The Portuguese Healthcare System

The Portuguese healthcare system is characterized by the coexistence and overlap of 3 systems: the universal National Health Service and health subsystems, insurance schemes based on professional group or company membership, and voluntary private health insurance. The National Health Service is a universal system funded by taxation.

The Ministry of Health and its institutions focus on planning and regulating the healthcare system.

The National Health Service is managed at the regional level by 5 Regional Health Administrations. Each regional health agency is responsible for managing the strategic health of the population, supervising and controlling hospitals, managing National Health Service primary care centers, and achieving national strategic health objectives. It reports to both the Minister of Health and a health council regarding its administration.

All hospitals belonging to the National Health Service fall under the Ministry of Health’s jurisdiction. Private sector hospitals, whether non-profit or for-profit, have their own management arrangements.

Private healthcare providers play a complementary role rather than serving as a comprehensive alternative to the national health system. Currently, the private sector primarily provides diagnostic, therapeutic and dental services, as well as outpatient consultations, rehabilitation, and hospitalization.

Autonomous regional health services exist in the Azores and Madeira. These services benefit from financial, administrative, and organizational autonomy.

Health insurance fully or partially covers the following services:

• Medical and surgical assistance;
• examinations and complementary diagnostic elements;
• treatment and home visits;
• medications and pharmaceutical products; nursing care;
• hospitalization and thermal treatments;
• prostheses and orthoses (including their renewal and repair);
• rehabilitation and professional and social reintegration, including workplace adaptation;
• psychological support for the patient’s family when needed;
• travel, food, and accommodation expenses for diagnosing or treating occupational illness, attending consultations, treatments, or medical committees, or attending legal proceedings.

I – Healthcare System Stakeholders and Management

a) The Ministry of Health

It is responsible for developing health policy, supervising and evaluating its implementation. Its main function is the regulation, planning, and management of the National Health Service. It is also responsible for regulating, verifying activities, and inspecting both public and private healthcare providers.

b) Regional Health Administrations

They are responsible for implementing national health policy at the regional level and coordinating all levels of healthcare. They handle insurance, purchasing, and healthcare provision functions for their population, and regulate all these aspects. There are five regional health administrations tasked with implementing health programs by developing strategic guidelines at the regional level, coordinating all aspects of healthcare delivery, supervising hospitals, managing primary care, and establishing agreements with private institutions and religious charitable organizations. They are also responsible for developing a long-term care network.

c) The Institute for Protection and Assistance in Case of Illness

It ensures effective access to social protection regarding health services for public administration civil servants and their families. This is the civil servants’ health subsystem and is administered indirectly by both the Ministry of Health and the Ministry of Finance.

d) The General Directorate of Health

It plans, regulates, directs, coordinates, and supervises all activities, institutions, and services related to health promotion, disease prevention, and the healthcare sector, whether integrated into the National Health Service or not. It is also responsible for public health programs, quality of care, epidemiological surveillance, health statistics, and studies.

e) The General Directorate for Prevention of Addictive Behaviors and Dependencies

It promotes the reduction of legal and illegal drug use, prevention and treatment of addictive behaviors, and reduction of drug and alcohol dependency.

f) The Blood and Transplantation

Institute It ensures the quality and safety of donation, analysis, treatment, storage, and distribution of human blood and blood components as well as human organs, tissues, and cells. Additionally, it regulates transfusion-related pharmaceutical products at the national level and ensures a safe blood and blood component supply is available when needed.

g) The Central Administration of the Health System

It is responsible for managing financial and human resources, facilities and equipment, systems and information technologies of the National Health Service. It is also responsible for policy implementation, regulation, and health planning, as well as regional health agencies, particularly in terms of healthcare service procurement.

h) The National Health Institute, Dr. Ricardo Jorge (INSA)

This is the reference laboratory for the Portuguese health system, integrating the functions of national observatory and national reference laboratory in the health sector. It is responsible for conducting, coordinating, and promoting health research. It also aims to produce evidence for public health policy and action. Currently, it comprises several departments: food and nutrition, infectious diseases and epidemiology, genetics, health promotion and chronic diseases, environmental health.

