The key features of the community support system in Greece for people with disability are financial empowerment through disability benefits and pensions, provision of aids and equipment and the provision of state-funded community-based or short-term residential rehabilitation services (L2072/1992). Local support started to appear in the form of small pilot projects with Help at Home in 1997 (L5814/1997), and developed through local social services departments and networks of support centres across the country only after 2003 (L3106/03).

Basic legislation for health and social care services

Law 2072/1992 first laid out regulations for establishing centres for institutional and community based rehabilitation service provision to people with disability. Expenses for rehabilitation are covered by social security and social welfare, through contracting with the Ministry of Social Welfare and Social Security (now named Ministry of Health and Social Solidarity). A further Ministerial Decision in 1998 set out conditions, prerequisites, processes, staff and resources for establishing “Housing for supported living” in the community for people with disability, with view to de-institutionalization and independent living.

A similar move to de-institutionalization has been made in the field of mental health service provision. Law 2716/1999 enabled the creation of long or short term housing and support for children and adults with mental health problems in protected hostels or flats, by either public bodies (including hospitals) or private (profit or non-profit) organizations, It also established regulations for Limited-Liability Social Enterprises.

Law 3106/03 Readjustment of National System of Social Care and other Regulations marked for the first time the de-centralization of the Social Welfare system. Regional Systems of Health (founded through Law Ν 2889/01) now also acquired responsibility for providing local social support services, and for implementing measures for de-institutionalization, rehabilitation and social inclusion of people with disability. The legislation provided indicative examples, such as the creation of residential hostels and flats in the community, as well as the creation of sheltered employment and training centres. Importantly, the Law also foresaw capacity for contracting between local authority and other public, private and non-governmental bodies for the creation of services. In addition, the law created the National Observatory for People with Disability, and set out a research plan with regard to all aspects of disabled people’s lives, including employment, education, equal access to services and coordination of policy and practice.

Law 3329/2005 National System of Health and Social Solidarity and other Regulations regulates in detail the internal organization, staffing, role and responsibilities of regional health and social care units, with regards to planning and implementing local measures for social protection and inclusion. Social Care units became public sector bodies with their own budgets, regulations and tax numbers. Article 21 and 22 of the law concern services for “de-institutionalization, rehabilitation and social inclusion” of people with disability. These may be provided by public social care units, private bodies or NGO’s, subject to further regulations for acquiring a license. Independent living is conceived of again only in terms of community flats, with no more than four residents.

Law 3370/2005 “Organization and Function of Health Services and Other Regulations” refined the role of the “National Council of Social Welfare”, which was renamed the “Institute for Social Protection and Solidarity”. Duties included proposing, developing and implementing measures for social support and protection. Particular responsibilities of the Institute, which reports to the Ministry of Health and Social Solidarity, are to maintain a national record of people with disability who need social services, to support, supervise and coordinate social welfare workers, to develop innovative programs in social support and disseminate best practice, as well as to manage 5% of lottery funds for scientific research in the field of social welfare.

Parallel to the de-centralization of welfare and the creation of local social support services, the “Help at Home” program was increasingly run by municipalities across the country with 3rd Community Framework EU co-funding. It was first piloted in two municipalities in Athens in 1997 (Law 5814/1997). “Help at home” was restricted to elderly people (as a separate target group of beneficiaries from disabled people), and it was not until 2006 that it was modified to include people with disability who need help at home. (Ministerial decision 110941/12.4.2006)
In 2008, a new policy for management, evaluation, monitoring and inspection of Help at Home and other social welfare programs allocated national funding for the continuation of the program (Ministerial Decision 60292/2158/ 2008).

Disability Benefits and Pensions

Disability benefits were legislated separately for different impairments, starting in chronological order with benefits for blind people (L.1904/1951), people with hearing impairment (Ministerial Decision D3b/423/1973), people with paraplegia and tetraplegia (Ministerial Decision 115750/3006/1981), people with learning disability (Ministerial Decision C4/1930/1982) and people with cerebral palsy (Ministerial Decision C4a/1434/1984). In 1989, a Ministerial Decision made benefits available to all other categories of disability not already covered, and who were regarded as being over 67% disabled (this exists only as welfare benefit, i.e. for the uninsured). It is worth noting that all benefits, except those given to blind people, require that recipients do not stay in welfare state-funded institutions for longer than 3 months.

