State and Health (1900-2013). Political Stability, Resources and Welfare

State and Health (1900-2013). Political Stability, Resources and Welfare Mónica Brito, Teresa Rodrigues, Carla Leão Introduction Throughout the twentieth century, Portugal has undergone major social, political, cultural and economic changes, and the same happened in matters of healthcare provision. But the most relevant changes in the way Portuguese governors perceived the need and urgency of a real and as effective health policy were an achievement of the mid 70 s. Swiftly Portugal progressed from a narrow understanding of healthcare provision still linked to charitable assistance to a universal approach, based on prevention and conscious of other needs, such as the provision of continued care. In the first decades of last century, the appearance of Ministries of Health throughout Europe was a sign of a full awareness assigned by the central governments about the importance of population s collective health. But in Portugal the first Ministry of Health was only created in 1958. In fact, it is inappropriate to speak of a national health policy before the second half of the twentieth century 1. As mentioned, public health policies do not surpass sixty to eighty years in terms of concerted decision-making. But their understanding implies a retreat in time. In this article we will take the period 1900-2013 as a chronological reference. In methodological terms we adopted a descriptive and chronological approach, based on the available Portuguese studies on the topic. The literature review allow us to identify the main characteristics and particular constraints of the various reforms in the sector of health and assistance. In addition, we also considered the legislative body on the subject, highlighting the main options they obviously reflect. Even if the approval of a given legislation does not necessarily meant a real achievement of its purposes, it is nevertheless the 1 António Correia Campos and Jorge Simões, O percurso da saúde: Portugal na Europa (Coimbra, 2011), p.65. 1

expression of informed choices and perceptions about the most suitable health policy in a given historical moment. Their analysis allows to track how policy options on public health evolved in Portugal. The text is divided into two main parts. The first attempts to systematise the main stages of the Portuguese health policies in the twentieth century, and analyses its stronger lines, highlighting the relationship between political stability, resources and Welfare State. The second summarises the milestones of health policy decisions and describes each of them. It starts in 1910, with the establishment of the Republic, goes through the Military Dictatorship and the Estado Novo 2, gives a larger description of changes occurred after the democratic regime and the origins of the Welfare State, and finishes in 2013. Actors and Temporalities Portugal registered considerable changes in the way the sectors of healthcare and protection in illness have been perceived in the past centuries. Having considered the legislation of the sector between 1910 and 2013, we realise that health policies have faced several constraints attached to the State s importance as an actor in the different political, economic and social contexts that characterise the contemporary Portuguese history. As in most European countries, the provision of healthcare and welfare had its genesis in religious and corporate initiative. Only progressively local stakeholders and the central government have regarded these issues as worthy of a legislative framework and permanent intervention. From the Middle Age until the eighteenth century the Misericórdias 3 were the most relevant institutions for the treatment of those affected by disease, particularly the economically most vulnerable. The prominent role they played was a consequence of their closeness toward population, and their regular allocation throughout the country. These two characteristics made them the visible face of population support in illness situations. The evolution of the Portuguese indicators on health, illness and mortality reflects the impact of political decisions concerning public hygiene and the sanitary control system. The importance given to health and assistance issues by the central government influenced the levels of morbidity and mortality since 2 New State in Portuguese. It corresponds to the political dictatorship that ruled the country between 1932 and 1974. 3 Institutions created in the late fifteenth century in major urban centres and later also in smaller towns and in the Portuguese African colonies. Their human profile and efficiency assured them a high prestige and a major role as providers of care assistance and solidarity. Currently, they remain active in Portugal, with strong ties to the State, despite its financial autonomy. 2

