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European Observatory on Health Systems and Policies

Portugal


Health Systems in Transition (HiT) profile of Portugal

5. Provision of services

Chapter summary

  • Public health services in Portugal include the surveillance of health status and identification of its determinants, health promotion and disease prevention at community level and health impact assessment.
  • Portuguese primary care is delivered by a mix of public and private health service providers, including: primary care centres integrated into the NHS, private sector (both non-profit-making and profit-making) and self-employed professionals/groups.
  • FHUs (2007) and ACES (2008) have restructured the organization of Portuguese primary care.
  • Secondary and tertiary care is mainly provided in hospitals, whose network was reorganized in recent years (e.g. for hospitals in 2002 and long-term care network in 2006).
  • PPPs have been introduced for renewed infrastructures in recent years but, at the time of writing, no additional PPPs are being planned for the health sector.
  • Vertical integration of health care has been enhanced since 1999 by the local health units (Unidades Locais de Saúde), which allow the integration of hospitals and primary health care units in the same organization.
  • The RNCCI (2006) combines teams providing long-term care, social support and palliative care with its origins in community services, and covers hospitals, ACES, local and district social security services and municipalities.
  • INEM is the organization within the Ministry of Health responsible for the coordination and functioning of an integrated medical emergency system in mainland Portugal, ensuring the rapid and appropriate delivery of emergency care.
  • A maximum number of pharmacies are allowed in each community and the location of those is highly regulated.

5.1 Public health

Public health services in Portugal include the surveillance of health status and identification of its determinants, health promotion and disease prevention at community level and health impact assessment. The organization of public health services at national level is the responsibility of the DGH. The DGH is in charge of designing the programmes, defining strategies and approving national plans. These plans are approved as needed, according to the National Health Plan. For example, the DGH is responsible for coordinating all priority health programmes established since 2012: diabetes, cerebro-cardiovascular diseases, oncological diseases, mental health, tobacco control, respiratory diseases, healthy nutrition, physical activity, prevention and control of antimicrobial resistance and infections, viral hepatitis and HIV/AIDS.

As a great deal of the population’s time is spent at school, at work and in leisure locations, public health interventions require a multisectoral approach. To strengthen this approach, the Ministry of Health cooperates with other ministries, such as the Ministry of Labour, Solidarity and Social Security (for workplaces), the Sports State Secretary (for sports spaces), the Youth State Secretary (for public leisure locations), the Ministry of Education (for primary and high schools) and the Ministry of Justice (for prisons).

Some of the health education initiatives are run as vertical programmes by separate bodies within the Ministry of Health. The Directorate-General for Intervention on Addictive Behaviours and Dependencies (Serviço de Intervenção nos Comportamanetos Aditivos e nas Dependências) coordinates the prevention and treatment of drug and alcohol addiction.

The NHS is responsible for implementing the National Immunization Programme (Programa Nacional de Vacinação), which includes the most important vaccines as set by the DGH (e.g. according to the epidemiology of disease in Portugal) for protecting population health. Vaccination is strongly advised but not mandatory. These vaccines can be altered from one year to the next in order to adapt the programme to the population’s epidemiological profile, usually by combining existing vaccines, or introducing new ones. People can be vaccinated in local primary care units and vaccines that are included in the national programme are free for all NHS users. High levels of immunization are achieved in Portugal (see section 1.4).

At regional and local levels, the main entities involved in the delivery of public health services are:

  • RHAs, supporting public health units within the ACES;
  • local health authorities consisting of a public health unit based in ACES;
  • public health doctors and sanitary technical staff; and
  • GPs, responsible for health promotion as part of their work, including family planning, antenatal services and screening programmes.

In 2008, the creation of the ACES restructured the organization of primary care and public health. The Decree-Law No. 28/2008, of 22 February 2008 established the regimen for the creation, organizational structure and financing of the ACES (see sections 2.6 and 5.3). These groups are formed by a set of teams, including PHCUs, FHUs, community care units (Unidades de Cuidados na Comunidade) and public health units (Unidades de Saúde Pública). Each unit contains a team of physicians, nurses, health ancillary technicians, among others, and works together with the primary care centres and the other units belonging to the same ACES. In 2009, the public health units were restructured to improve coordination with both the RHAs and the ACES. In the same year, a new public health surveillance system was created.

