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Bull World Health Organ vol.86 n.11 Genebra Nov. 2008
Portugal's rapid progress through primary health care
Portugal has made rapid progress in providing a comprehensive range of health services to the whole population, but gaining public acceptance of a reduction in the number of health centres remains a challenge. Richard Waddington reports.
"It really is a great time for a family doctor to be working in Portugal," says Dr André Biscaia. Speaking from the Cascais Health Centre where he works at Sao Joao de Estoril, some 15 kilometres north along the coast from Lisbon, Biscaia says that reforms initiated by the Portuguese government are transforming the way family practitioners work and the way they relate to their patients.
Launched in 2005, these changes have improved job satisfaction among family doctors and are beginning to reverse a worrying decline in their numbers, while at the same time winning strong levels of approval from patients attending the country's health clinics.
At the heart of the changes are the new Family Health Units, Unidades de Saúde Familiares (USF), groups of family doctors, nurses and administrative staff who work together as a single team to bring a more personal and flexible approach to the care of patients.
"The key thing about the USFs is that they really encourage team work," says Biscaia. "They function in an autonomous way. The big decisions within the team are taken democratically, by vote one health professional, either doctor, nurse or administrative staff, one vote," he adds. Patients benefit because important decisions on health issues and on treatment are brought closer to the communities in which they will be applied.
"The USF teams know their communities very well and can organize resources to meet community needs. We can adjust our schedules very quickly, in accordance with what is needed and wanted at any particular time," he says.
In the year of the 30th anniversary of the World Health Organization's (WHO) Declaration of Alma-Ata on health for all, the Portuguese reform embodies the spirit of that landmark agreement.
At a conference in Alma-Ata, the then capital of the former Soviet Socialist Republic of Kazakhstan, now called Almaty, countries pledged to combat health inequities both within and between countries. They agreed that a primary health care approach would be the key strategy for achieving what they called 'health for all', in other words, equal access to a comprehensive range of health services for everyone, regardless of ability to pay.
Portugal is one of the countries that has been determined to put those primary health care principles into practice over the past three decades. And the results are plain to see. Since the 1970s, infant mortality rates have halved every eight years to reach three per 1000 in 2006, on a par with levels in the rest of western Europe, and down from more than 40 per 1000 in 1975. Life expectancy among the country's 10.6million people has increased 9.2years in a generation.
Portugal first recognized the right to health in its 1976 Constitution, approved two years after a democratic, army-led revolution ended more than 40years of authoritarian rule. Under political pressure to reduce large health disparities, the democratic government created a national health system (NHS), which the constitution describes as universal (for everyone), comprehensive (full-range of services) and "approximately" free of charge.
"Primary health care in Portugal is one of the pillars on which the public health system rests," says Anabela Coelho Candeias, head of the integrated disease management division at the General-Directorate of Health in Lisbon.
But it would be wrong to say that health reform in Portugal began with democracy. Even before the so-called Carnation Revolution of 1974, the previous authoritarian rulers had already sought to address the country's appallingly high levels of infant and maternal mortality.
"A lot of studies were done in the 1960s that showed that in Portugal the health situation was 'catastrophic'. We were at the bottom of the table for all health indicators," says Biscaia.
The solution adopted was to promote universal access to a comprehensive set of health services through a nation-wide system of public sector health centres.
"The spirit of those health centres was the spirit of Alma-Ata, but several years before that meeting," says Biscaia, referring to the 1978 International Conference on Primary Health Care where WHO Member States agreed on the Declaration of Alma-Ata.
"Portugal was at the forefront of public health reform in Europe at that time and perhaps now it is again," he says.
To be eligible for NHS benefits, patients need to register with a family physician in a health centre, considered the first point of contact.
But these health centres are often large organizations with as many as 70doctors attached to them and with tens of thousands of patients. It was to make these centres more manageable and responsive to patients' needs that the USF reforms were launched. Doctors and nurses were once paid a fixed salary, but now remuneration is based on performance and productivity.
"There are more doctors wanting to become general practitioners. Conditions are competitive with the private sector and they have more autonomy," says Biscaia. Some 20% of the total population now has access to USFs and this percentage could more than double within the next year, Biscaia says. "Patients are very satisfied. For instance, in a recent study in my health centre levels of satisfaction with the USF were twice those of other health centres."
The next phase of the 2005 reforms will focus on the health centres themselves to make them more responsive to community needs. They will be given more financial autonomy and their number will be cut from 355 to 74 a move that may not be easily accepted by the public.
Moreover, despite its achievements, the Portuguese health system is not without its problems. The Portuguese face some of Europe's highest out-of-pocket expenditure for health services, at 22.1% of people's incomes in 2005 according to World health statistics 2008, despite the constitution's promise of a system that would be largely free.
Most services, whether for drugs and medicines, for in-patient care or consultations at health centres, carry some charge to the user. However, half of the population is exempt from such payments either on economic grounds or because they fall into one of the more vulnerable groups pregnant women, students, children and people with diabetes that are excluded from health payments.
There are also imbalances between the number of nurses and doctors. Many health-care professionals who retire are not being replaced due to restricted admissions to medical schools in recent years, according to the 2007 publication Health systems in transition: Portugal health system review. Also, many patients still go to the emergency department of a hospital for treatment rather than to the local health centre. But this is a problem which should ease as the USFs take root around the country, Biscaia says.
Coelho Candeias agrees: "While 95% of the population's health needs can be taken care of at health centres, we recognize that not everybody has a family doctor and some people go to the emergency rooms rather than a health centre."
She adds: "This is because they think that going to the hospital ensures better quality care. Resolving this requires a cultural change and mass information campaigns among the general population."