All Institute units develop multidisciplinary programs in research and development, health surveillance, training, laboratory quality assessment, and general health services.

i) The National Authority for Medicines and Health Products (INFARMED)

It is responsible for:

approving all pharmaceutical products to be reimbursed by the National Health Service (NHS) and suggesting to the Ministry of Health the level of copayment charged to insured persons;
ensuring the quality and safety of pharmaceutical products;
contributing to national health policy, particularly regarding the design and manufacture of pharmaceutical products, medical devices, and cosmetics;
regulating, evaluating, authorizing, disciplining, auditing, and verifying, as the national reference laboratory, and ensuring surveillance and control of research and development, production, distribution, and sale of medical devices and consumption of cosmetic products;
ensuring compliance with regulations regarding clinical trials on pharmaceutical products and good clinical practices;
guaranteeing the quality, effectiveness, and cost-effectiveness of pharmaceutical products, medical devices, and cosmetics, controlling the consumption and use of pharmaceutical products.

j) Professional Associations and Trade Unions

The Medical Association is the professional organization for doctors, and membership is mandatory for practicing physicians. Its functions include accreditation and licensing, certification of postdoctoral medical training. As for trade unions, their main role is to defend doctors’ rights as employees, especially regarding wages and employment. There are also equivalent orders for pharmacists, dentists, nurses, psychologists, and nutritionists.

The National Association of Pharmacies plays a specific role, managing the majority of pharmaceutical payments between the National Health Service and associated pharmacies. Its mission includes pharmacist education and continuing training, disseminating information about the latest practices in pharmaceutical management and distribution, implementing an information system for pharmacies, and collaborating with the government on public health projects and campaigns.

II – Care Organization

a) Public Health

The General Directorate of Health monitors the population’s health status and identifies its determinants, ensures health promotion and disease prevention, and conducts health impact assessments. It is responsible for coordinating all priority health programs while regional agencies implement them:

• detection of communicable diseases (viral hepatitis and HIV/AIDS) or non-communicable diseases (cerebrovascular diseases, oncological diseases, respiratory diseases, diabetes, as well as mental health);
• addiction treatment (tobacco, alcohol, drugs);
• health prevention (vaccination programs, antimicrobial resistance control);
• health promotion (recommendations for healthy living and nutrition).

Local health units, which group various healthcare providers, also integrate teams of doctors, nurses, auxiliary health technicians, and public health officials who work collaboratively with all providers within the same health unit. Public health physicians are responsible for epidemiological surveillance of the population’s health status and activities such as health promotion and disease surveillance. However, in many primary care centers, these responsibilities fall to general practitioners.

b) Ambulatory Care (Primary and Specialized) and Preventive Care

A range of public and private healthcare providers deliver primary care. These include primary care units integrated into the National Health Service, the private sector (both for-profit and non-profit), and healthcare professional groups practicing in private offices. These primary care networks ensure healthcare management as well as health promotion and disease prevention.

In the public sector, primary care is mainly provided by public health centers. Each center can decide its own organization and consists of several units that coordinate primary care, with their budget provided by regional health administrations. They aim to guarantee primary care for the population in a given geographical area. To achieve this, these centers develop prevention, diagnosis, and treatment of diseases as well as specific activities to address health risks. Health centers also provide services to integrate patients into the long-term care network.

The range of services offered by general practitioners in primary care centers includes: general medical care for the adult population, prenatal consultations, child protection, maternal protection, family planning and perinatal care, first aid, issuing work incapacity certificates, home visits, prevention services including vaccination and cancer screening and other diseases.

Most primary care is provided either by general practitioners and nurses in primary care units or centers or long-term care units under the national health system, or by private providers. Some primary care centers also offer a limited range of specialized care. Ambulatory specialties covered range from mental health to psychiatry, dermatology, pediatrics, gynecology, obstetrics, and surgery. The current trend of providing some of these hospital specialties within primary care aims not only to improve population access to care but also to avoid excessive access to hospital services (emergencies).