In 1998, important modifications were made to the benefit given to people with paraplegia and tetraplegia across all social security bodies and welfare (Law 2646/1998). Eligibility was extended to people with 67% disability with paraplegia or tetraplegia caused by any impairment to nervous and muscular system (previously restricted to paralysis), to people with single amputation on lower limbs (previously restricted to people with double amputation), people with myastheneia and multiple sclerosis, as well as to family members in instances where the entitled person lacked legal capacity. An additional modification made was that half the amount of the benefit was given to people living in institutional settings.

Disability pensions are legislated for by different social security bodies, who have differing eligibility criteria, mainly in terms of insured working days. The minimum threshold for disability pensions for all social security bodies is 50% disability (as assessed by the health commission of each social security body).

Disability- related pensions are based on the following definition of “disability”:
“A person is considered to be suffering from severe invalidity when, as a result of illness or physical or mental disability which appeared or worsened after affiliation, he or she cannot earn more than a fifth of the normal earnings of a worker in the same category or training during at least 1 year. However, those who can no longer earn more than 1/3 of the normal earnings obtain 75% of the benefit and those who can no longer earn more than 1/2 obtain 50% of the pension” (MISSOC 2007)

Disability pensions of the social security body for private sector employees under the Ministry of Employment and Social Protection are coordinated on the basis of Law 612/1977 and 1902/1990, those of the agricultural social security body under Ν.2458/1997, and those of public sector employees under Law 2227/1994 and 3620 /2007, which entitles people with disability to a full pension if they have completed 15 years of work.
In 2004, Law 3232 (applicable to all main social security bodies under Ministry of Employment and Social Protection) allowed early retirement for mothers and spouses of people with disability with 80% or over, after 25 working years, regardless of age. The law also established that people with severe disability are entitled to their parent’s pension after their death.

With regards to state contribution to pensions, there is a minimum amount of pension guaranteed to people (general population) with 15 years of insured employment which stands at € 445.37 per month for persons insured before 1993, and €453.71 per month for persons insured since 1993 (Figures for 2008). Maximum pension is set at €2,172.25 per month and € 2,538.28 per month accordingly. Pensions are payable from the date when disability is deemed to exist. Periodically (after 1 or 2 years depending on circumstances) the insured persons are assessed by the health committees.

For people insured before 1993, the amount of the pension is calculated on the basis of the wage assumed for each of 28 insurance categories corresponding to average gross earnings in the 5 years before retirement. From 1 January 2005, the insured person may choose as calculation basis the five best years during the last ten years before retirement.

The pension varies according to the degree of disability (severe disability receives full pension, the pension is reduced by 25% for 67% incapacity, the pension is reduced by 50% in cases of 50% incapacity.) For people insured after 1993, along with the amount of wage of last five years and degree of disability, the number of years insured are also taken into account. Each year corresponds to 2% of pensionable income.

Totally blind persons, persons with paraplegia/tetraplegia and kidney failure, having accomplished 4,050 days of contribution, receive a full pension corresponding to 35 years regardless of their age. Moreover, in case of total disability, a pension supplement is paid for care provided by a third person. The supplement cannot exceed € 543.60 per month.

Pensions are subject to taxation. There are exemptions regarding income tax which allow for income tax relief or tax reduction for paraplegics, blind, and victims of war.

Other policy provisions

Other measures that can be argued to indirectly assist community living through financial relief are: (please note all apply only to people with 67% disability or over):

• Housing loan benefit (1 year) (Law 2736/99, Official Journal of Government 172Α΄)
• Rent benefit (1 year) (Law 1849/89, Official Journal of Government 113Α΄) and Ministerial Decision 2000 number 50262)
• Benefit for housing adaptations (only for houses older than 20 years old) (Law 2224/94 and Ν.2736/99)
• Revenue Tax relief (Law 2238/1994, Official Journal of Government 151Α΄and L 3522/2006 O.J.G 276Α΄)
• Motor tax relief (Law 490/1976, O.J.G. 331Α΄ and L. 3156/03 O.J.G. 157 A΄)
• Free travel within city (buses, underground) and 50% reductions for coach and train travel (Law 2072/92, O.J.G 125/Α΄)
• Social Tourism funding (Law 2224/94)
• Free access to cultural sites (Ministerial Decision Ε/22240, 2003, O.J.G. 1705/Β’)

Social Services in the Community

Community-based services that have developed in the last decade in the move away from institutionalization, mainly provide support with diagnosis, information and counseling, training, including lifelong learning, sheltered employment programs, day centers and physical rehabilitation services (such as physiotherapy, occupational therapy and speech therapy). These are provided on a local level.

