- Observatory: EurWORK
- Labour market policies,
- Work organisation,
- Disability and chronic disease,
- Offentliga tjänster,
- Working conditions,
- Social policies,
- Published on: 14 november 2014
Disclaimer: This information is made available as a service to the public but has not been edited by the European Foundation for the Improvement of Living and Working Conditions. The content is the responsibility of the authors.
Chronic diseases are a complex field that is particularly difficult to define, with many particularities in terms of symptoms and their impact. Especially in the field of employment, deficiencies are being discovered with respect to the recording and the monitoring of the issue, in the legislation and the implementation of specific measures for the protection or facilitation at work of people suffering from chronic diseases. The protection of workers with chronic diseases is governed mainly by across-the-board policies that protect the health and safety of workers and, by way of exception, specific measures are taken for certain diseases. Special regulations are in force mainly in the field of occupational diseases and disabilities.
Block 1: Concept, definitions, sources of information and methodological issues on chronic diseases and work from the national perspective
1.1. National definition of chronic disease
In Greece, the concept of chronic diseases follows the definition of the World Health Organization. That is to say, chronic diseases are those having a long history and requiring constant treatment for years or decades. This definition includes, by way of example, diseases such as: cardiovascular diseases, high cholesterol, diabetes, allergies, cancer, asthma, chronic bronchitis, multiple sclerosis, rheumatoid arthritis, osteoarthritis, etc.
Additionally, in the Greek legislation one may find the similar term "refractory diseases and illnesses". According to Ministerial Decree 16884/2001 (Ministry of Health), refractory diseases “are the unhealthy conditions and diseases that require long-term hospitalisation or treatment, infect one or more organs and are characterized by remissions and elations. These diseases are considered curable or treatable and it is expected that the good use of a twofold sick leave contributes to the functional rehabilitation of public Employees, when the sick leave ends. The refractory diseases per system are: Psychiatry, neurology, rheumatology, vascular surgery, ophthalmology, gastroenterology, pulmonology, cardiology, orthopaedics, neoplasms, kidney disorders, infectious diseases, hematology and endocrinology”.
At the same time, however, the disabilities also constitute chronic diseases, which are dealt with in a special way, mainly in terms of the allowance and retirement policy governing them.
Moreover, another category of diseases that can also be chronic diseases are the occupational and the infectious diseases. .
1.2. Information on national sources of statistical information dealing with the issue of chronic diseases and their relation to employment and working conditions
The Hellenic Statistical Authority (EL.STAT.) conducted a Special Survey on the Employment of people with health problems (Ad hoc 2011), the findings of which were made public in 2013. The objective of the survey was to collect information on work-related health problems and on the position of people facing a health problem in the labour market. The survey is a sample survey, was carried out in the 2nd quarter of 2011, was addressed to the age bracket of 15-64 years and was nationwide.
Any condition or illness from which the surveyed person suffers and lasts or is expected to last more than 6 months was considered as a health problem. The chronic problems that were investigated are: Musculoskeletal, cardiological, mental illnesses, pneumonic diseases, cancer, etc.
The questions posed are:
- Are you experiencing a health problem?
- Does the health problem limit you: a) as regards the number of hours that you can work; b) as regards the type of work that you can do; c) as regards your journeys to and from work?
- Do you use: a) personal assistance, or b) special equipment, or c) do you do any special form of work (sedentary work, teleworking, flexible working hours, work with less intensity) at work because of the health problem that you have?
- Do you need any of the above in order to work, due to the health problem that you have?
Earlier, in 2009 the EL.STAT. conducted a “National Health Survey” across the Country, in the context of its participation in the European Health Interview Survey. "Chronic health problems or diseases are those that last or are to last more than six months”. The diseases that were investigated are: asthma, chronic bronchitis, coronary disease, myocardial infarction, congestive heart failure, valvular heart disease, coronary artery bypass, angioplasty, arrhythmia, hypertension, stroke, multiple sclerosis, rheumatoid arthritis, osteoarthritis, back problems, neck problems, diabetes mellitus, cholesterol disorder, allergy, stomach ulcer, liver cirrhosis, cancer, migraine, urinary incontinence, chronic stress, chronic depression, schizophrenia, other mental disease, permanent trauma or injury due to accident, thyroid disorders, osteoporosis, Parkinson's disease, poliomyelitis, myasthenia gravis, hemorrhoids, hepatitis, Alzheimer’s disease, other.
