,
the burden of contributions to workers through lowering wages, this is not applicable for people
who earn the minimum wage, e.g. young and unskilled workers (Nicolitsas, 2007). As a result,
the wide use of both flexible contracts and undeclared work is encouraged. This seemed to be the
case in Greece, at least in the times before the current crisis (Burtless, 2001).
On the basis of the above mentioned institutional distortions, many international
organizations (OECD, IMF) as well as the European Commission have recommended particular
institutional reforms in order to tackle youth unemployment in Greece. These are well known
measures, largely in force in many other countries, such as the introduction of sub-minimum
wages for young workers, the enhancement of apprenticeship and the reductions of social
contributions for new entrants. Indeed, recent reforms in the Greek labour market have followed
to a large extent these recommendations, as discussed later in this article.
Areas of concern arising from such reforms refer to the low entering wages and their
consequence to future career paths. However, it has been shown that the long or repeated
unemployment spells have more adverse (and scarring) effects for young people than their
involvement in low-paid or temporary jobs positions (Cagliarducci, 2005). Moreover, as Smith
(2010) notes, working in temporary jobs, low paid or even unpaid (e.g. voluntary work in non-
governmental organizations and other bodies) is for young people a key mechanism for enhancing
their employability. Not only by improving their cognitive and social skills, but also by providing a
strong sign of productivity to employers who want to minimize the risk of a recruitment failure.

Therefore, it is reasonable to argue that it is better for the career progression of young
people to be working in a low paid job than to have no job at all (Smith, 2010). The crucial
point is, as mentioned above, the existence of an inclusive labour market without excessive
institutional or administrative obstacles in order the exit rates from low pay job positions to be
relatively high, even higher than the exit rates from non-employment.
At this point, relevant is the issue of young people attitudes about their career paths. The
next section explores the role of strong family ties in Greece in the formation of social beliefs and
work attitudes that prevent the smooth transition from school to work.
5. The role of family and attitudes
It is well known that in Greece as well as in the other Mediterranean countries, the family apart
from its social cohesive action plays a significant role, both in welfare state and labour market
(Ferrera, 1996). Strong family ties constitute the most important protective mechanism for young
people, providing housing, financial and emotional support for a very long time. Over the past 30
years, these countries have witnessed a dramatic increase of the fraction of young adults living with
their parents. As a result, well over half of all young adults (18–33 years old) live with their parents
in Greece, Italy, Portugal and Spain, while their counterparts in United Kingdom, Germany and
Scandinavian countries is less than 30% (Giuliano, 2007). Obviously, apart from social norms and
cultural causes, other reasons that have contributed to this trend are the increased housing prices
and the deterioration of employment perspectives for the new entrants in these countries.
However, the fact that young people in Greece live for many years with their family causes
negative side effects. Firstly, it postpones the transition of young workers to an economically
independent adult life (Chtouris et al. 2006), allowing them to enter into the labour market with
a long-wait strategy until the “appropriate job” to be found (Karamesini, 2010). In other words,
strong family ties increase the reservation wage of young people (i.e. the wage level above of which
accept to work), contributing so to the formation of a voluntary fraction of youth unemployment
(Scherer, 2005). Secondly, the fact that this long-wait strategy is chosen instead of alternative
strategies such as the productivity enhancement through work experience, even in insecure job
positions, means employability losses for youngsters. Thirdly, the shrinking youth labour supply
leads – according to mainstream economics - to higher equilibrium wages and lower employment
levels, contributing so to the cumulative deterioration of youth employment perspectives.
In this sense, it has been argued that strong family ties incite or support work attitudes that
are actually doubtful regarding the employability of youths. Characteristic examples are the short
extent that Greek youngsters combine study and work as well as the persistent trend for career
choice in the public sector.
Combining study and work is not a widespread behavior among the Greek students (Mihail and
Karaliopoulou, 2005; Nicolitsas, 2007). In 2008, the share of working students aged 15-19 and 20-
24 was in Greece below to 3% and 10% respectively, much lower than the OECD average (21% and
35%). It should be noted, that the share of working students is higher in countries that either have
more deregulated labour relations such as Denmark, the Netherlands, UK, and apparently the U.S. or
have well organized apprenticeship systems. The same countries score high on youth employment.
It has been well documented that students working to an extent that doesn’t compromise
the educational achievements, has positive effects on youth employment perspectives (OECD,

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