A tale of two islands
Within easy reach of the UK and most of the EU, the Middle East, Russia and Central and Eastern Europe, the Republic of Cyprus is a popular tourist destination. Robin Gauldie reports on the healthcare provision of an island that has been split in two for over 30 years
First published in ITIJ 114, July 2010
Within easy reach of the UK and most of the EU, the Middle East, Russia and Central and Eastern Europe, the Republic of Cyprus is a popular tourist destination. Robin Gauldie reports on the healthcare provision of an island that has been split in two for over 30 years
Cyprus has been divided since 1974 when Turkey invaded and occupied the northern part of the island. The primarily Greek-speaking Republic of Cyprus, which comprises the southern part of the island, is internationally recognised as the legitimate government of the whole of Cyprus. The so-called Turkish Republic of Northern Cyprus is recognised only by Turkey, which has encouraged large numbers of its nationals to settle in the occupied zone since the 1970s.
A United Nations-administered ceasefire line (sometimes called the ‘Green Line’) has separated the island since the cessation of hostilities in 1974. This de facto frontier bisects the capital, Nicosia (or Lefkosa in Turkish) and can be crossed at only two checkpoints – one on the outskirts of Nicosia and one in the historic centre. The population of the Republic of Cyprus is around 800,000 (2009 estimate), with 73 per cent of people aged between 15 and 64, 17 per cent under 14, and only 10 per cent over 65 years of age. Life expectancy, overall, is 77 years.
The Republic of Cyprus has been a member of the European Union (EU) since 2004, and holders of the EU’s European Health Insurance Card are entitled to state-provided healthcare at reduced cost or, in some instances, free. This does not, however, apply in the Turkish occupied North. Ambulance travel is free for EHIC holders, but air ambulance travel is not covered. Prescriptions issued by a state doctor and supplied by a state pharmacy are also free. EHIC holders are also entitled to treatment from doctors and dentists practising in state healthcare centres at a charge of €2 per visit. In-patient hospital treatment is also available through referral by a state doctor, or by admission through the accident and emergency department of a state hospital.
As in mainland Turkey, pharmacies in Northern Cyprus sell a large number of drugs that are available in the UK and EU only on prescription
Around 70 per cent of Cyprus’s population lives in or near the major urban centres of Nicosia (Lefkosia), Limassol (Lemesos), Larnaca and Paphos. This is a small country (Paphos, near the southwest tip of Cyprus, is only 175 km from Agia Napa, on the east coast) and the public general hospitals in major towns and cities should, in theory, be quickly accessible even by patients from the most remot rural villages.
However, the existing public ambulance system has been heavily criticised as being inadequate, and the government has promised an overhaul this year, providing new district stations, modern equipment and fully trained paramedics to replace the existing system, which has been heavily censured for its inefficiency.
An alluring destination
Tourism is an extremely important sector of the economy, with around 2.7 million visitor arrivals each year. The UK is overwhelmingly the country’s largest market, accounting for roughly 50 per cent of all arrivals – around 1.3 million annually. Russia, Germany and Greece each account for around six per cent, but almost all tourist markets have exhibited stagnation or decline over the last two years. There is a significant expatriate community, most of whom hail from the UK and Ireland. Some of these expats own second homes on the island, while others are permanent retirees. Almost by definition, this is an ageing community with its own healthcare needs. However, many expats (arguably too many) do not buy travel or health insurance, preferring to rely on the public sector, or returning to the UK for treatment under the country’s National Health Service.
Cypriot tourism promoters have boasted for years that this is a destination where one can ski and swim all in the same day. Cyprus’s ski slopes, located in the Troodos mountains, are not world class, and skiing is more popular with local residents (and British forces personnel) than with holiday visitors; however, skiing accidents do occur and generate a trickle of insurance claims each year. Scuba diving, another sport with some attendant risks attached, is also popular. Larnaca General Hospital has hyperbaric care facilities, and there is also a private diver decompression centre with a six-person decompression chamber, 24-hour operation and four hyperbaric physicians on call in Limassol.
Driving arguably puts visitors at greater risk than either of these more exotic sports. Many visitors rent cars or motorcycles, and are not necessarily aware that Cyprus has the third highest rate of fatal road accidents in the EU, with around 10 fatal road accidents annually per 100,000 of population – more than double the UK’s 4.3 deaths per 100,000.
The UK Foreign and Commonwealth Office rates Cyprus as generally safe, with around 500 British nationals requiring consular assistance annually.