Public health doctors (medical doctors who have completed a four-year postgraduate medical training in public health) are responsible for the epidemiological surveillance of the health status of the population and also for activities such as health promotion and disease surveillance. However, in many primary care centres, these responsibilities are transferred to GPs due to a shortage of public health doctors. Public health doctors’ responsibilities include:

  • surveillance and control of communicable diseases;
  • surveillance of water quality;
  • environmental health surveillance (with municipalities);
  • ensuring compliance of local services (including health facilities) with health safety standards;
  • environmental inspections of workplace and work conditions; and
  • building safety and housing inspection (with municipalities).

Public health doctors currently have a low status within the NHS and there are problems with recruitment. Until now, their tasks have included acting as health inspectors and occupational health officers, which are both heavily bureaucratic and meant working under old directives. The aim of the latest policies set out in the National Health Plan is to link the development of local health systems with the new public health structures, giving public health doctors a broader remit in terms of the health of the population. In 2016, the government engaged in a broad reform entitled “a New Ambition for Public Health” (Uma Nova Ambição para a Saúde Pública), considering upcoming challenges such as population ageing and inequalities, and the increasing importance of the Internet and social networks, which offer innovative ways of communicating with the population. The reform is currently being discussed with public health professionals and civil society.

A National Health Observatory (Observatório Nacional de Saúde) was established in 1998 as part of the INSA. This Observatory aims to centralize major national health information systems and to produce timely reports on the health of the population and its determinants, which directly impacts policy-making (see section 2.9.2).

Public access to health information has also been developed further with the mass dissemination of telecommunications, especially the Internet. The Saúde 24 Call Centre provides sorting, counselling and guidance according to the disease, including urgent situations. This service responds to personal primary care needs through health promotion and disease prevention, as well as public health needs, while participating in partnerships with other services to improve the health status of certain groups and communities: advising people on how to protect themselves from environmental risks such as heat waves or cold snaps, or the existence of polluted air due to particles in suspension (e.g. a consequence of forest fires); helping to prevent disease from spreading in epidemic situations such as influenza or acute respiratory syndrome; and promoting and encouraging healthy behaviours (nutrition and family planning).

Another useful means of getting public health information to a vast proportion of the population in a straightforward manner is the development of Internet websites dedicated to public health issues, such as those provided by the Ministry of Health (the new NHS website www.sns.gov.pt) and the DGH (www.dgs.pt) (see section 2.9.1).

In 2016, the Portuguese Government launched the National Programme for Health Education, Literacy and Self-care, which aims to make information, knowledge and informed decisions the major drivers of citizens’ involvement in the health system. The new Programme was launched in the framework of a “New Ambition to Public Health” (see above), stated in the Government’s Programme, and uses the existing body of evidence that education, literacy and self-care are critical not only to the population’s health promotion and protection but also to health care provision effectiveness and efficiency. The DGH is responsible for leading the Programme implementation at the national level, while the public health departments in RHAs and public health units in ACES will coordinate the Programme at regional and local levels, respectively.

Box5.1 provides the assessment of the effectiveness of public health interventions in Portugal.

New regulation from the end of December 2019 has expanded the Portuguese National Immunisation Programme (NIP) (Diário da República, 2019).

The NIP is ongoing since 1965. It is implemented in all public primary health care units across the country and it is available for free for all citizens. Since its implementation in 1965, the Portuguese NIP has been progressively updated with new vaccines and schedules, having a major role in decreasing mortality and morbidity associated with preventable infectious diseases in the country (Rechel et al., 2019). In fact, Portugal is among the EU member states with higher vaccination rates (INE, 2020).