The questions posed are:
- What is your occupation?
- What chronic condition you are experiencing?
- Was a disease caused or has it worsened in the past 12 months because of your work?
- Were you absent from work for health reasons in the past 12 months? If yes, for how many days?
The methodology used is the multistage stratified sampling of Households.
Source of information for the 2 preceding surveys: http://www.statistics.gr/portal/page/portal/ESYE
Block 2: Prevalence, recent evolution and effects of the problem of chronic diseases among workers and companies
2.1. People affected by chronic diseases and employment
The results of the “Special Survey on the Employment of people with health problems (Ad hoc 2011)”, conducted by EL.STAT., show that:
- Of the total number of persons aged 15-64, 6.3% face a health problem (6.4% are men and 6.2% are women), the main diseases being: Heart, blood pressure or circulation problems: 25.4% (31.1% men, 20% women); problems with back or neck (which includes arthritis or rheumatism): 13.8%, (12.8% men, 14.7% women); problems with legs or feet (which includes arthritis or rheumatism): 12.4% ( 9.9% men, 14.7% women); chronic anxiety: 5.9% ( 5.3% men, 6.5% women); problems with arms or hands (which includes arthritis or rheumatism): 6.5% (5.4% men, 7.6% women); other mental, nervous or emotional problems (5.6%); stomach, liver, kidney or digestive problems (4.9%); diabetes (4.6%); severe headache such as migraine (4.3%). etc.
- Among the age groups, the age bracket of 45-64 years shows the highest percentage with a health problem (12.8%)
- Of the total number of respondents who have a health problem, 40.9% say that they can work for a limited number of hours, 41.4% say that there are limitations as regards the type of work that they can do and 20.1% say that there are limitations as regards their journey to and from work. In terms of gender distribution, there are negligible percentage differences (approximately 0.5%)
Furthermore, the National Health Survey of 2009, conducted by the EL.STAT., shows that:
- A percentage of 39.75% of the total population (15 +) face a chronic health problem, while in the population aged 65 years and over the percentage is 77.89%.
- The distribution of diseases is as follows: 3.46% of the population suffer from chronic bronchitis, 1.45% from myocardial infarction, 2.17% from coronary heart disease, 2.09% from congestive heart failure and 5.68% from arrhythmia; 4.33% of the population suffer from asthma, 20% have hypertension, 5.04% of the population suffer from rheumatoid arthritis, 7.92% from diabetes mellitus, 14.98% of the population suffer from cholesterol disorder, 1.72% from cancer, 4.22% from chronic stress e.t.c.
- Of the total number of respondents who have a chronic health problem (i.e. 39.75%), 27.4% are workers.
- Of the total number of respondents, 6.4% declared that in the past 12 months, the disease was caused or worsened because of the work, and 44.3% declares the opposite
- Of the total number of workers, 15.8% were absent from work in the past 12 months for reasons of health and 83.7% were not absent.
- More than 50% of workers were absent from work for health reasons for a period of 1-6 days, 9.6% for 10 days, 4.9% for 15 days, 5.3% for 30 days, 2.4% for 100-210 days, etc.
Other general surveys that are related to chronic diseases are listed below:
- The National public opinion Survey of 2011 carried out by the National School of Public Health (ESDY) titled “Health services evaluation survey”. On the question whether there is a diagnosis of some chronic health problem is answered positively by 40%, of whom 43.6% are men and 36.4% are women. In terms of age distribution, a positive answer is given by 12.6% of those aged 18-24, by 17.5% of those aged 25-39, by 33.8% of those aged 40-54, by 57.2% of those aged 55-64 and by 68.1% of those aged 65 years and over. As regards the system of organs affected by the chronic condition, in descending order, 37.6% of respondents suffer from a cardiological or cardiovascular health problem, 25.8% suffer from a metabolism/endocrinological problem, 21.7% suffer from an orthopaedic problem, 12.8% from a gastrointestinal problem, 9.8% from a respiratory problem, 5.5% from a kidney disorder, etc.
