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Siskou O et al. - Economic, social and cultural factors such as low average household income, high unemployment, obligatory and full coverage by social insurance, lead to reluctance to pay for second-tier insurance. Instead, there is a preference to pay a doctor or hospital directly even in the form of under-the-table payments (which are remarkably high in Greece), when the need arises. There are also factors endogenous to the PHI industry, related to market policies, low organisational capacity, cream skimming, and the absence of insurance products meeting consumer requirements, which explain the relatively low state of development of PHI in Greece.


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