Healthcare in Portugal
Healthcare in Portugal is provided through three coexisting systems: the National Health Service, special social health insurance schemes for certain professions and voluntary private health insurance. The SNS provides universal coverage, although in 2012 measures were implemented to ensure the sustainability of the service by the introduction of user fees to be paid for at the end of treatments. In addition, about 25% of the population is covered by the health subsystems, 10% by private insurance schemes and another 7% by mutual funds. The Ministry of Health is responsible for developing health policy as well as managing the SNS. The Health Regulatory Entity is the public independent entity responsible for the regulation of the activity of all the public, private and social healthcare providers. In 2019 the government proposes to scrap all fees, which constitute about 2 percent of the NHS's budget, apart from some hospital emergencies.
Healthcare system
National Health Service (SNS)
The National Health Service is the system by which the State assures the right to the health protection, in the terms established by the Portuguese Constitution. It was created in 1979 and operates under the supervision of the Ministry of Health.The SNS is characterized as being national, universal, general and free. It is national as it should be provided nationwide, although presently it still only covers Continental Portugal. It is universal as all Portuguese citizens and foreign residents have access to it. It is general as it encompasses the whole range of healthcare, including the health surveillance and promotion, the disease prevention, the diagnosis and treatment of patients and the social and medical rehabilitation. It is free, as the system is publicly funded, with the health services being tendentiously free of charge for the users. However, some fees are charged, not in order to finance the system but serving mainly to moderate and filter unnecessary access to the services.
The system is managed by the Central Administration of the Health System and by the five regional health administrations. The ACSS is responsible for the central management of the financial, human, equipment and facility resources of the system, as well as for the establishment of health policies, plans, rules and standards. The regional health administrations are responsible for providing the healthcare services to the populations of their respective regions, as well as to execute the national health plan.
Besides being public funded, the health services provided by the SNS are mainly delivered by public health units. These include:
- Health centers groups - providing mainly primary health care to the local communities. Each ACES congregates several health centers. There is at least one health center covering each municipality, each of which can have one or more extensions in its jurisdiction. The ACES include specialized units of family and personalized healthcare, community healthcare and public health;
- Hospital establishments - providing mainly secondary health care. Most hospitals are now administratively part of a hospital center, which groups and manages together several hospital units located in the same city or region. Independent hospitals and hospital centers are classified as group I, II, III or IV ;
- Local health units - grouping together the health centers and hospitals located in the same city or region in a single comprehensive administrative unit, which is responsible to provide both primary and secondary health care.
Regional health services
Despite the Constitutional and other statutory provisions and being referred as "National", the SNS is not really nationwide, as it was never expanded to the Portuguese autonomous regions, only covering Continental Portugal. In the scope of their devolved powers, the autonomous regions of the Azores and Madeira created their own separate regional health services, managed by the respective regional governments.The exact status of these regional services and its relation with the SNS is however not clear, as both the Statute of the SNS and the Basic Law of Health are silent about the SRS, with this last one only vaguely mentioning that the health policy in the autonomous regions is defined and executed by the respective bodies of self-government. The question of the status of the SRS was raised when a number of SNS hospitals sued the Regional Government of the Azores to force it to pay the costs of the services provided to residents in the Azores who received treatment in those establishments. The Azorean government argued that the Azores SRS should be considered a regional extension of the SNS, so its users should also have universal access to SNS healthcare free of charges. However, in a decision taken in May 2015, the Supreme Administrative Court considered that the Azores SRS was autonomous regarding the SNS and should be considered a health subsystem, so being obliged to pay SNS for the services provided to its beneficiaries.
The Azores SRS is managed by the regional secretary of Health and is organized in nine island health units, which include 14 health centers, three hospitals and a center of oncology. Each USI groups all the public healthcare establishments located in the same island in a single administrative unit. There are two types of USI. Those that groups both hospital and health centers are similar to the local health units of the SNS, providing both primary and secondary healthcare. USI that groups only health centers are similar to the health centers groups of the SNS and provide only primary healthcare.
The Madeira SRS is managed by the regional secretary of Health. It includes two hospitals, two specialized centers and 15 health centers. All these healthcare units are grouped in a single administrative unit, the SESARAM, EPE. The SESARAM, EPE is similar to a local health unit of the SNS, providing both primary and secondary healthcare.
