Tiago Villanueva: Portugal’s health system in intensive care

Tiago_VillanuevaAusterity is already asphyxiating Portugal’s health system, and recent developments may soon put it in the intensive care unit. The current state of affairs is so serious that for the first time ever, Portugal’s two medical unions and the Portuguese Medical Association have joined forces to bring forward the first national industrial action supported by all three organisations. It is due to take place on 11 and 12 July. The most recent development, which drained all the patience out of doctors, unions, and medical organisations, was the government’s announcement that they are going to tender about 2.5 million hours worth of locum work hours in hospitals and primary health centres (corresponding to about 1700 doctors working full time) to medical recruitment companies, at the lowest cost. In other words, a significant part of Portugal’s medical workforce in the national health service will be outsourced.

In my view, Portuguese medical recruitment companies already operate in a different way than in the UK, since they’re mostly used to cover permanent needs rather than sporadic or temporary gaps in the system like sick leave or maternity leave. This is particularly true in primary healthcare and hospital emergency departments. But this announcement takes things to a whole new level. And many have interpreted this announcement as a suspicious sign of a progressive move towards the privatisation of Portugal’s national health system, which took decades to build, and which some years ago was considered by the World Health Organization as one of the best in the world. But what really outraged doctors here is that the sole adjudication criteria for companies was the lowest payment rate for doctors and nothing was said about the quality of the professionals to be hired.

At a time when there are hardly any permanent admissions to the public administration system, when the medical careers system is practically frozen (and thus career progression), and when many doctors who have just completed their specialist training remain on the same salary as trainees despite having additional responsibilities, the prospects and stimulus for career development seem to be at an all time low. It may prove very difficult to train future generations of specialists without a stable workforce of specialists, since under this system doctors would have no job stability and could be easily exchanged. Moreover, it is likely that doctor’s hourly rates would drop towards dangerously low figures. For nurses, this is already the case. Dozens of nurses working in primary health centres finished their contracts last week, and for contract renewal purposes, a rate of 3.96 euros per hour was offered to them this week. After taxes and social security this equals about 300 euros per month, which, if not below, is not too far from the poverty line in Portugal. This has shocked the whole nation, who could not believe that many nurses were being paid less than housekeepers, who on average earn around 5 to 6 euros per hour.

I know cases of administrative staff in health centres who preferred to become unemployed rather than accept similar rates in order to get their contract renewed, since their unemployment subsidy is superior to their wage.

Following the announcement of the strike, the health ministry has said recently that it is considering revising the conditions of the tender, but that may not be enough to call off the strike, as doctors currently have very little trust in the ministry. If the situation is not reversed, future generations of doctors face a very difficult future. The number of slots in medical schools have increased significantly and new medical schools have been opened in the last 10 years, but there is a limited postgraduate training capacity. In other words, not every newly qualified doctor will be able to secure a specialty training post, and may have to contend with unstable and low paid work.

Due to the generalised public perception of doctors as “fat cats,” the strike may not end up earning the general public’s widespread support, but if it goes forward, it will be a historical moment for Portuguese doctors, for several reasons. One of the reasons is that it may unite doctors towards a common end once and for all. Above all for the sake of patients, I sincerely hope so.

Tiago Villanueva is a locum GP based in Portugal, and former BMJ Clegg Scholar and editor, StudentBMJ.