the beginning of last century. In 1901 one of the most relevant Reforms took place, aiming to reorganise public health and regulate public charity. It built the basis of Portuguese public health, inspired by the English model, recognised at that time as the most relevant model of hygiene and medical organisation 4. But until the mid-twentieth century, the deliberations adopted in the sphere of healthcare kept an ad hoc character and was mostly concerned with effective responses to specific episodes 5. Decision making on matters of health and disease were mostly materialised as a response to situations of national emergency, such as epidemic outbreaks or other humanitarian catastrophes. In Portugal, the decision-making on healthcare policies faced different constraints, which influenced the way the promotion of health services was seen and executed. Although others actors were involved (such as religious and private charity institutions), the State played the key role, decisively influencing both the articulation of providers, and the breadth and quality of services. The legislation enacted throughout the last hundred years reflects its influence, and shows the central government main options in a median and long-term perspective. In this sense, when projecting the evolution of health policies in Portugal in the twentieth century we must consider the State, its configuration and its resources, as a key element. We identified six historical periods in what concerns this issue (Table 1). The State role differs in each of those conjunctures, according to three factors or exogenous conditions: 1. the level of political stability. 2. the existence of public financial resources. 3. the shape of the welfare state. By political stability we mean the existence of the necessary governance conditions for the design and implementation of public policies. The existence of public financial resources refers to the financial capacity of the state to promote public policies that it considers as priorities. State intervention concerns the role it assumes in its relation with economy and society, largely reflecting the model adopted for the provision of public policies. Indeed, if on the one hand, the political stability and the existence of financial resources are important 4 Jorge Simões, Retrato Político da Saúde. Dependência do Percurso e Inovação em Saúde (Coimbra, 2009), p.26; Ministério da Saúde, História do Serviço Nacional de Saúde, Portal da Saúde. Retrieved from: <http://www.minsaude.pt/portal/conteudos/a%2bsaude%2bem%2b portugal/servico%2bnacional%2bde%2bsaude/historia%2bdo%2bsns/historiadosns.htm> [Accessed on 23 July 2014]. 5 Teresa Ferreira Rodrigues, As estruturas populacionais, in José Mattoso, ed., História de Portugal (Lisboa, 1993), p. 127. 3

conditions in the definition of a health policy, on the other, setting the role of the state determines the healthcare model. Table 1. Health Policy in Portugal. Attempted periodization (1910-2013). Year Substantial Public financial Political stability intervention of resources State 1910-1926 NO NO YES 1926-1933 NO NO NO 1933-1971 YES YES NO 1971-1995 YES YES YES 1995-2011 NO YES NO 2011-2013 NO YES NO Source: Author s elaboration. Health as a Major Priority The first phase corresponds in political terms to a historical period called the First Republic (1910-1926) and can be described as moment of real concern with health issues and the desire to provide the State with mechanisms for effective intervention. Although the role of the central government was not consensual, the assurance of population s health had been taken as a symbol of the regime. However that permanent aspiration was impossible to assure. This failure is mainly explained by political instability, and by the constant shortage of public funds, essential to meet many of the Republican promises. The First Republic considered collective health a right of all citizens, which governments were obliged to provide. The 1911 Constitution enshrines in its text the right to public welfare. However, as had happened in the past, health continued to be understood as welfare, i.e., as the provision of basic medical and healthcare services to economically disadvantaged groups. In fact, the separation concerning health and welfare reflects the difference assumed by stakeholders in this sector, which made a clear distinction between the right of all the Portuguese to public hygienic conditions and the assumption of a duty to aid and care to the poorest ones. The Republican Revolution of 5 October 1910 generated justifiable expectations on health sector reform. The reformist rhetoric of the Republican 4

Party while in opposition, the national and international expansion of the hygienist movement, and the advances in medical knowledge and experimental medicine, suggested that the new political regime would have the will and the capacity to develop and implement a coherent and effective health policy. In its political program, the government promised a fraternal society and a healthy lifestyle for all citizens. So, it elected as one of its main objectives the implementation of the reform held in 1901 by Ricardo Jorge, which represented a significant progress in health care organisation, inspired by the English model 6. In terms of Welfare, the nature of the State intervention was limited, confined to the standardization and control of medical care which would be provided at the municipal level, extending to the entire country the experience of primary healthcare. The reformist impetus of the First Republic was mitigated by the unfavourable economic and financial environment. Still, some positive reforms took place in terms of medical formation, public health and mandatory vaccination in the African colonies, and public health, particularly in the sectors of water supply, sanitation, housing conditions and food quality control. In May 1919 the organisation of health services in the colonies was harmonised, and on the same day was created a mandatory social insurance for sickness, invalidity, old age and survival 7. Those diplomas reflected a change in the concept of public health and demonstrated an increasing willingness to expand population s access to health and strengthen the State s role 8. These achievements were highlighted in the official discourse, which regularly assumed Public Welfare as the greatest Republican achievement. Indeed, the relationship between State and citizens was changing, endowing the latter with some rights that the first should promote 9. Thus, taking the first steps towards the creation of the future Welfare State. Some authors consider that Portugal was then a liberal Welfare State, with a modest social security based on the inspection of means and aimed at the working classes 10. 6 Jorge Fernandes Alves, Saúde e Fraternidade A saúde na I República, in Maria Rita Lino Garnel, ed., Corpo: Estado, medicina e sociedade no tempo da I República (Lisboa, 2010); Jorge Simões, Retrato Político da Saúde. Dependência do Percurso e Inovação em Saúde (Coimbra, 2009), p.26. 7 Teresa Rodrigues and Carla Leão, Health in Portugal: actors and temporalities, in Teresa Ferreira Rodrigues and Maria do Rosário Oliveira Martins, eds., Portugal 2031. Ageing and Health Policies, from demographic changes to political options (Lisboa, 2014, forthcoming). 8 Maria Rita Lino Garnel, Médicos e saúde pública no Parlamento republicano, in Pedro Tavares Almeida and Fernando Catroga, eds., Res Publica: cidadania e representação política em Portugal (Lisboa, 2010). 9 Ibid. 10 Miriam Halpern Pereira, As origens do Estado Providência em Portugal: as novas fronteiras entre público e privado, Ler História, 37 (1999), p. 61. 5

