Portugal's healthcare infrastructure
With tourism to the beautiful country of Portugal helping to shape healthcare infrastructure in recent years, Tatum Anderson investigates just how far the industry has come with regards to the processing of international patients
Portugal’s tradition of formal healthcare extends back centuries. The first charitable hospitals, Misericórdias, appeared in 1498 and later spread throughout the Portuguese empire from Sri Lanka to Macau. While many Misericórdias have since disappeared, the capital Lisbon is still home to Santa Casa da Misericordia, one of Portugal’s most prestigious public hospitals. Actually, most of the best hospitals are located in or around Lisbon, and the quality of care available is of an international standard. Here, we take a closer look at how visitors to the country can access healthcare – for both general medical needs and for emergency care – and we analyse the nature of the relationship between assistance companies operating in the country and local hospitals.
Taking the strain
Generally, Portuguese citizens enjoy good health and increasing life expectancy, although lower than many other western countries. In fact, Portugal spends the least amount on health per person than any other western European country. That was around US$2,151 on health per capita in 2006, the most recent figures available, and this lack of investment seems to have had an impact on the country's national health system (NHS).
Portuguese citizens enjoy good health and increasing life expectancy, although lower than many other western countries
The European Observatory on Health Systems and Policies in 2007 concluded that crowded hospital emergency departments and long waiting lists for surgical procedures are just a few failings of the NHS in Portugal. There have been shortages of physicians due to an uneven distribution across the country too. “Many times, in a state hospital, patients have to stay in a corridor on a stretcher, as there are no beds available, and then the insurance company may opt for the patient to be transferred into a private facility,” says Silva. That’s why companies such as Luzdoc, a private clinic group and local assistance partner, say they use the private sector for tourists. “We prefer to use private hospitals as we can refer the patient to a known and trusted facility and a physician who will keep us informed of the progress of the patient,” she adds. “It deals with the situation faster and in a more suitable environment.” Administration can be difficult in public hospitals too, explains Silva. In public hospitals, she says, there are no dedicated ‘international departments’. As a result, public hospitals are generally only interested in getting the patient well and then discharging them to free up an acute bed. “The doctors and nurses do not comprehend that there are logistical problems for international patients, such as having to fly home (fitness to fly), and being discharged to a hotel that may not have suitable conditions for a recovering patient,” she says. The public sector sometimes also has difficulty processing foreign patients, adds Silva, with language barriers posing a particular problem.
This isn’t just an issue in Lisbon. Down south in the ever popular Algarve, services in public hospitals can reach capacity at peak season too. “It can get very difficult, and tourists put a lot of strain on [the system] and they are short of staff, nurses and beds. People are well-looked after but you do hear stories of people waiting in corridors before they are diagnosed,” says Angela Barden of Lloyd & Whyte, an international travel and medical insurance broker.
The result is that although Portugal runs an NHS that is funded through taxation, there is a huge demand for private healthcare facilities from tourists, expats and Portuguese citizens. This demand exists despite the fact that the private sector does not generally provide more specialist services than the public sector, and that state-of-the art specialist treatments are still the preserve of government academic hospitals.
The public Santa Maria de Lisboa and Hospital Universitario De Coimbra, near the Coimbra University, come recommended as general hospitals. Lisbon’s Cruz Vermelha, too, serves both private and public patients. These three hospitals also house trauma units. Patients that require specialist treatment, including tourists, have traditionally been transferred to Lisbon from the district hospitals in the rest of Portugal. Examples of good specialist hospitals in the capital include the Hospital Dona Estefania for paediatrics, the Maternidade Alfredo da Costa for maternity cases, and Instituto Portugues de Oncologia, a cancer hospital which has branches in other major cities in the north, Porto and Coimbra. There is also a good reported standard of heart care in these three cities.
But things are changing, says Dr Maria Alice Silva, medical director at Luzdoc: “Presently, [transfers to Lisbon] are happening less and less, as the district hospitals are beginning to develop many more specialised services themselves.” With its expansive southern and central coasts that have become a magnet for tourists and expats, there has been a large rise in the number of both public and private healthcare facilities in both the Algarve and Albafeira. Until a few years ago, for instance, coronary cases in the Algarve, such as angioplasty and stenting, were transferred to Lisbon. Now, there are two dedicated cardiovascular units in Faro – Hospital Distrital de Faro and the private Hospital Particular Faro, which is part of the Alvor hospital group.