Direct services across Greece include:

• The “Supportive Social Services Network” which is being implemented in 93 municipalities all over Greece, aimed at social inclusion
• The National Network for the Social Support and Training of people with disabilities (KEKYKAMEA). (24 in Greece)
• After-Care Centres for Physical and Social Rehabilitation (KAFKA). 15 in operation while another 4 have not yet staffed
• The National Centre for Emergency Social Assistance (renamed National Center for Social Solidarity) which has put in place 15 structures in Attica and 3 structures in Thessaloniki.
• 21 centres of child care
• 6 National Institute of Hearing impaired and Centers of Professional Re-establishment Of Blind people
• 71 Health and Social Centres
• The National Foundation on Rehabilitation of People with Disabilities
• The Hellenic Society for the Protection and Rehabilitation of people with disabilities
• One Autistic Individuals Support Centre
• One Spastic Children’s Unit
• One Rehabilitation Centre for Children with disabilities in Athens
• One Physical and Social Rehabilitation Centre for people with disabilities in Crete
• Therapeutic Centres on Chronic Conditions
• Hospitality Centres for the Elderly (KHFH)
• Enterprises, Non- profit Private Law Entities. (838) and 71 associations
• 320 Centres for the Protection of the Elderly (KAPI)

Source: Ministry of Internal Affairs and Decentralization (2006) National Strategy Report 2006-2008 ANNEX 4.1.2 Long-term care
Although these services enhance community living and social inclusion, they do not provide support with daily life activities at home. The only exception is the Help at Home program of which there are now almost 1200 all over the country (National Strategy Report for Social Inclusion 2008-2010). However, it is worth noting that the overwhelming majority of beneficiaries are elderly people (seen as a different target group from disabled people).

Even though disabled people have also been eligible for home help since 2006, there are basic reasons why this is far from adequate support for independent living:

• Hours of support are decided by the respective social worker of the department on the basis of resources/staff available, rather on the basis of needs assessment.
• Eligibility depends on annual income, meaning that certain groups are excluded altogether. (Ministerial Decision 60292/2158/ 2008)
• There is a limited range of tasks that can be performed. These include personal care, housing and shopping. In addition, assistance can only be provided at home, i.e. there is no assistance available for education, work or social activities.
• There is a limit to the amount/ intensity of support performed, due to inadequate resources/ staff availability. Thus, a person with daily support needs with personal care cannot be covered by the program.
• No choice over staff/ hours
• No support is available to family members/ informal careers

For people with higher support needs the only option left is employing personal assistance through private funding or informal care. In this sense, for people without adequate family support or income, institution may become the only viable option.

Personal Assistance

Personal assistance schemes do not feature per se in Greek social policy, in the sense that this has been defined by the independent living movement across Europe (involving choice and control over who provides support; where, how and when assistance is provided). There is no discourse on the role of self-directed support in social policy in independent living, and consequently no provision or planning with regards to individually tailored service provision or direct payments for support with daily life activities within the community. Importantly, the current system of assessment and provision, which is overwhelmingly based on a medical model rather than support needs, impedes the inclusion of personal assistance schemes in the current system of social support.
The only available measures that indirectly enhance the ability of an individual to purchase personal assistance are disability benefits. In only one instance, exclusively for people with physical disability such as/ similar to paraplegia and tetraplegia, this benefit is intended for people who live in the community and who need assistance from a third person. In essence, however, this benefit does not differ from other benefits given to other disability categories, such as people with hearing or sight impairments, learning difficulties and so on, as part of policy programs for financial empowerment of people with disability.
In particular:

1. The benefit is given exclusively to people with 67% disability or over, with the following impairments: people with paraplegia or tetraplegia, myastheneia, multiple sclerosis, and amputation (either one or more limbs).
2. The monthly amount of the benefit equals 20 times the daily rate of unskilled worker at any given time, currently standing at 673€ (2009), with a 7% yearly rise from 2008 (629€) and thereafter until 2011, when it is foreseen it will reach 771€ (Ministerial Decision P.3a/18/ 63731/2008)