- According to a previous research, which was carried out in 2006 by the Faculty of Medicine of the University of Athens, 35% of the Greek population say that they suffer from some chronic disease. The arterial hypertension is the most frequent one (16%), followed by hypercholesterolaemia (9.1%), hip or knee osteoarthritis (6.1%) and diabetes mellitus (6%). Women say that they suffer from a chronic disease at a greater rate than men (39.6% versus 30.7%), with the exception of cardiovascular diseases. Source: National action plan for public health 2008-2012)
- Are certain chronic diseases associated to or more prevalent in certain economic sectors/occupations?
Chronic diseases are often associated also with the sectors or the professions of workers. Therefore, there is a distinct category of "occupational diseases" (see section 1.1. above), as well as the obligation to adopt specific measures in some sectors.
A survey conducted by EL.STAT. in 2008 titled “Special Survey on accidents at work and work-related health problems" shows that 8.7% of the entirety of workers have health problems that were caused or worsened by their work. This percentage is higher among farmers, cattle-breeders, foresters, fishermen (12.9%), blue-collar workers (9.8%), while the lowest rates are being recorded in scientific, artistic and similar professions (3.2%) and among office employees (3.3%). Moreover, 40% of workers reply that they are negatively affected by some factor, such as the exposure to chemicals, dust, fumes (11.6%), the handling of heavy loads, difficult postures (15.5%), accident hazard (10.1%) and noises, vibrations (2.9%).
Studies on the evaluation and prevention of occupational hazard for individual sectors and professions have been carried out by the Hellenic Institute for Occupational Health and Safety (ELINYAE) and concern: Harbour services, call centres, administrative services, (banking sector), hospitals, etc.
Additionally, a partial monitoring of the evolution of the occupational diseases was existed under the responsibility of the Social Security Institute (IKA) until 2009.
- What are the typical employment trajectories of workers affected by chronic diseases? (entry/exit patterns)
There are no official statistics on the professional course of persons suffering from chronic diseases.
However, various programs are occasionally implemented, facilitating the entry of persons from Special Social Groups (EKO) in the labour market, including people with chronic diseases. For example, the Greek Manpower Employment Organization (OAED) implements: a) subsidy programs for 800 young own-account workers, who are persons with disabilities and rehabilitated addicts, and b) a special three-year aid program for employers, providing for the subsidy of social security contributions, for hiring 2,300 unemployed persons from the population categories mentioned above and provided that they have received personalised support. Persons with disabilities must be certified as having a disability of over 50% and not identified as persons "incapable to do a gainful job". As far as addicts are concerned, they are required to produce a rehabilitation certificate.
Moreover, in the public Sector, pursuant to Law 2643/1998, a quota system is applied in the employment of vulnerable groups of the population, including also disabled people or relatives of persons with disability. The appointment and hiring of these persons is effected through general and special notices.
- What are the main difficulties/problems for people with chronic diseases to access or stay in the labour market?
See above section 2.1.
- Are there differences in the previously mentioned patterns by types of chronic diseases or groups of pathologies? are there differences according to age or gender
See above section 2.1.
- Is it possible to identify some changes in the previously mentioned patterns in recent years?
The recent years, there is an increase of the chronic diseases (especially those of mental and psychological nature). This evolution emerges from different studies and various publications. An example is the increase of the number of suicides, linked to psychological problems in conjunction with the economic crisis.
- reasons for this and possible specific effects of the economic crisis
The economic crisis in Greece and the cuts expenditures on health, has in turn created increased difficulties of the persons with chronic diseases in accessing the health services.
In relation to the crisis, a recent research of the ESDY (March 2013) on the subject “economic crisis and chronic diseases”, focuses on the effects of the crisis on patients suffering from hypertension, Diabetes, chronic obstructive pulmonary disease and Alzheimer's disease. Some of the study’s conclusions are that: the evaluation of the health level decreased by 4% in one year (2012-2013); there is a lack of screening programmes; 64% of those suffering from chronic diseases face difficulties in accessing a doctor and medical services due to financial/income-related limitations, and 60% because of the time required due to waiting lists; the primary health care provided is considered worse compared to three years ago by 29% of patients and the third-level services by 32.5% of the chronic sick; 2 out of 10 patients have reduced health expenses due to an income reduction, etc.
