Portugal will test a new public health management model, which aims to rescue it from the critical situation it is going through. The new statute of the National Health System (SNS) drawn up by the Government provides for the creation of an independent management team, which will not have to be accountable at the political level. The decree-law that regulates it was promulgated in mid-September by the President of the Republic, Marcelo Rebelo de Sousa, and will enter into force this Saturday, October 1. At the head of the executive management of the SNS, a kind of CEO of the system, will be Fernando Araújo, until now president of the board of directors of the São João hospital, in Porto, considered an effective model in the face of the chaos that exists in some large complexes from Lisbon.
Araújo, a doctor who has opted for health management, considers that one of the system’s problems is continued precarious financing, which collapsed during the 2010 crisis and only partially recovered in the boom years due to strict control of the budgets that all the finance ministers of the prime minister, the socialist António Costa, have exercised, concerned with cutting the public debt and deficit since he came to power in 2015. Araújo also did not share some decisions of the previous Minister of Health, Marta Feared, that he tried to make up for the lack of personnel with overtime and reinforcement with external personnel, especially in emergencies. “The problem with political managers is that they sometimes commit the imprudence of opting for populist solutions in complex systems. Giving more money without a clear strategy and proper planning does not solve the limitations and can create new problems”, he wrote in an article in Jornal de Notícias.
The SNS paid 530 million euros for overtime in 2021, a figure that has not stopped growing since 2018. In addition, the unequal remuneration received by the toilets of the centers (25 euros per extra hour) and the “tarefeiros” (external contractors for a service), which can receive up to 100 euros per hour, has increased the discomfort of the staff.
Marta Temido, who became the best valued minister in Portugal for her performance during the pandemic, resigned a few weeks ago after chaining several critical episodes. The one that triggered her resignation occurred on August 30, when a 34-year-old pregnant woman died while she was being transferred between two public hospitals in Lisbon. That same afternoon Temido presented her resignation to the prime minister, António Costa, who had sponsored her to join the Socialist Party a year ago and had come to see her as a possible successor in the days when the minister won the applause of the Portuguese. “It was an episode of such gravity that personal responsibility was necessary,” Temido observed days later, after passing the portfolio to her successor, MEP and doctor Manuel Pizarro.
The former Portuguese Minister of Health, Marta Temido. Horacio Villalobos (Corbis via Getty Images)
This summer, two babies also died in different hospitals with closed gynecological emergencies, which highlighted the lack of personnel in the obstetrics and neonatology area. Yet another specialty that was cracking. Collective complaints (sometimes with block resignations) due to work overload have been repeated for months throughout the country.
10 years ago public spending on health bottomed out in Portugal. The State, then intervened by the hawks of austerity (European Commission, European Central Bank and International Monetary Fund), transferred barely 7,500 million euros for health activity in 2012. A machete blow that aggravated the cuts of 2010 and 2011. It took a change of government and a decade for public health to recover the financial muscle prior to the first crisis of the 21st century. Since 2015, when the Socialist Party entered the Government, the budget has grown to exceed 13,500 million euros this year.
The Portuguese Observatory of Health Systems recorded an increase of 30,000 health workers compared to 2016, but also a drop in productivity, favored by the effects of the application of 35 hours per week and the increase in absenteeism, which reached 20% of the workforce during the pandemic. Poorly paid professional careers (a surgeon with 30 years of experience earns less than 1,800 euros) and impossible family reconciliation trigger discontent and demotivation of the staff.
The great paradox is that the system is cracking now that there are more doctors and more money than a decade ago. And he does it from small to large. They lack from pillows in some emergencies to beds in hospitals that force patients to accumulate in corridors. Some surgery waiting lists exceed two years. More than a million people do not have a family doctor assigned. A figure that improves that of a decade ago (1.8 million), but worsens that of the last six years.
Eduardo Costa and Joana Pestana, researchers at the Nova School of Business and Economics in Lisbon, analyzed the data from 2015 to 2021, when Portuguese went from 751,000 to 1.13 million without their own doctor. “This does not mean that the centers provide worse care than in 2015. There are factors that help explain this phenomenon. On the one hand, the new contracted doctors may not be placed in the units with the greatest shortages and on the other, the increase in the elderly population and those most in need of care means that the number of users per doctor is reduced,” Costa maintains in an email. .
The situation in primary care will worsen if the 1,800 doctors who could do so between 2022 and 2024 retire. The half a thousand graduates that can be incorporated into the market each year will not be enough to replace them. This is one of the changes that the Government wants to introduce. “It is unacceptable that students with good grades in secondary education are deprived of access to medical courses due to the numerus clausus restriction,” said the Prime Minister, António Costa, in a recent interview with CNN Portugal, where he recalled the “fight ” to expand places, which has the reluctance of the universities and the Order of Physicians (the professional association).
Portugal has become one of the main exporters of doctors and nurses, who seek better working conditions in other countries. The president of the Ordem de Enfermeiros, Ana Rita Cavaco, estimates that some 20,000 nurses work in other countries. “Right now there is no unemployment in Portugal,” he explained in an email, “but the conditions they are offered are not worthy of the profession: four-month contracts and less than a thousand euros a month, a salary that is the same when they have 20 years of experience”.
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