When Dr. Ana Rita de Jesus arrives in the morning at the Alcântara health center, in the west of Lisbon, she always finds the same picture: a queue of patients goes around the corner. They usually have been there from 7 in the morning, one before the consultations start. At 8:30, the quota is full. Those in the queue leave. Maybe they’ll try the next day, maybe they’ll try their luck at the hospital. Hopefully, it won’t be anything serious.
The National Health System (SNS) was one of the great achievements of the April 1974 revolution, pride for the Portuguese, but today it is in serious crisis. The failure of the Government’s budgets for 2022, which has precipitated the electoral call and certified the rupture of the understanding between the Socialist Party, the Bloco de Esquerdas and the Communist Party, is largely explained by the disagreements on how to tackle the decline of public health.
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“The SNS is exhausted, impoverished, degraded,” repeated the communist leader, Jeronimo de Sousa, in an interview this week to explain his negative vote. The Bloco spokeswoman, Catarina Martins, recalled in Parliament a devastating official figure at the base of the system: “More than a million people do not have a family doctor.”
Primary care in Portugal has been in a fragmentation process since 2005 that has generated obvious dysfunction. In that year a reform was devised that created the so-called Family Health Units, centers with great management autonomy. One of its modalities, the “B units” pay physicians by objectives, have a stable reference population and provide quality care, but in practice they are closed reserves: they do not receive more patients than they are assigned.
On the other side of the coin are the old health centers, today known as Personalized Health Care Units (UCSP) that act as a catch-all: they treat patients who do not have an assigned family doctor. They do not give appointments, they cannot do a rigorous follow-up of the patients and in general they pay the professionals worse, according to the administrative tables. In the health center of Dr. de Jesus, the specialists who start earn 1,600 euros. Of the 20,000 people he cares for, “almost half” do not have an assigned doctor.
There are not enough doctors in the Portuguese public system. It is not that the country does not train cadres, but between emigration (400 doctors requested the certificate to practice abroad in 2019, according to the newspaper Expresso) and the temptation of an expanding private sector, with much more generous salaries and less burden of work, the places are not filled.
The vice president of the Portuguese Association of General and Family Medicine (APMGF), Paula Broeiro, also points out the existing territorial imbalance: in the north, with more economic power, the calls for places are filled without difficulty. But in the Lisbon and Tagus Valley region, with a population of about 3.5 million people (one third of Portugal’s total), coverage rates are very low.
The Socialist Party, always with an eye in which the deficit does not skyrocket, proposed to recover the exclusive dedication that until 2009 the public doctors charged, but has renamed it as “full dedication” and only for managerial positions. The parties of the left refused to support the move.
The queues at the Alcântara health center are not an anecdote. 40 minutes from Lisbon, the residents of Carregado, a population of 15,000 inhabitants of the municipality of Alenquer, they manifested in september, fed up of having to wait their turn “sleeping at the gates of the center, in the street or in the car,” according to the Lusa agency.
At the Odivais health center, north of the capital, the situation is not so dire, but Broeiro understands the frustration. “It’s hard for me to see that people need care and don’t get it. Patients don’t understand it; they tell me ‘it’s not my fault,” he says. Broeiro and another companion are divided to serve a population of 11,000 people without an assigned doctor. It costs them, but they fix themselves. His obsession is that pregnant women and children do not go without consultation.
Advertising of private health is very common in Lisbon. On bus shelters, on posters. There are also advertisements on television, very similar to those that are broadcast lately in Spain. Between 2018 and 2020, 19 private hospitals were opened in the neighboring country, according to Diario de Noticias. The president of the hospital employers’ association, Oscar Gaspar, was the Secretary of State for Health in the last government of José Sócrates, socialist prime minister between 2005 and 2011 (today awaiting trial for money laundering).
“To be inclusive and democratic, the SNS must be a quality service. By weakening it, it becomes a service for the poor,” laments Dr. Broeiro, who is 57 years old and faces the last decade of her professional career “without losing the enthusiasm”.
For the youngest, the vocation is almost activism. De Jesus is 34 years old and he had to direct the Alcântara health center due to the lack of candidates. “I am in the cause,” he explains. “For these people I am extremely useful. They have no alternative. They have no plan B.”