Health subsystems
The health subsystems are the special schemes - parallel to the SNS - responsible for the providing of healthcare to the members of certain professions or organizations. The adhesion to them is mandatory for these groups of persons, with its financing being made either by the beneficiaries or by their employers. There are public and private subsystems, with the first type being responsible for the providing of healthcare to public servants and the second to the members of private organizations.The most important public health subsystem is the ADSE, which covers all public servants not covered by other special schemes. ADSE has more than 1.3 million beneficiaries, including servants of the central, regional and local public administrations. The other public subsystems cover some special groups of public servants and are the ADM for the military personnel of the Armed Forces, the SAD/GNR for the military personnel of the National Republican Guard, the SAD/PSP for the police personnel of the Public Security Police and SSMJ for some special professional groups of the Ministry of Justice. All these public subsystems are entirely financed by the State.
The private subsystems are mainly characterized by their occupational basis. They cover either members of certain professions - independently of their employer - or cover the employees of specific private organizations. They can be financed by the beneficiaries - usually through a discount in their salaries - or by their employers. Example of private subsystems are the SAMS for the bank employees, the PT-ACS for the employees of Portugal Telecom and the SSCGD for the employees of Caixa Geral de Depósitos.
The subsystems usually provide the healthcare to their beneficiaries both through public and private medical establishments. This is done by previous conventions agreed between the subsystems and the medical services providers or - when there are not previous conventions - by the post reimbursement of the beneficiaries for the healthcare payments they advanced. Some subsystems are able to provide directly healthcare services through their own medical establishments. This is the case of the ADM through the Hospital of the Armed Forces and other military health units and is also the case of the SAMS through the SAMS Hospital and SAMS clinics.
Health insurances
The health insurances complement both the SNS and the health subsystems, with the adherence to them being usually voluntary. Being considered a healthcare complementary activity, the health insurances are also under the supervision of the Ministry of Health.The insurances healthcare services are provided to the insured persons through either direct or free schemes. In the direct scheme the services are provided by medical establishments which have a previous convention with the insurance network. In the free scheme, the services are provided by entities with no previous conventions, with the insured person advancing the payment and then being reimbursed by the insurance.
A number of health insurance networks exist in Portugal, with the larger ones being the Multicare, the AdvanceCare and the Medis.
Emergency medical services
The Integrated System of Medical Emergency is the main emergency medical service of Portugal, managed by the National Medical Emergency Institute, an agency of the Ministry of Health. It is activated by the emergency number 1-1-2, under the coordination of four regional urgent patients guidance centers and an additional CODU for emergencies at the sea. The SIEM also includes an anti-poison information center and a subsystem for the emergency transportation of high risk newborns to specialized hospital units.Under the coordination of the CODU, a number of specialized mobile resources operate, including ambulances, fly cars, air ambulances, motorcycle ambulances and disaster response vehicles. The ambulances are either directly operated by the INEM from its regional branches or are operated from the medical emergency and reserve posts installed in the local fire departments or in the local branches of the Portuguese Red Cross.
The interface between the pre-hospital emergency care and the hospital care is made through three levels of urgency services. The basic emergency services deal only with basic medical-only or very simple chirurgical emergencies. The medical-chirurgical emergency services deal with medical and also chirurgical emergencies. The polyvalent emergency services deal with the most serious emergencies that need a very differentiated medical and/or chirurgical treatment. The SUB are installed in the ACES, the SUMC are installed in the hospitals or hospital centers and the SUP are usually installed only in group III hospital establishments.
Although also supporting the Portuguese Atlantic islands with some specialized services, the SIEM covers mainly the territory of Continental Portugal, with the Azores and Madeira having their own separate medical emergency services. In Madeira, the services are provided by the Regional Medical Emergency Service, which has features similar to those of the INEM. In the Azores, the medical emergency services are provided by the local fire departments under the coordination of the Regional Civil Protection and Fire Service.
Hospitals
Public hospitals
The public hospitals are part of the National Health Service or of the regional health services of the Portuguese Atlantic islands.Although some hospitals continue to constitute themselves separate administrative hospital establishments, most of the hospital units are now administratively grouped in hospital super-establishments designated "hospital centers". A next phase of hospital administration is being implemented, with the creation of comprehensive health mega-establishments designated "local health units". The ULS group not only the hospitals but also the health centers located in the same city or region, integrating the providing of both primary and secondary healthcare in a single administrative unit. Most of the public hospital establishments constitute State-owned enterprises. However, some public hospitals are managed by private entities as public-private partnerships.