2.2. Working conditions of employed people affected by chronic diseases
As to the legislative framework, Law 3850/2010 about the “Ratification of a code of laws on the Health and Safety of workers”, among other things, explicitly refers to the employer's responsibility to protect the health and safety of workers, to the employer's obligation to use the services of a Safety Technician and an Occupational Physician, to take prevention measures, to inform and train employees, to notify employees of the occupational hazard, to ensure the right of workers to medical examination in general, and in particular of workers who are exposed to certain agents at work, and to see that the work is adapted to humans.
Moreover, employers must be in possession of a written assessment of all existing health and safety hazards and those that may appear, including those concerning groups of workers exposed to particular risks.
The assessment of the employee's suitability for a specified job by the occupational physician, who gives advice also on issues of job change for health reasons, on a temporary or permanent basis, as well as of integration or reintegration of disabled persons in the production process, even by suggesting a job reforming, is applicable also in the case of workers with chronic diseases.
The Labour Inspectorate (SEPE) is responsible (Law 3996/2011) for carrying out inspections in enterprises and in every workplace for the supervision and implementation of the labour legislation, for the safety and health of workers, for investigating the causes of severe and fatal accidents at work and of occupational diseases, for suggesting to employers measures for safeguarding the health and safety as well as for providing information, advice and guidance to employees. The workers have also the right to complain before the SEPE in case of violation of the operative labour legislation.
- Reconciliation of working and non-working life: are people with chronic diseases allowed special conditions in terms of work-life balance, flexibility at work to cope with the diseases/attend treatment, ability to set their own working time arrangements, etc.?
The organisation of working time is regulated by Presidential Decree 88/99, which applies to all workers of the public and private sector and sets the minimum standards for the creation of a protective framework with regard to the conditions of the working environment also for the group of workers in question. Among other things, provision is made for the transfer of workers from night to day work if medical examinations show that they have health problems that are due to the fact that they perform night work.
- Career and employment security: to which extent and how is the employment status of people with chronic diseases affected by their health situation?; is there an impact in their remuneration levels/conditions?; in what measure is there a repercussion on their employment security and working career?; are they allowed/forced to changes in their jobs?
In the private sector, provision is made for an additional leave due to particular diseases, as follows:
- Leave of absence for blood transfusion or haemodialysis: Salaried employees with 4 years of service with the same employer, suffering from a disease that requires blood transfusions, are entitled to an additional paid leave of up to 22 days per year (article 8 of the National General Collective Employment Agreement [EGSSE] of 2002).
- Leave of absence of AIDS patients: Workers with 4 years of service with the same employer, who are HIV carriers or suffer from AIDS, and have been deemed able to work, are entitled to an additional paid leave of up to 1 month per year (art. 11 of the EGSSE of 2004)
In the public Sector, the legislation provides for a paid sick leave for employees suffering from “refractory” diseases that is twice as long as that granted to other employees (Law 3528/2007). The list of refractory diseases is incorporated in the decision/decree.
Also from November 2013, in application of Law 3731/2008, provision is made for a reduction of the working hours by one hour per day without reducing the salary of civil servants and employees of the Local Government who: a) are blind, paraplegic, or end-stage nephritic or have a certified disability at a degree of 67% or more; b) have children with intellectual, mental or physical disability at a degree of 67% or more, and c) have a spouse who is disabled by 100%, whom they support. Especially as regards blind telephone operators, the working hours are reduced by 2 hours/day.
Moreover, the Ministerial decree about the “Single table for the determination of the degree of disability” (Gov. Gazette 1506/4-5-2012) determines the degrees of permanent or temporary disablement for the evaluation of any serious disease or disability by the sanitary committees of the IKA and of the entitlement to the relevant allowance or not.
- Are there any significant differences in these working conditions according to different groups of affected workers (type of disease, gender, age, sector, etc.)?