The inadequacy of this “de-institutionalization” benefit is due to the following issues:

• The benefit is limited to certain categories of disability, based exclusively on diagnosis rather than support needs
• The benefit is provided at a fixed rate for all eligible individuals, without regard to different levels of need
• The amount of the benefit is inadequate to employ personal assistance for people with high level of needs (minimum wage in Greece is 680,59 €, for 48 hours per week – Eurostat, 2008). In reality, for many people this benefit constitutes their primary source of income and this is insufficient to cover the additional cost of personal assistance.
  In any case, benefit policy cannot substitute for a framework of policy measures needed to create the conditions for self-directed support. These would include: legislation and regulations for direct payments based on individualised needs assessment, a network of public services for personal assistance, and the creation of independent living centres for peer support and training of employers, which are altogether lacking in Greece.

Aids and Equipment

Provision of assistive equipment is managed through social security bodies, which set their own regulations in terms of eligibility, range of equipment and cost ceilings.

In all cases, social security bodies provide only rehabilitative equipment. Therefore, the cost of assistive equipment such as home adaptations and assistive technology for access to Information and Communication Technology, which are arguably vital for independence and social participation of disabled people, is not covered by the state. The only kind of home adjustment that is covered by all main social security bodies (private, public and agricultural sector) is raised toilet seats.

Equipment for sensory disabilities is limited to basic technical aids, such as hearing aids, speech aids, glasses and walking sticks (provided by all social security bodies). For physical disability, the range of assistive equipment includes:

1. (Provided by all social security bodies): electric and manual wheelchairs, orthopaedic products, air mattresses and wheelchair cushion for protection against pressure sores, walking aids, artificial body parts/ prosthetics, and expendable medical supplies such as catheters, or ventilators.
2. (Provided only by IKA and OPAD): electric beds, hoists, physiotherapy bicycles (passive and active exercise), orthostatic equipment, electric stimulators, and commodes.

There are limits to the cost covered for equipment, which vary according to the type. For instance, under IKA (2009), the cost met for a simple, manual wheelchair is 269€, for an enhanced light weight manual wheelchair 1800€, for a child’s wheelchair 1743€, while for a simple electric wheelchair it is 3.850€, and 5.810€ for a powered electric wheelchair. In comparison, the social security body for those insured in the public sector provides up to 400€ for a simple manual wheelchair, 1100€ for a light weight manual, and 4000€ for a powered electric wheelchair (OPAD, 2005)

Similarly, eligibility also depends on the type of equipment. For instance, under IKA an electric wheelchair is funded only for people with tetraplegia, and only under specific circumstances in cases of paraplegia (e.g. increased body weight, or a long distance between work and home). OPAD is a bit more flexible with eligibility on the basis of impairment, as people with any neurological condition that causes similar impairment to paraplegia or tetraplegia (with 80% or over disability) are entitled to equipment such as manual or electric wheelchairs. All eligible individuals pay 25% contribution, except in cases of paraplegia and tetraplegia, for whom the social security bodies pay full cost (this applies to both IKA and OPAD).

Despite differences between social security bodies in terms of eligibility, range of equipment and cost ceilings, there are two strands in common. Firstly, social security bodies cover part of the cost of equipment, i.e. provision is in cash, rather than in kind. Therefore, people are free to choose and buy equipment from the private market as it suits their needs and preferences. It also means that there are no restrictions with regards to moving across the country, as equipment is owned by disabled people themselves.

Secondly, the process of assessment is similar in all social security bodies: eligible people require certification of their impairment from two people: a specialised doctor who is contracted with the respective social security body, and a social security doctor or health commissioner designated for provision of equipment. In all cases, the certification of impairment has to be an exact match with the conditions and prerequisites of the social security body. This is the strongest critique against this system of provision; assessment is based on diagnosis, rather than need. For instance, a person with mobility problems but not with complete paraplegia will have to privately fund a wheelchair. The strict medical model used means that many people with mobility problems are excluded and have to bear the extra costs of impairment in living independently in the community.

Disability NOW (www.disabled.gr)
December 2009