EHIC holders are also entitled to treatment from doctors and dentists practising in state healthcare centres at a charge of €2 per visit
Out of 1.3 million Britons visiting the island, only 86 required consular help with hospitalisation, but there were 149 deaths in the last year that statistics have been made available.
Perhaps more surprisingly, more than 200 of the cases in which consular help was required involved arrests for a variety of offences.
In contrast, consular representatives in Greece – a destination that welcomes around three million British visitors annually – handled only 118 deaths and 237 arrests. The figures for deaths may reflect an older clientele visiting Cyprus, while figures for arrests probably indicate an increasingly tough response by Cypriot police to rowdy behaviour, drunkenness and the possession of drugs, especially in Agia Napa, which has established a high profile as a ‘party destination’ for younger Britons. Arguably, there is now an ‘arrest first and ask questions afterwards’ approach to policing after-dark altercations in resorts, and some clients (even if they have no intention of engaging in drug use or breaking the law) might be well advised to ensure they have bail bond and legal cover in case they are involved in a clash with the law.
A work in progress
Five new general hospitals have opened in recent years to cover the Nicosia, Limassol, Larnaca, Paphos and Famagusta districts. In addition, tertiary care has developed to such an extent that many cases that were formerly treated abroad, are now routinely treated in Cyprus. However, despite this considerable investment in the public healthcare infrastructure over the last decade, the overall picture is perhaps not quite as rosy as the Cyprus Health Service Promotion Board would wish.
In 1999, the government recognised that the public health system – a colonial relic that was notorious for its fragmented services and lack of co-operation between the private and public sector – needed a complete overhaul. In 2001, legislation was enacted to create a national health system, also referred to as the General System of Health Insurance (GESY). The aim of the new structure was (and still is) to create a genuinely universal primary healthcare system, which would also be economically viable, based on the public-private partnership model. This, the government hoped, would be achieved by giving public hospitals more control over their own finances and by introducing an element of competition between public and private sector healthcare providers.
“The public system tends to be used predominantly by civil servants and their dependents, pensioners and low-income patients who cannot afford the private option,” opines Charles Charalambous of the island’s newspaper of record, the Cyprus Mail. According to Charalambous, there remains a common perception that Cypriots can only receive top quality healthcare on demand through the private sector. Progress on implementing the new system has been slow, in the face of opposition from some public sector healthcare workers, including the Pancyprian Union of Government Doctors, which has accused the government of wanting to sell off the public sector.
Although the ministry of health wants to see the new scheme up and functioning by the end of 2011, officials concede that it could take even longer. Meanwhile, those Cypriots and visitors who can afford to do so will continue to rely even more heavily on private treatment.
Medical tourism
“The cost of private healthcare here is very favourable compared with other European countries,” says Dr Nikos Maroudias, president of the Cyprus Health Service Promotion Board. “There are practically no waiting lists.”
The average cost of a consultation is €50, while hip or knee replacement surgery costs an average €7,000.
The Cypriot government is keen on medical tourism – not least because it has the potential to generate income for the country’s public healthcare sector, which the government is trying to modernise. But the road map to establishing Cyprus as a health destination while balancing the requirements of the public and private sector is still unclear. “Health tourism to Cyprus is set to continue growing, and this is a time of opportunity for Cypriot healthcare providers to raise their international profile and reach potential partners,” says Keith Pollard, managing director of Treatment Abroad.
The country has six main public hospitals – most of them built within the last five years – and more than 80 private hospitals and clinics, offering a total of 2,500 beds. Healthcare cadres include some 2,000 doctors and around 720 dentists, and current expenditure on health is more than €700 million annually, equivalent to six per cent of gross national product, says the Cyprus Health Service Promotion Board, a non-profit organisation set up four years ago by the Cyprus Chamber of Commerce and Industry. The private sector covers around 50 per cent of primary and secondary healthcare.
there are more than a dozen smaller airstrips and nine heliports strategically located around the country
Many healthcare professionals have trained in the UK or the US, and English is widely and fluently spoken throughout the healthcare sector. According to the US State Department, fees for private medical services are generally lower in the country than in North America and most European Union (EU) countries, but medical supplies are often more expensive.
When things go wrong
“In cases where a patient needs to be repatriated, Cyprus Airways (the largest airline in Cyprus) offers services of a high quality and comfort, with medical equipment, allowing the patient to be escorted by a qualified medical practitioner back to their home country,” says Dr Phivos Economou, medical director of Global Voyager Assistance.
