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Troika’s legacy on health in Portugal

8598The austerity imposed in Portugal had a very negative impact on the overall capacity of the healthcare system.

Devastating austerity measures slashed out years of progress in the Portuguese National Health System (NHS) with the arrival of the troika of international lenders – European Commission, European Central Bank and the International Monetary Fund.

The Portuguese government imposed an austerity package in September 2010, however the international assistance was officially requested in the first half of 2011, when Portugal was set to receive a €78 billion IMF-EU package in a bid to stabilise its public finances. Yet, the cost of this bailout deeply disregarded its social impact, according to a posting dated 18th October on the Marta Che blog.

Since the 1980s, Portugal had undergone remarkable changes tackling material deprivation and improving access to healthcare. The government progressively increased expenditure on healthcare, particularly in the public sector. When the financial crisis first hit, in 2008, expenditure for healthcare represented nearly 10% of GDP. However, the intensification of the crisis led to a decline on healthcare expenditure by 5% per year in real terms in 2011 and 2012.

In total, the Memorandum of Understanding (MoU) demanded savings of €670 million in Portuguese healthcare. Drug expenditure was heavily hit, prescriptions, workforce and user charges were also targeted. Since the very beginning it seemed conspicuous these measures would harshly damage the entire capacity of the NHS and lower people’s living conditions.

Impact of the recession on healthcare
A study published in the Health Policy Journal named “Effects of the financial crisis and Troika austerity measures on health and healthcare access in Portugal” (2016) reached the conclusion that unmet medical need doubled in the years 2010 to 2012 in the southern country and the quality of care saw a sharp decline as co-payments were introduced in public hospitals.

However, segments of the population (almost 56%) were exempt from increases in co-payments, though the struggle to have official eligibility was hard due to several bureaucratic obstacles involved.

Overall, the impact of the recession on health was huge.
Unit costs were forced down, the government negotiated lower prices for drugs while encouraged the marketing of generics and cut salaries of health workers. In addition, supplementary cuts were introduced in prevention, public health and research. Last but not the least were the already mentioned measures implemented to reduce demand for care, mainly by increasing co-payments.

What was the human cost of these reckless policies?
Mortality from respiratory diseases has increased by 16% between 2011 and 2012, following decades of continuing progress. Moreover, 2012 saw an increase in hospitalisations for respiratory diseases up by 9.9% since 2011. Excess mortality was largely associated to the seasonal flu outbreak as Portugal has one of the highest rates of people unable to keep their houses properly warm (28% in 2013).

Access to healthcare
According to Eurostat, risk of poverty and social exclusion in the population rose from 24.4% to 27.5% between 2011 and 2013 whereas material deprivation increased from 20.9% to 25.5% with severe material deprivation rising from 8.3% to 10.9%. In addition, the poverty rate among children under 18 years of age also grew from 28.6% in 2011 to 31.7% in 2013.stethascope

The crisis was accompanied by rising deficits (9.9% of GDP in 2010) and the government debt reached 129% of GDP in 2013. Hence, the Portuguese government was required to reduce the deficit to 3% of GDP by 2013 while “minimising impact on vulnerable groups”. However, this formality under the MoU was rather overlooked throughout the implementation of wide-ranging structural reforms in the country.

“What is happening now in Portugal can be called invisible genocide,” said Rui Viana Pereira, a Portuguese citizen who was unemployed during five years until he decided to immigrate. “Because of the drastic Troika’s austerity measures, many hospitals and health centers in all parts of the country were closed and very poor people who are living in countryside can’t get the medical help.” Unemployment in Portugal saw a sharp rise already in 2008 (7,6%) reaching its peak in the first quarter of 2013 (17,3%).

Between 2011 and 2013, the NHS lost 2.3% of its workforce, including 3.2% of its nursing staff. In 2013 alone, 1,211 Portuguese nurses registered to exert in the UK, compared to 20 in 2006/07. It is thus important to point out that during this period, the NHS saw an increase on its workforce although their salaries were target of successive cuts.

According to a survey conducted among 3,448 physicians from the NHS, 65% reported a shortage of medical equipment/products in their facilities and 80% reported that cuts in the NHS budget compromised care quality and access.

Medication Adherence
A 2012 patient survey including 375 patients provided a glimpse of medication adherence in patients suffering from chronic diseases. Its main findings revealed that 22,8% of patients did not purchase prescribed medication due to financial reasons. Physicians also estimated that 60% of patients failed to attend follow up treatment due to financial hardship.

It is undeniable that the troika’s presence in Portugal left behind a wave of destruction on the social structure of the State, particularly on the quality, delivery and access to healthcare.

Nevertheless, Portugal’s efforts to reform its drug pricing policy have contributed to significant reductions in pharmaceutical spending since 2010, even though greatly at the expense of the sustainability of pharmacies and wholesalers. Generic drugs have played a key part of the emphasis on cost control in Portuguese pharmaceutical policy.

Overall, the Portuguese NHS is gradually recovering and the different groups of health professionals - such as doctors, nurses and pharmacists - in the country have recognised the need to boost the capacity and sustainability of the NHS to deliver better outcomes.

The most remarkable reform to the Portuguese health system has been the introduction in 2014 of a new national system of health technology assessment (HTA), the Sistema Nacional de Avaliação de Tecnologias de Saúde (SiNATS), as part of Infarmed, the Portuguese drug authority.

With SiNATS, Infarmed wants to contribute in particular to maximize health gains and quality of life. The resort to HTAs aims to ensure the sustainability of the NHS and the efficient use of public resources for health, monitoring the use and effectiveness of technologies, reducing waste and inefficiencies, promoting and rewarding the relevant innovation development, and finally promoting equitable access to health technologies.

The health minister Adalberto Fernandes is confident that the NHS is on the right track. “The budget for 2016 was better than the budget from 2015 and the next year’s budget will be better. We are in the good way,” said the minister on RTP.

© Marta Che, 2016


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