Patients must register with a general practitioner and can choose from those available at the primary care center in their area of residence. Some people seek healthcare services in the region where they work, but most choose a general practitioner in their residential neighborhood. General practitioners manage patient lists, and patients can change their general practitioner by submitting a request explaining the reasons for the change to the health center director. There is no legal limit regarding how often people can change their general practitioner.

The primary care sector faces several challenges including inequitable distribution of resources (staff shortages in remote regions), very limited public provision of long-term care and home care services, and a shortage of qualified auxiliary staff in primary care centers. Furthermore, difficulty accessing care leads to overcrowding of emergency services.

c) Hospital Care

Secondary and tertiary care is accessible by general practitioner referral, except in emergencies. They are mainly provided in hospitals, although some primary care centers employ specialists who provide specialized outpatient services. Hospitals are classified according to the services they offer:

• Group I: includes hospitals offering certain internal medicine and surgery services; other services may be offered such as oncology, hematology, nuclear medicine, depending on the population served and the framework set by the Central Health System Administration. This framework defines which healthcare facility a patient should visit according to the specialty sought and the region where they reside.
• Group II: includes hospitals that provide internal medicine and surgery services, including services not provided by Group I hospitals; this group does not include clinical pharmacology, genetics, pediatric cardiology, cardiothoracic and pediatric surgery.
• Group III: includes hospitals providing all internal medicine and surgery services, including specialties not provided by Group II hospitals.
• Group IV: includes hospitals specialized in oncology, internal medicine and rehabilitation, psychiatry, and mental health.

The problem of poor coordination between hospitals and primary care centers, and the large number of patients who bypass the requirement to first consult a general practitioner and go directly to emergency services, has led to the development of local health units. These are organizations that integrate one or more hospitals and a number of primary care centers, created based on geographic proximity on one hand, and the balance of specialties and availability of emergency services on the other. However, health units have not achieved all the expected improvements in coordination and have not met the objective of integration, coordination, and continuity of care.

Day ambulatory care is provided by the national long-term care network. This includes services provided to patients who need particular healthcare without staying overnight, for example for hemodialysis or physiotherapy. It also involves providing coordinated support services to improve autonomy and offer psychological support in an outpatient setting, without requiring intensive institutional care. Ambulatory care has developed significantly in hospitals and, in addition to ambulatory surgery, an increasing number of treatments are performed in this setting, including dialysis, dermatology, psychiatry, and hematology.

d) Emergency Care

The National Institute of Medical Emergencies is an organization under the Ministry of Health responsible for coordinating and operating a coordinated medical emergency system in mainland Portugal. This system ensures rapid and appropriate delivery of emergency care. Its main tasks are to provide medical assistance at the scene of accidents, ensure patient transport to the appropriate hospital, and coordinate between various system participants. Through the European emergency number (112), the institute has several means to respond quickly and effectively at any time to emergency situations and provide effective medical care in case of accident or sudden illness, using the following services: emergency guidance center, maritime emergency guidance center, poison control center, and high-risk newborn transport center.

e) Pharmacy

There are a number of independent pharmacies in each municipality where patients must bring prescriptions received either from a primary care unit physician or from a hospital outpatient service. However, non-prescription products can now be sold outside pharmacies provided they have been registered with the National Authority for Medicines and Health Products, with their prices being unregulated.

Pharmacy location is highly regulated. A maximum number of pharmacies is authorized in each municipality. The Ministry of Health decides if a new pharmacy is needed in an expanding residential area. First, there must be proof of at least 3,500 new customers, and there must not be another pharmacy within 350 meters of the proposed site. A maximum of four pharmacies can be owned by the same owner, but a technical director with a degree in pharmaceutical sciences must be present in each pharmacy.