In terms of service, the SNS hospitals, hospital centers and ULS are either classified as group I, II, III or IV :
- Group I are hospital establishments with an area of direct influence of 75 000 to 500 000 inhabitants, providing the medical and chirurgical valences of internal medicine, neurology, medical pediatrics, psychiatry, general surgery, orthopedics, anesthesiology, radiology, clinical pathology, hemotherapy and rehabilitation medicine. Group I hospitals can also provide some additional valences like ophthalmology and cardiology, but never provide the valences of medical genetics, allergology, pediatric cardiology, vascular surgery, neurosurgery, plastic surgery, cardiothoracic surgery, maxillofacial surgery, pediatric surgery and neuroradiology;
- Group II hospitals provide the group I valences in their own area of direct influence and also provide the medical and chirurgical valences of ophthalmology, pneumology, cardiology, rheumatology, gastroenterology, nephrology, clinical hematology, infectiology, medical oncology, neonatology, allergology, gynecology-obstetrics, dermatology-venereology, otorhinolaryngology, urology, vascular surgery, neurosurgery, pathological anatomy, nuclear medicine and neuroradiology in an indirect area of influence. Group II hospitals can also have additional valences, except those of clinical pharmacology, medical genetics, pediatric cardiology, cardiothoracic surgery and pediatric surgery;
- Group III are hospitals that provide all medical and chirurgical specialties in both direct and indirect areas of influence. The providing of some highly specialized valences like medical genetics, pediatric cardiology, cardiothoracic surgery and pediatric surgery is reserved to group III hospitals;
- Group IV hospitals are those specialized in the areas of oncology, rehabilitation medicine and psychiatry and mental health.
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| Region | Hospital establishment | Locations / units | Group |
| Alentejo | ULS do Norte Alentejo, EPE | Portalegre and Elvas | I |
| Alentejo | ULS do Baixo Alentejo, EPE | Beja and Serpa | I |
| Alentejo | ULS do Litoral Alentejano, EPE | Santiago do Cacém | I |
| Center | Centro Hospitalar Cova da Beira, EPE | Covilhã and Fundão | I |
| Center | Centro Hospitalar de Leiria, EPE | Leiria, Pombal and Alcobaça | I |
| Center | Centro Hospitalar do Baixo Vouga | Aveiro, Águeda and Estarreja | I |
| Center | Hospital Distrital da Figueira da Foz, EPE | Figueira da Foz | I |
| Center | ULS da Guarda | Guarda and Seia | I |
| Center | ULS de Castelo Branco | Castelo Branco | I |
| LVT | Centro Hospitalar Barreiro/Montijo, EPE | Barreiro and Montijo | I |
| LVT | Centro Hospitalar de Setúbal | Setúbal | I |
| LVT | Centro Hospitalar do Oeste | Caldas da Rainha, Torres Vedras and Peniche | I |
| LVT | Centro Hospitalar Médio Tejo | Abrantes, Torres Novas and Tomar | I |
| LVT | Hospital de Cascais, PPP | Cascais | |
| LVT | Hospital de Loures, PPP | Loures | I |
| LVT | Hospital de Vila Franca de Xira, PPP | Vila Franca de Xira | I |
| LVT | Hospital Distrital de Santarem, EPE | Santarém | I |
| LVT | Hospital Fernando da Fonseca, EPE | Amadora | I |
| North | Centro Hospitalar do Alto Ave, EPE | Guimarães and Fafe | I |
| North | Centro Hospitalar do Médio Ave, EPE | Santo Tirso and Vila Nova de Famalicão | I |
| North | Centro Hospitalar Entre Douro e Vouga, EPE | Santa Maria da Feira, São João da Madeira and Oliveira de Azemeis | I |
| North | Centro Hospitalar Póvoa do Varzim/Vila do Conde, EPE | Póvoa do Varzim and Vila do Conde | I |
| North | Centro Hospitalar Tâmega e Sousa, EPE | Penafiel and Amarante | I |
| North | Hospital Santa Maria Maior, EPE | Barcelos | I |
| North | ULS de Matosinhos, EPE | Matosinhos | I |
| North | ULS do Alto Minho, EPE | Viana do Castelo | I |