For the protection of workers against hazards, specific legislation is in force as regards the hazards deriving from the exposure:
- to carcinogenic agents (Presidential Decree (P. D.) 399/1994),
- to natural factors (vibrations) - compliance with directive 2002/44/EC (P.D. 176/2005).
- to natural factors (noise) - harmonisation with directive 2003/10/EC (P. D. 149/2006)
- to natural factors (artificial optical radiation) - compliance with directive 2006/25/EC (P.D. 82/2010)
- Are there any significant changes in recent years? Possible effects of the economic crisis on these situations, if any.
Under the new system of insurance coverage of medicines by the National Organisation of Primary Health Care (EOPPY), as from April 2013 the participation share of the insured in the purchase of medicines was increased even in cases of chronic diseases such as diabetes, cancer, etc. and changes were brought about in prescribing. In general terms, the participation share of the insured people in buying medicines, has increased from 10% (2009) to 25% (2013).
Block 3: Policies and measures adopted by public and private agents to favour the employment situation and working conditions of people with chronic diseases
3.1. Description of main policy measures/initiatives developed by public authorities or social partners
Most of the measures and policies adopted by the authorities have already been described in section 2.2. These include: a) Law 3850/2010 about the “Ratification of a code of laws on the Health and Safety of workers”, b) Law 3528/2007 regarding paid sick leave in the public sector, c) Law 3731/2008 regarding the reduced working time in the public sector.
Law of 3304/2005 on the “Application of the principle of equal treatment irrespective of racial or ethnic origin, religion or other belief, disability, age or sexual orientation” protects also the right of persons with disabilities to equal treatment in employment. This category may include also chronic sick employees, as a chronic disease has no permanent cure and can cause temporary disablement during periods of recurrence. In the event of a violation of the law in the private sector, employees may appeal to the Labour Inspectorate (SEPE). In fact, the new law on the reform of the SEPE (Law 3996/2011) expressly provides that its competences also include the check of compliance with the principle of equal treatment for people with disabilities. Labour inspectors often provide advice to employers and employees and try to ensure the access to and staying of people with disabilities in employment as well as their participation in training.
As regards the administration of medicines, provision is made for the possibility of issuing a three-month prescription -instead of a monthly one- to insured persons with chronic diseases who are under continuous medical treatment.
The Social Partners, within the framework of the national collective employment agreements, have agreed to the granting of additional leaves of absence, which were subsequently incorporated in the labour law and are described above:
Leave of absence for blood transfusion or haemodialysis: Additional paid leave up to 22 days per year (article 8 of the EGSSE of 2002). Also, both parents with a child suffering from a similar disease are entitled to an additional leave of 10 days per year, until the child reaches the age of 16 (art. 12 of the EGSSE of 2004)
Leave of absence of AIDS patients: additional paid leave of up to 1 month per year (art. 11 of the EGSSE of 2004)
At European level, the European Network for Workplace Health promotion - ENWHP is in operation, aiming at the promotion of programmes, at influencing policies and at improving the public awareness on the promotion of health. In this context, it has implemented the European programme “Promoting healthy work for employees with chronic illness - Public Health and Work”. The Ministry of Labour, more specifically the Centre for Occupational Health and Safety (KYAE), participates in the European Network as a National Contact Office. A guide of good practice was recently published with the collaboration of the Institute of Social and Preventive Medicine (www.neaygeia.gr), aiming at the promotion of healthy working conditions for people with chronic diseases, an awareness campaign and a scientific two-day meeting were held, etc. (see section 3.2.)
At national level, the programmes for the “social economy” support actions also for the chronic sick. By way of example, we mention the project “Equal opportunities for labour integration of the chronic sick in Thessaloniki”, which is implemented by the Developmental Partnership “Chronic sick - Work without discriminations” since May 2012 and includes counselling support of Employment and Entrepreneurship as well as the Vocational Training of 100 unemployed persons from vulnerable groups of the population, such as: people with disabilities, people suffering from chronic diseases (e.g. thalassemia and sickle cell disease, pulmonary diseases, haemophilia, etc.).