For reimbursement, medications or pharmaceutical products must be included in a list of medications reimbursable by the National Health Service. Prescribed medications require variable patient copayment based on established efficacy criteria, with full payment required for pharmaceutical products without proven medical service or that do not present good cost-effectiveness. Medications prescribed for patients with serious illnesses are fully covered by the National Health Service. Primary care centers provide vaccines that are part of the National Vaccination Program free of charge.

f) Long-term Care

The long-term care network is organized at two territorial levels: regional and local, through integrated and continuous intervention of social action and healthcare. Long-term care is defined according to dependency situations: situations where sick, elderly, or disabled persons cannot independently perform daily living activities and permanently need help from another person and specialized healthcare and/or residential care.

Professional providers (promoters and management entities of Network units and teams) include legal entities of various types such as hospitals, health centers, social security centers, private social solidarity institutions, NGOs, local authorities, for-profit entities, and charitable organizations. The national long-term care network combines long-term care, social support, and palliative care teams. This network offers services in the following areas:

Home care services including: daily healthcare, personal comfort, hygiene, housekeeping, laundry, meal delivery, accompaniment to medical consultations. Home care is granted without time limit. These services can also be provided in foster families for maximum periods of three months;

Rehabilitation services (short or medium-term patient recovery): aimed at stabilizing the patient after hospitalization and ensuring functional rehabilitation (permanent medical and nursing care, psychological support for an estimated maximum duration of 30 days for short-term and between 30 and 90 days for medium-term);

Long-term care: these are temporary (day or night care centers) or permanent hospitalization or placement services that provide care to people with chronic diseases, physically disabled or mentally disabled persons, with different levels of dependency who cannot be treated at home. These services aim to provide care that will prevent and delay increased dependency by promoting comfort and quality of life for more than 90 consecutive days. They offer maintenance and stimulation activities, daily medical and nursing care, prescription and administration of pharmaceuticals, psychological support, periodic psychiatric monitoring, physiotherapy and occupational therapy, sociocultural animation, hygiene, comfort, nutrition, and support in daily life activities. Long-term care integrates palliative care at home or in healthcare facilities.

III – Treatment Facility Contacts

Mainland
Public or private healthcare providers (including pharmacies): search by facility type, region, city, and provider name
Hospitals, units, and health centers
Healthcare professionals registered with their respective associations:
– physicians
– dentists
– nurses

Azores
Health centers and hospitals

Madeira
Health centers, hospitals, healthcare providers by specialty

IV – Healthcare System Monitoring

a) The General Directorate of Health
Public health physicians are responsible for epidemiological surveillance of the population’s health status as well as activities such as health promotion and disease surveillance. However, in many primary care centers, these responsibilities are transferred to general practitioners due to a shortage of public health physicians. The responsibilities of public health physicians include:

• surveillance and control of communicable diseases;
• water quality monitoring;
• environmental hygiene surveillance with the help of municipalities;
• compliance of facilities including healthcare establishments with health safety standards;
• inspection of workplaces and working conditions;
• inspection of building and housing safety with municipalities.

b) The General Inspection of Health-Related Activities

It performs audit, supervision, and disciplinary functions in the health sector, both in institutions and in the National Health Service and private organizations.

c) The National Authority for Medicines and Health Products (INFARMED)

It regulates and supervises the pharmaceutical and health products sector according to the highest standards of public health protection. It aims to ensure that all healthcare professionals and patients have access to safe, effective, and quality pharmaceutical and other health products.

d) The Health Regulation Agency

It is an independent body responsible for regulating the healthcare sector. Its functions include supervising healthcare establishments regarding operational requirements, patient access to healthcare and defense of their rights, quality of care provision, economic regulation, and promotion of competition in the healthcare sector. Its functions also include the accreditation of establishments operating in the healthcare sector.

e) Professional Associations

Their functions include provider accreditation and licensing, and enforcement of the disciplinary code, with the power to warn and sanction physicians.

f) The National Institute of Medical Emergencies

It defines, participates in, and evaluates the activities and performance of the Integrated Medical Emergency System, ensuring immediate assistance to injured or seriously ill patients.