| North | ULS do Nordeste, EPE | Bragança, Macedo de Cavaleiros and Mirandela | I |
| Alentejo | Hospital do Espírito Santo, EPE | Évora | II |
| Algarve | Centro Hospitalar do Algarve, EPE | Faro, Lagos and Portimão | II |
| Center | Centro Hospitalar Tondela-Viseu, EPE | Tondela and Viseu | II |
| LVT | Centro Hospitalar de Lisboa Ocidental, EPE | Lisbon and Carnaxide | II |
| LVT | Hospital Garcia de Orta, EPE | Almada | II |
| North | Centro Hospitalar de Trás-os-Montes e Alto Douro, EPE | Peso da Régua, Vila Real, Chaves and Lamego | II |
| Algarve | Centro Hospitalar Vila Nova de Gaia / Espinho, EPE | Vila Nova de Gaia and Espinho | II |
| North | Hospital de Braga, EPE | Braga | II |
| Center | Centro Hospitalar e Universitário de Coimbra, EPE | Coimbra | III |
| LVT | Centro Hospitalar de Lisboa Central, EPE | Lisbon | III |
| LVT | Centro Hospitalar de Lisboa Norte, EPE | Lisbon | III |
| North | Centro Hospitalar de São João, EPE | Oporto and Valongo | III |
| Algarve | Centro Hospitalar do Porto, EPE | Oporto | III |
| Center | Instituto Português de Oncologia de Coimbra, Francisco Martins, EPE | Coimbra | IV-a |
| LVT | Instituto Português de Oncologia de Lisboa, Francisco Martins, EPE | Lisbon | IV-a |
| Center | Instituto Português de Oncologia do Porto, Francisco Martins, EPE | Oporto | IV-a |
| Algarve | Centro de Medicina Física de Reabilitação do Sul | São Brás de Alportel | IV-b |
| Center | Centro de Medicina Física de Reabilitação da Região Centro - Rovisco Pais | Cantanhede | IV-b |
| North | Centro de Medicina Física de Reabilitação do Norte | Valadares | IV-b |
| LVT | Centro Hospitalar Psiquiátrico de Lisboa | Lisbon | IV-c |
| North | Hospital de Magalhães Lemos, EPE | Oporto | IV-c |
| Azores | Unidade de Saúde de São Miguel | Ponta Delgada | N/A |
| Azores | Unidade de Saúde da Terceira | Angra do Heroísmo | N/A |
| Azores | Unidade de Saúde do Faial | Horta | N/A |
| Madeira | Hospital Central do Funchal | Funchal | N/A |
Social hospitals
The social hospitals, are those ones managed by private institutions of social solidarity, namely the traditional Portuguese misericórdias. These hospitals have agreements with the National Health Service, being public subsidized and providing healthcare to the users of that system in the same way as the public hospitals.Historically, the misericórdias were the main hospital care providers in Portugal, since their creation in the end of the 15th century to the nationalization of the management of their hospitals in the 1970s. Traditionally, the State only kept the direct administration of some public hospitals, located mainly in Lisbon, Coimbra and Oporto. The vast majority of the rest of the hospitals were owned and managed by the misericórdias, although under the administrative and technical supervision of the State and inserted in the public hospital network. In 1974, the administration of all central and district hospitals owned by the misericórdias was nationalized and transferred to the State direct management, although not their property. In 1975, the same disposition was applied to the local hospitals and later to other specialized hospitals owned by the misericórdias. The Basic Law of Health of 1990 and the National Health Service Statute of 1993 allowed the devolution to the misericórdias of the administration of the hospitals owned by them. However, only some cases of devolution occurred.
Presently, there are 12 hospitals of social nature under the administration of the misericórdias.
Private hospitals
Portugal has a number of private hospitals mainly focused in providing medical care to the health subsystems and private health insurance schemes beneficiaries.Many of these are part of hospital and clinic networks owned by private healthcare corporations, with some major players being the Luz Saúde, SA, the José de Mello Saúde, SA and the Lusíadas Saúde SGPS, SA.