Following the latest revision by the Directorate General of Health (the technical body of the Ministry of Health), the Portuguese Government decided to expand the National Immunisation Programme by the end of 2019 (Diário da República, 2019), by including:

- HPV vaccine (including the genotypes for anogenital condylomas) for males at 10 years of age, applicable to all boys born after 2009, even if they have already started the vaccination scheme (HPV vaccine was available only for girls until now);

- Vaccine against group B Neisseria meningitidis (vaccine MenB) for all children born after 1st January 2019, at 2, 4 and 12 months of age;

- Rotavirus vaccine for risk groups, to be later defined by the Directorate-General of Health through clinical guidelines.

The new vaccination scheme will come into force on the 1st of October 2020.

 

References

Diário da República (2019). Dispatch No. 12434/2019, of 30 December 2019(https://dre.pt/application/file/a/127588331, accessed 15 January 2020)

INE (2020). Vaccination coverage rate to persons aged 2 years old (https://www.ine.pt/xportal/xmain?xpid=INE&xpgid=ine_indicadores&indOcorrCod=0007455&selTab=tab0&xlang=en, accessed 15 January 2020)

Rechel et al. (2020). The organization and delivery of vaccination services in the European Union (http://www.euro.who.int/__data/assets/pdf_file/0008/386684/vaccination-report-eng.pdf?ua=1, accessed 15 January 2020)

Following the Law No. 30/2019, of 23 Abril  2019, on restrictions to advertising of unhealthy food products for children under 16 years of age (Health Policy Update 26/04/2019), the Directorate General of Health has issued a list of foods and drinks characterised by high energetic value, sugar content, salt content and fats, which jeopardize a healthy diet.

The selection of drinks and foods took into consideration the WHO recommendations according to the WHO Regional Office for Europe Nutrient Profile Model. The list contains a total of 18 groups of products that include, among others, juices, milk, vegetable drinks, dairy, ready meals, bread and bread-based products. For each group, a maximum threshold for saturated fats, added sugar, salt, trans fats and energetic value (in Kcal) per 100g of product is defined. All products above this threshold are considered unhealthy and, as so, advertising and consumption should be restricted in the terms defined in the Law No. 30/2019.


More information (in Portuguese):
Dispatch No. 7450-A/2019, of 21 August 2019, Diário da República, No. 159, Serie II, 21 August 2019 https://dre.pt/application/conteudo/124097542 

The Parliament has approved changes to the Advertising Code aimed at restricting advertising of unhealthy food products for those under age 16 years (15 March 2019). The new Law establishes restrictions to advertising products with high calories, sugar, salt and fats in kindergartens, basic and secondary level schools; in public playgrounds; and in a perimeter of 100 meters of the places mentioned before.

Furthermore, these restrictions also apply to radio adds 30 minutes before or after programmes targeting children; TV adds 30 minutes before or after programmes which have at least 25% of audience under 16 years of age (including commercial breaks); commercials in movie theatres in movies classified for under 16 years of age; in advertising targeting people under age 16 years.

Advertising food or drinks with high calories, sugar, salt and fats should be, according to this Law, clear and straight, and should not associate the product with potential health benefits. Advertising these products should not encourage excessive consumption; create a permanent need (in the viewer) to consume that product; associate the product to social fulfilment, popularity success or intelligence; communicate the features of the product as beneficial for health, leaving out the deleterious effects for health.

 The Directorate-General of Health will publish the criteria to classify the food products as high in calories, sugar, salt and fats before the Law comes into force on 23 June 2019.

 Source: Law No. 30/2019, of 23 April https://dre.pt/application/conteudo/122151046

HIV self-testing, as well as Hepatitis B and Hepatitis C self-testing, will be available over the counter in Portugal, as the government has approved their sale in community pharmacies (with no need for medical prescription). The Council of Ministers has approved Decree-Law No. 79/2018, of 15 October 2018, that makes possible the free disposal of self-testing kits in pharmacies and drug stores. Tests are already available in community pharmacies in Cascais (since October 10th), and will be gradually expanded to other pharmacies all over the country.

This decision follows 2016 WHO guidelines on HIV self-testing which recommend that: “HIV self-testing should be offered as an additional approach to HIV testing services”, aiming to reduce late HIV diagnosis and eliminate HIV epidemics by 2030.
 