Ambulances can enter the airport terminal after receiving a permit from the Civil Aviation authority, and the patient can be placed onboard the plane with the use of a micro lift. Local institutions offering medical assistance services employing qualified staff usually deal with such cases. “The only service not offered yet in Cyprus is air ambulance transportation, however, such cases are swiftly and adequately met using services from nearby EU or eastern Mediterranean countries,” continued Economou.
Air ambulances can use the island’s two main international airports at Paphos (close to the southwest tip of the island) and Larnaca (on the south coast). These are well located to serve the island’s main resort clusters, at Paphos, Limassol, Larnaca and Agia Napa. Nicosia’s international airport has been abandoned since the Turkish invasion of 1974; however Larnaca airport is less than 40 minutes by motorway from the capital. In addition, there are more than a dozen smaller airstrips and nine heliports strategically located around the country.
A recent development is the launch of a new air ambulance link between Larnaca and Jerusalem by International Medical Evacuation and Referral, (iMER) the innovative Cypriot-Israeli joint venture that functions as the international arm of Hadassah University Hospital. “This has dramatically upgraded the availability factor,” comments iMER co-founder George Georgiou. “We will be able now to bring in expertise or technology if required in no time, or to evacuate the patient anywhere in the fastest way possible.”
iMER claims the service can transfer the patient from Larnaca to the Hadassah emergency room in less than 180 minutes. “We faced events in the past where we couldn’t help to save a Cypriot patient at short notice because the air ambulance was not immediately available,” says Prof. David Linton, of the hospital’s intensive care unit. “Some of these cases were to take a patient to a specialised institution for live saving treatment, or to bring a super-specialised medical expert or specific technology to the island to assist the local medical team.
Northern Cyprus
Occupied by Turkish forces since 1974, the so-called Republic of Northern Cyprus is recognised only by Turkey. Despite this, and despite the failure of successive attempts to reconcile and reunite the two communities, the North has become a relatively successful tourism destination. However, the North is not a part of the European Union, and EHIC, E106 and E121 forms are not valid, so private health insurance is essential for those travelling to this part of Cyprus. Due to the North’s anomalous status, all flights into and out of its Ercan airport must operate via Turkey, and this obviously poses some limitations on air ambulance and emergency medevac operations.
Public healthcare provision in the North is limited. According to the US State Department: “The standard of medical care in the area administered by Turkish Cypriots is improving, but still falls below that found in the government-controlled area.”
In public hospitals, it is assumed that family members will carry out many of the basic tasks that in most European countries would be performed by nursing staff. There are state-run hospitals in the four main population centres in Northern Cyprus, namely Lefkosa (Nicosia); Gazi Magusa (Famagusta); Girne (Kyrenia) and Guzelyurt (Morphou). There are also a number of private clinics and hospitals.
Health insurance is not currently compulsory in Northern Cyprus, but the government has recently begun discussing plans to implement a statutory insurance scheme, using the proceeds to finance improvements to the under-funded public health sector.
As in mainland Turkey, pharmacies in Northern Cyprus sell a large number of drugs that are available in the UK and EU only on prescription, such as Viagra, numerous wide-spectrum antibiotics and tranquillisers such as diazepam and temazepam. There is, therefore, a risk that clients may self-medicate before (or instead of) seeking professional medical assistance.
The country has six main public hospitals... and more than 80 private hospitals and clinics
Cyprus won its independence from Britain in 1960, but the UK maintains two ‘sovereign bases’ (administered by the Royal Air Force) at Akrotiri and Dhekelia. Around 3,500 British Forces personnel are stationed in Cyprus, and their healthcare needs are met by The Princess Mary’s Hospital at RAF Akrotiri, which is staffed by RAF and British Army medical personnel. There are two general medical and surgical wards and a maternity unit. Operations are performed in fully manned theatres and specialist consultants are flown out from the UK at need. The hospital does not generally provide care to holidaymakers, but it has been used to provide care for expatriate civilian refugees during a number of international crises, most recently during the Israeli invasion of Lebanon in 2006.
In conclusion, it is fair to say that tourists, by and large, are well-served in terms of healthcare provision in Cyprus – in the event of an accident, the infrastructure is in place for them to be hospitalised or evacuated as is deemed necessary. The increasing number of expatriates in the country is only going to encourage the further development of such services, so it seems like things are only going to get better on the island.