Private growth
“Over the years, because of the influx of tourists to the Algarve, the hospital and clinic system has got a lot better,” agrees Barden. “Today, there are more private centres in the Algarve that are aimed at the English-speaking and German-speaking expat communities here.” In fact, many people choose to bypass the national health system altogether. Indeed the majority of specialist consultations take place in the private sector and it is possible to go straight to a specialist in Portugal rather being referred by a gatekeeper at the public primary care level. Specialist consultancy costs anything between €80 to €200.
It’s unsurprising, then, that the private sector is growing rapidly with both larger central hospitals and smaller clinics owned by private companies. Apart from a faster service, a major reason that tourists and expats use private health services is that they are able to choose a doctor who speaks English or German well, rather than risk being seen by a doctor who may have fewer language skills. But better language skills and shorter waiting times come at a price. Private services are very expensive. On the whole, the private institutions recommended for touristic use are large hospitals and not clinics, and they generally provide 24-hour emergency and trauma care. Larger private hospitals in Lisbon include British Hospital, Hospital da CUF, Hospital Particular de Lisboa and Hospital SAMS, and they all have intensive care or emergency departments. There is also some consensus about hospitals in the Algarve, with most providers recommending the same ones: Hospital Particular do Alvor, Hospital Particular Gambelas-Faro, Hospital Particular São Camilo.
Tourists in need
Although there are no dedicated tourist drop-in health centres, Portugal’s hotels do usually maintain a list of both public and private providers. “This is also helpful if the client requires a home call as the hotel should know of the doctors in their area that provide this service,” says Luzdoc’s Silva.
“Over the years, because of the influx of tourists to the Algarve, the hospital and clinic system has got a lot better,”
Tourists accessing the public system can opt for a Centro de Saúde (CS) primary health centre, which deal with non-urgent situations and are normally open during working hours on weekdays. They act as GP surgeries but also deal with minor accident and emergency cases.
For more serious cases, local hospitals run 24-hour accident and emergency services, called Permanent Attendance Service – Serviço Atendimento Permanente (SAP). These have more recently begun operating a triage system. Experts warn, however, that a few SAPs do close earlier in some regions.
Tourists with a European Health Insurance Card (EHIC) are treated as Portuguese citizens. That means some services are free, but others require some form of co-payment (EHIC also enables discounts on some private services). Children up to the age of 11, pregnant women and the elderly are usually exempt from all charges. For everyone else, visiting GPs at a Centro de Saúde costs a nominal fee of around €2. Consultant services are usually free but diagnostic tests, from x-rays to blood tests, can vary between €80 and €200 a go. Similarly, ambulance services are subsidised and top-up payments are calculated based on distance.
Co-payments have been increasing over time, and pharmaceutical products can be expensive too. Indeed, Portuguese patients pay the highest amount out-of-pocket (OOP) on health in Europe. Including cost-sharing within the national health system and direct payments for private sector services, OOP was around 23.5 per cent of total health expenditure in 2004.
Quality of healthcare also varies geographically. Generally, urban coastal regions have much better healthcare services than rural interior regions. Health resources are concentrated in the capital, Lisbon, and Porto, and there are many facilities along the coasts. In contrast, there are no tertiary or specialist hospitals in the Alentejo region in the rural interior.
The number of doctors and nurses to serve 1,000 people is vastly different too. In 2004, there were six doctors and six nurses per 1,000 people in Lisbon and Porto, but just 1.6 doctors and 2.4 nurses in 2005 in Alentejo (although the relative number of doctors nationally is above average, the relative number of nurses in Portugal is well below that of other countries). “Services in the Alentejo (region) are very limited. People usually travel to Lisbon and the Algarve,” says Barden.
The island of Madeira, in contrast, has three hospitals and many health centres. Some are equipped with emergency service facilities. Some of the private clinics also provide emergency services too and there are many English-speaking doctors and dentists, say experts.