In Portugal, more than half of new HIV cases are late diagnosed particularly among individuals aged 50 and over. This measures aims to reach populations who do not use health services to get tested and, thus, reduce the number of late diagnosis and halt HIV epidemics.

More information here (in Portuguese):
https://www.portugal.gov.pt/pt/gc21/governo/comunicado-de-conselho-de-ministros?i=225; https://dre.pt/web/guest/pesquisa/-/search/116673879/details/normal?q=autodiagnostico

The Portuguese NHS is undergoing a process of modernization through the project “SNS+Proximidade”, which aims to place the citizen at the centre of the health system. One of the cornerstones of this process is health literacy promotion, under which the Health Literacy Library has been created in June 2017. This online tool facilitates access to health information, promoting people’s autonomy towards their own health and the health of those around them.

The Health Literacy Library collects, analyses, selects and disseminates resources for good practice in health education, literacy and self-care. Currently, the available resources cover topics such as active life and health promotion and protection in different life stages, without focusing on specific conditions. These themes will be gradually expanded while an Intelligent Network of Health Literacy is developed. The Health Literacy Library also provides access to a Personal Health Agenda, which is an online, personalized and confidential tool that includes relevant information regarding an individual’s health. These instruments are pivotal to empower citizens and, consequently, to promote their participation in decisions regarding their healthcare.

For more information (in Portuguese): http://biblioteca.sns.gov.pt  

Context

The smoking ban in Portugal was firstly implemented almost a decade ago (Law 37/2007, of 14 August), but is far from being consensual.

In 2006, when the first smoking ban started to be discussed, the Ministry of Health was trying to be ambitious. The first version of the policy included the prohibition of smoking in all indoor public places as well as the banning of selling tobacco to those under 18 years of age. The catering industry was openly against the total smoking ban, arguing that owners should be allowed to choose if their establishment should be for smokers only (Diário de Notícias, 2006). This was and still remains the crucial point in the legislation.

Initially, the Ministry of Health claimed that “the constitutional principle that ensures the right of health protection for all citizens must prevail”, adding that “accepting that change might jeopardise the efficacy of the smoking ban” (Diário de Notícias, 2006). Back in 2006, the initial proposal from the Ministry of Health was not well received by many members of the parliament, including those supporting the government at that time, arguing that “the rights of smoking citizens must also be assured” (Público, 2007).

Finally, when the Law was approved in August 2007, becoming effective from 1 January 2008, Article 5 of the 2007 Law included a long list of exceptions to the smoking ban, namely bars and restaurants. In particular, if the dimension of the place was less than 100 square metres, the owner could “choose to allow customers to smoke indoors”, as long as that choice was clearly signed and ventilation was assured. If the dimension of the venue was higher than 100 square meters, the owner could have areas for smoking costumers, which had to be clearly signed, separated from non-smoking areas and ventilated.

  

Impetus for the reform

The 2007 smoking ban in Portugal was responsible for banning smoking indoors in workplaces, public transport, schools, universities and health facilities. Despite the exceptions for bars, clubs and restaurants, the exposure to passive smoking was significantly reduced. Comparing the results from the Global Burden of Disease study in 2010 and in 2015, there was a reduction in the number of deaths due to smoking and second-hand smoking (IHME, 2016). However, tobacco smoking still is responsible for more than 11,000 deaths in Portugal and is the leading risk factor driving death and disability among Portuguese males (IHME, 2016).

The 2007 smoking ban was supported by yearly rises in the price of cigarettes, as well as the adoption of European directives on warning and photos on cigarette packs. The impact of those measures on the population can be measured by the results from national health surveys in 2006 and 2014. Although the prevalence of smoking was reduced from 20.9% to 20.0% in eight years, there is reason for concern as the prevalence of smoking is increasing among women. On the bright side, between 2006 and 2014, the percentage of former smokers increased from 16.1% to 21.7% (INE/INSA, 2009, 2016). The Director-General of Health, Francisco George, assumes “there were some improvements, but very few” (Público, 2016). The smoking ban and the increasing prices of cigarettes were not enough to discourage people from trying cigarettes and start smoking. The slight reduction in the number of smokers in Portugal are the result of more people quitting smoking, but there are no signs that fewer people are becoming new smokers.