3.2. Examples of enterprises and/or collective agreements implementing initiatives or establishing clauses to support people with chronic diseases
Traditionally it is the National General Collective Agreement (EGSEE) (see section 3.1.) that regulates at the social partners’ level issues like supporting people with chronic diseases. Also, the collective agreements at the sectoral or at the company level usually include and apply the clauses of the EGSEE. For example, the Additional paid leave up to 22 days per year for blood transfusion or haemodialysis, is included in the collective agreement for the personnel working in the Public Power Corporation, in the Private Sector Employees (commerce, services), in shipping companies, in the personnel of binders, in the staff of the Hellenic Post company etc. Additionally and according to the Greek legislation, the EGSEE is totally applied to all the workers of the country, independently of sector/company.
Also, there are some few in number more favoured regulations in the collective agreements for the persons with chronic diseases. Such an example is the company based agreement of the Hellenic Post S.A. (postal sector) which provides for reduced working time by 2 hours per day for persons undergoing blood transfusions and reduced working hours by one hour per day for paraplegic and tetraplegic workers.
Moreover, during a scientific seminar on the subject “promotion of healthy working conditions for persons with chronic diseases” that took place on 13/3/2013, the 2 cases that follow were recorded as good practices for addressing chronic diseases in Greece.
1) COSMOTE, the largest company in the sector of mobile telephony, with 2,129 employees (persons working at heights/technicians, office employees and call centre employees), through the development of a cooperation between Cosmote's Safety and Health Team and an interdisciplinary medical team, implement a programme for the reintegration into the labour market and the support of persons with chronic diseases as well as for the prevention of the chronicity of diseases through appropriate interventions. The programme includes the evaluation of the medical history - medical record by a medical team, the identification of the physically and mentally diseased, the communication with attendant physicians and other experts involved in the person's support, counselling and decision-making on a possible change of job or the creation of a new post in cooperation with the employee and with competent company executives, and the continuous evaluation of the employee's condition. For the prevention of health promotion, relevant printed informative material is issued and articles are published on the Company's intranet, consultancy services are provided and the personnel practice in stress-avoiding techniques and in skills for balancing personal and working life. Source of information: http://www.neaygeia.gr/, http://www.cosmote.gr
2) HELLAS EMPLOYEE ASSISTANCE PROGRAMS (HELLAS EAP), a private company of corporate advisory support for the prevention and management of psychosocial risks and their impact on the working environment, has developed a service named “disability management”, which is a holistic work approach that focuses on the continuous support, emphasising on the employee's remaining in his/her job and on supporting the quick and safe return to work. During the 2006-2013 period, the "disability management" service was provided to 7 companies in the banking, industrial, trade and pharmaceutical sectors and included the support of workers with chronic diseases (organic and/or mental), who are either absent from work for a long period of time or continue to work but have difficulties in performing their tasks.
As far as the results are concerned, reference is made to 91 cases of dealing with workers with chronic organic or mental diseases such as: musculoskeletal disorders, cancer, stroke, heart disease, diabetes, multiple sclerosis and other diseases.
The personnel managers or the persons in charge of health and safety of the enterprises as well as the benefiting employees assessed both the programme and the results thereof as very satisfactory.
Link to the identified case study: http://www.neaygeia.gr/page.asp?p=1148
Also the Public Power Corporation (PPC) implements an Occupational Medicine programme, which, among other things, provides for:
- the conducting of preventive medical check-ups intended for each team of workers;
- the connection of the check-up findings with the particular working conditions of each team (work spaces, exposure to harmful agents, etc.);
- an intervention for the improvement of the specific working conditions, where necessary.
Chronic diseases and their impact on employment are an important issue for employees, employers, insurance organisations, the health care system, etc.
Addressing the problem of chronic diseases, given their extent and peculiarities, requires an integrated approach, which will include actions and policies of prevention and treatment of people suffering from chronic diseases. This approach presupposes the mobilisation, participation and coordinated action of all the relevant institutions and organisations on the basis of a comprehensive plan.
Moreover, in the context of this investigation, it was discovered that the recent economic crisis as well as the changes that were brought about in the insurance system and the health care system rendered the access to health services difficult and, consequently, had negative repercussions on employment.