Despite these variations in care, and despite the strains on the public health system, some aspects of the NHS are improving. With better training, a new generation of health workers is now learning many more languages or studying abroad, say experts. And an investment programme in recent years has focused on poorer regions. New hospitals have opened, such as Santiago do Cacém in Alentejo, for example, and the government has also struck public-private partnerships to upgrade various hospitals.
Tourists accessing the public system can opt for a Centro de Saúde (CS) primary health centre, which deal with non-urgent situations and are normally open during working hours on weekdays
And in an effort to reduce the backlog of waiting lists, many procedures are carried out on state patients in a private setting. That’s why certain diagnostic services, renal dialysis and physiotherapy treatments are so often carried out in the private sector under contractual arrangements with the NHS.
But what of some of the other reported issues, such as over treatment or over charging, that are so rife in other European countries? Luzdoc reckons there is not an issue of overcharging or over treatment here in Portugal. However, Juan Carlos Cortiletti, manager of SOS International’s International Network, says the level of overcharging is comparable to Spain. “Medical standards can vary from facility to facility,” he says, “and some private facilities may have tendency to over treat and over charge.”
Emergency services
Emergency services are largely run as a public service. The Portuguese fire department runs general transportation services for patients, while the National Institute of Emergency Medicine (INEM) also has ambulances that carry doctors and nurses for more acute emergency situations. That said, private facilities do use their own ambulances and often contract public ambulances to transfer patients to private entities, and such services are paid for on the spot.
The INEM is the Ministry of Health organisation, responsible for co-ordinating the Integrated Medical Emergency System in Portugal, and is called into action by the national emergency number – 112. Emergency calls are usually transferred to one of four centres: Lisbon, Porto, Coimbra and Faro, which assess the gravity of the emergency and determine whether ambulances, motorbikes or helicopters are most appropriate. INEM provides two emergency helicopters – based in Lisbon and Oporto - but despite calls for more helicopters, the service announced crisis measures in June, with plans to ground the helicopters as part of cost-cutting measures. These plans have not yet been put into action, however, and a pay-off is thought to have been made to various ambulance and emergency response vehicle operators in an overtime payment settlement.
Assistance companies say they tend to use international companies to provide air ambulances or repatriation. However, SOS International says it often uses OMNI, a Portguese-owned company, for intra-national ambulance flights, but it has also used SATA Air Açores (SATA), a state-owned airline that operates from the Azores, as well as Mayoral Aviation, a Spanish company.
Future development
Private health insurance is being actively promoted to offset the deficiencies of the public system, say the authors of the European Observatory report, Pedro Pita Barros of the Universidade Nova de Lisboa and Jorge de Almeida Simões at the Universidade de Aveiro. Indeed, around a quarter of the 10.7 million-strong Portuguese population has private health insurance coverage through work-based health insurance schemes and private voluntary health insurance. It is not at all unusual to find patients who access healthcare through all three kinds of coverage – public, work-based and voluntary private too.
By law, companies must offer work-based health insurance to their employees. The largest occupational health scheme, Assistência a Doença dos Servidores do Estado (ADSE), covers civil servants – or almost 10 per cent of the population.
In addition, some companies now also offer an additional optional health insurance perk that covers general sickness, rather than just work-related injuries. It is usually purchased as a group policy and employees often pay for their own families to be included.
Despite improvements in the public system, new forms of private managed care are being experimented with in Portugal
Needless to say, policies vary. Some employees may pay around €12 to €15 to see a doctor while others contribute 10 per cent of the total cost of cover. “Over the last ten years, there have been more schemes here that work within a network of providers that provide a certain number of hospitals and doctors,” says Lloyd & Whyte’s Barden.
Médis is an example. It operates a network of healthcare providers, for instance, with over 6,000 doctors, 1,500 auxiliary diagnoses test facilities, 600 clinics and 90 hospitals. It offers outpatient treatment, hospitalisation, physiotherapy and diagnosis.
So, despite improvements in the public system, new forms of private managed care are being experimented with in Portugal. Managed care companies such as Médis use medically trained call centre employees to provide a 24-hour service to each policyholder and direct them to the most appropriate healthcare service. That, say experts, reduces administrative costs and unnecessary consumption. It’s a model many are watching.