 

Content of the reform

From 1 January 2018, smoking in public places for children (including outdoor venues), such as holiday camps or playgrounds, will be forbidden. The parliament has approved the change in the tobacco law on 1 June 2017 (the law is yet to be published in the government gazette). This is the second change to the law and will be effective from 1 January 2018. The legislative change alters 17 articles and adds 2 new ones, including the levelling of e-cigarettes to normal cigarettes. New articles establish that occupational health services should promote actions and programmes for tobacco control and prevention in workplaces as well as support workers who wish to quit smoking.

The increasing demand for smoking cessation consultations in the NHS forced the Ministry of Health to expand these services by opening 145 new consultations in 2016. This demand is a sign of more people seeking help to quit smoking. To encourage their efforts, the government has announced, for the first time, that the NHS will support 37% of the price of medications (Champix®) to help people quit smoking. This NHS co-insurance is in place since January 2017 and is estimated to cost €1.3 million annually.

 

References

Diário de Notícias (2006). Lei do tabaco não penaliza donos de restaurantes [Tobacco law does not penalize restaurant owners] (http://www.dn.pt/dossiers/sociedade/nova-lei-do-tabaco/noticias/interior/lei-do-tabaco-nao-penaliza-donos-de-restaurantes--1006730.html, accessed 24 July  2017)

IHME (2016). Global Burden of Disease. Institute for Health Metrics and Evaluation (https://vizhub.healthdata.org/gbd-compare/, accessed 24 July  2017)

INE/INSA (2009). Inquérito Nacional de Saúde 2005-2006 [National Health Survey 2005-2006]. Lisbon, Instituto Nacional de Estatística, Instituto Nacional de Saúde, Dr. Ricardo Jorge (http://www2.insa.pt/sites/INSA/Portugues/Publicacoes/Outros/Documents/Epidemiologia/INS_05_06.pdf, accessed 24 July 2017)

INE/INSA (2016). Inquérito Nacional de Saúde 2014 [National Health Survey 2014]. Lisbon, Instituto Nacional de Estatística, Instituto Nacional de Saúde, Dr. Ricardo Jorge (https://www.ine.pt/xportal/xmain?xpid=INE&xpgid=ine_publicacoes&PUBLICACOESpub_boui=263714091&PUBLICACOESmodo=2, accessed 24 July 2017)

Público (2007). Tabaco: nova lei obriga comerciantes a denunciar clientes fumadores [Tobacco: new law forces traders to report smoking clients] (https://www.publico.pt/2007/05/01/sociedade/noticia/tabaco-nova-lei-obriga-comerciantes-a-denunciar-clientes-fumadores-1292666, accessed 24 July 2017)

Público (2016). Em nove anos, apesar da lei do tabaco, consumo baixou menos de 1% em Portugal [In nine years, despite the tobacco law, consumption fell by less than 1% in Portugal] (https://www.publico.pt/2016/03/02/sociedade/noticia/em-nove-anos-consumo-de-tabaco-baixou-menos-de-1-em-portugal-1724946, accessed 24 July 2017)

In March 2016, the Portuguese Government launched the National Programme for Health Education, Literacy and Self-care, which aims to make information, knowledge and informed decisions the major drivers of citizens’ involvement in the healthcare system. The new Programme was launched in the framework of a “new ambition to Public Health”, stated in the Government’s Programme, and lays on the existing body of evidence that education, literacy and self-care are critical not only to the population’s health promotion and protection, but also to healthcare provision effectiveness and efficiency.

The Directorate-General of Health is responsible for leading the Programme implementation at the national level, while the Public Health Departments in Health Regional Administrations and Public Health Units in Groups of Healthcare Centres (ACES) will coordinate the Programme at regional and local levels, respectively. Monitoring reports will be issued every six months, and a final implementation report is expected by June 2017. Several projects ranging from health literacy to informal care provision are to be put into practice during 2017.
 
For further information, see (in Portuguese): https://www.sns.gov.pt/programa-nacional-educacao-literacia-e-autocuidados/