Health or Security. Between a choice The period 1926-1933 corresponds to the Military Dictatorship, a complex period characterized by the previous financial difficulties, and political instability. The design and implementation of a coherent and sustainable policy in the sector was no longer possible, due to disputes within the regime and its transience. The few available resources were directed to the maintenance of order and ensuring healthcare was one of the less important priorities of the military governors 11. A few months after the military rebellion of 28 May 1926 and the rise of a military dictatorship, the diagnosis made on the evolution of public health and hygiene was very pessimistic, and considered that Portugal faced a situation of considerable delay, detrimental to the life and health of citizens, vexing to the national pride 12. A new law on public health services was published in 1926. The reorganisation of health services proceeded, favourable to a greater autonomy of local medical authorities. National government created then the called Municipal Boards of Hygiene, designated Sub-inspectors of Health, and sanitary brigades with the mission of addressing possible disease outbreaks. However, this reform did not have the desired effect since the priorities of the new regime soon focused on the control of public finances 13. Health and Assistance. The Poor and the Wealthy A new chapter begins with the implementation of the dictatorial regime known as Estado Novo (1933). During a long period which lasted until 1971 political stability was ensured, in spite of significant cyclical variations in what concerns health issues. A conception grounded on a subsidiary intervention of the central government in economic and social affairs prevailed in those decades. Although it withdrew State s initiative, it did not decrease its role in the implementation of specific measures, some of which related to healthcare, part f which due to the enlargement of public funding 14. With Salazar s rise to power and the implementation of the Estado Novo, the political and doctrinal stability conditions were gathered to improve healthcare services. In this matter the propaganda of the new regime was particularly 11 Fernando Rosas, O Estado Novo (Lisboa, 1994). 12 Decreto 12477 of 12 October 1926 13 Ibid. 14 Ibid. 6

adverse to First Republic health policy, which was considered too centralized. Salazar s 15 position on this issue was very clear and Misericórdias regained their condition of leading responsible for charitable welfare on the basis of ethical criteria. Estado Novo was the golden age of private and religious welfare institutions 16. A corporative model of society prevailed, based in an up-to-bottom system of representation of professional interests controlled by the State, which sustained a corporative vision of welfare based on legislation approved in 1933 17. The model predicted solidarity within each corporation and the upgrading of private public charitable initiatives that the State should regulate, promote and support but only in a subsidiary way 18. The assignment of the 1940 Concordat between the Portuguese government and the Catholic Church gave to the clerical institution a relevant role in internal affairs and reveals the deliberate choice to integrate the Church in the welfare system, in opposition to the values assumed by the First Republic. The 1933 Constitution sustained in its art. 40 and 41 the right and obligation of the State to preserve morality, nutrition, and health of its citizens, and to promote and encourage charity, welfare, cooperation and mutual aid. The document did not include any direct reference to public welfare and health, but advocated the need for charitable welfare, which should remain essentially private. Charity prevailed as a traditional form of aid to those who were in a precarious situation, and the State continued to have just a supplementary intervention and a supervisory assignment on those institutions. Following this general policy, the basis for the legal regime of Social Security was established. The 1998 Act of 15 May 1944 reaffirmed the supplementary nature of the State s action, and defended a gradual disestablishing of institutions and charity work from it. The Act maintained the central role of the Misericórdias in healthcare provision. These measures were the peak of the charitable-corporatist model 19, very ideologically marked. Meanwhile, the Welfare State reached European democracies. Within an internal context of temporary freedom due to the elections of 1945 a new reform on national health takes place (Law Decreto Lei 35108 of 7 November 1945). In 15 António de Oliveira Salazar served as Prime Minister of Portugal from 1932 to 1968. He founded and led the Estado Novo (New State). 16 Rui Manuel Pinto Costa, O poder médico no Estado Novo (1945-1974) (Porto, 2009), p.77; António Correia Campos, Sau de: o custo de um valor sem prec o (Lisboa, 1983), p.26. 17 Philippe C. Schmitter, Portugal: do Autoritarismo à Democracia (Lisboa, 1999). 18 Rui Manuel Pinto Costa, O poder médico no Estado Novo (1945-1974) (Porto, 2009), p.76. 19 António Correia Campos, Sau de: o custo de um valor sem prec o (Lisboa, 1983), p.25. 7