Below is the list of some of the main private hospitals in Portugal:
| Hospital | Location | Owner / network |
| Hospital da Luz Torres de Lisboa | Lisbon | Luz Saúde, SA |
| Hospital da Cruz Vermelha Portuguesa | Lisbon | Portuguese Red Cross |
| Casa de Saúde - Clínica Infante Santo, Lda | Lisbon | |
| Casa de Saúde de Amares, Lda | Amares | |
| Casa de Saúde de São Mateus, Lda | Viseu | |
| Casa de Saúde do Barreiro | Barreiro | |
| Casa de Saúde do Senhor da Serra, Lda | Belas | |
| Centro de Genética Clínica Prof. Amândio Tavares, SA | Oporto | |
| Centro Hospitalar de São Francisco, SA | Leiria | SANFIL Medicina, SA |
| Clínica de Todos os Santos, Lda | Lisbon | |
| Clinigrande - Clínica da Marinha Grande, Lda | Marinha Grande | |
| Cliria - Hospital Privado de Aveiro, SA | Aveiro | Luz Saúde, SA |
| Cliria - Hospital Privado de Aveiro, SA | Aveiro | Luz Saúde, SA |
| CLISA - Clínica de Santo António, SA | Amadora | |
| HOPALIS - Hospital Particular de Lisboa, SA | Lisbon | |
| Hospital CUF Descobertas | Lisbon | José de Melo Saúde, SA |
| Hospital CUF Infante Santo | Lisbon | José de Mello Saúde, SA |
| Hospital CUF Porto | Oporto | José de Mello Saúde, SA |
| Hospital da Arrábida - Gaia, SA | Vila Nova de Gaia | Luz Saúde, SA |
| Hospital da Luz | Lisbon | Luz Saúde, SA |
| Hospital da Luz Guimarães | Guimarães | Luz Saúde, SA |
| Hospital da Misericórdia de Évora, SA | Évora | Luz Saúde, SA |
| Hospital da Ordem Terceira | Lisbon | Third Order of St. Francis |
| Hospital da Trofa | Trofa | Trofa Saúde SGPS, SA |
| Hospital de Saint Louis | Lisbon | Société Française de Bienfaisance en Portugal |
| Hospital de Santiago | Setúbal | Luz Saúde, SA |
| Hospital Particular de Viana do Castelo, Lda | Viana do Castelo | |
| Hospital Particular do Algarve, SA | Portimão | |
| Hospital Privado da Boa Nova | Perafita | Trofa Saúde SGPS, SA |
| Hospital Privado de Braga | Braga | Trofa Saúde SGPS, SA |
| Hospital Residencial do Mar | Bobadela | Luz Saúde, SA |
| Clipóvoa - Hospital Privado | Póvoa de Varzim | Luz Saúde, SA |
| HPA - Hospital Particular de Almada, Lda | Almada | |
| HPP Hospital da Boavista | Oporto | Lusíadas Saúde SGPS, SA |
| HPP Hospital de Santa Maria de Faro | Faro | Lusíadas Saúde SGPS, SA |
| HPP Hospital de São Gonçalo de Lagos | Lagos | Lusíadas Saúde SGPS, SA |
| HPP Hospital dos Lusíadas | Lisbon | Lusíadas Saúde SGPS, SA |
| Instituto CUF Diagnóstico e Tratamento | Senhora da Hora | José de Mello Saúde, SA |
| SANFIL - Casa de Saúde Santa Filomena, SA | Coimbra | SANFIL Medicina, SA |
| Hospital SAMS | Lisbon | Trade Union of the Bank Employees |
Other hospitals
- Hospital das Forças Armadas
- Hospital Real de Todos os Santos
- Hospitais Civis de Lisboa
- Santa Casa da Misericórdia
Health Cluster Portugal
In order to develop that potential, in 2008, several public and private organizations related with the health sector - including medical services providers, pharmaceutical industrial companies, universities and research and development entities - founded the Health Cluster Portugal. Its objective is to make Portugal a competitive player in the research, design, development, manufacture and marketing of products and associated health services in niche markets and selected technology, targeting the most demanding and most important international markets.
The strategy of the HCP focuses in the development of the following areas:
- Welfare and active ageing;
- Preventive medicine in the areas of neurodegenerative, cancer, cardiovascular, osteochondropathy, inflammatory, infective and metabolic diseases;
- Health tourism;
- eHealth.