theory it recognised the weaknesses of individual and corporative welfare and advocated larger obligations from the government towards its citizens. The creation of the Federation of Social Security Funds (Caixas de Previdência), allowed the gradual extension of socio-medical services to all the Portuguese. The State authorised the foundation of several independent health subsystems according to professional activities. This system continued to exclude a large percentage of the population and created differences among the beneficiaries, since each Caixa had different services. Thus, the Portuguese had no health service, but various health services, which increased social inequalities 20. In 1958 Salazar condescended with public opinion and a Ministry of Health was created; but this fact had no relevant practical consequences. Nevertheless, the creation of the Ministry witnesses a re-evaluation of the health sector and demonstrates a slight change in the design and practice of welfare in Portugal 21. The 60s were a period of economic growth based on the industrialisation and controlled economic liberalisation allowed by the European Free Trade Association (EFTA). In 1961 the Colonial War started and social tension rise, partially as a result of greater information on the living conditions in other European countries, namely in the context of social security systems 22. Still, the creation and development of health subsystems remains the official policy of the regime and in 1963 the Social Welfare for the Public Servants of the State is founded. The State kept practically unchanged the basic principles of its welfare policy, but other improvement were outlined. One of the most significant was the Law on Health Policy and Welfare, which recasts the 1944 Basic Law, essentially by removing the charitable character of welfare and starting a movement of centralisation of health services. Thus, barriers to the development of a consistent health policy continued to exist. The health coverage of the country progressed slowly, combining the action of private institutions with the State s activity, although this last one was expanding its participation to other sectors, such as hospitals, maternal and child care, preventive policies) 23. 20 Rui Manuel Pinto Costa, O poder médico no Estado Novo (1945-1974) (Porto, 2009), p.89; Arnaldo Sampaio, Evolução da política de saúde em Portugal depois da Guerra de 1939-45 e suas consequências. Arquivos do Instituto Nacional de Saúde (Lisboa, 1981), p.27. 21 Carlos Farinha dos Santos, Assistência social pp. 13-74 in Fernando Rosas and José Maria Brandão Brito, eds., Dicionário da História do Estado Novo (Lisboa, 1996). 22 Rui Manuel Pinto Costa, O poder médico no Estado Novo (1945-1974) (Porto, 2009), p.97. 23 Octávio Gonçalves Lopes, Planeamento em saúde, para a história da evolução das estruturas de saúde em Portugal, Revista Crítica de Ciências Sociais, 23 (1987), p. 360. 8

In the middle of the 60s the Ministry of Health gained financial autonomy. This political decision involves a new perception about the importance given to collective health issues and the desire to ensure a growing state intervention. This change was due to the increase in public administration of young technocrat staff with international experience 24. Portuguese reality was changing. Seizing the window of opportunity allowed by the rise to power of Marcello Caetano 25, critics to the medical profession arose. In 1969, Miller Guerra claimed the urgency of creation and enhancement of the health professional careers, the establishment of sub-regional Hospitals or Health Centres, the unification of medical health and social action, the growth of qualified medical other technical staff and also the creation of a Ministry that would join Healthcare and Welfare and improve the coordination of national healthcare policies 26. Health and Democracy. The Welfare State Since the Reform of 1971 until 1995 a different phase takes place. In the final stretch of the Estado Novo and especially since the establishment of democracy, the State assumed a dominant role in the definition and implementation of health policy. Thus developing a network of primary and hospital care, which from 1979 onwards will embody the National Health Service (SNS). It was a period of favourable economic conjuncture mainly associated with the integration in the European project, and also of political stability (despite the 1974 revolution and the following regime transition between 1974 and 1976). Economy and political order provided structural conditions for the consolidation of the welfare state 27. Despite the improvements achieved in the past years, at the beginning of the 70s the balance was just slightly positive. One of the major problems remained the scarce state s role, and the fact that private health institutions were much 24 António Reis, Portugal Contemporâneo (Lisboa, 1996). 25 Marcello José das Neves Alves Caetano was the last prime minister of the Estado Novo regime, from 1968 until his overthrow in the Carnation Revolution of 1974. He contributed to less rigid policies in social and health terms. 26 Miller Guerra, Saúde, educação e ciência. Três notas programáticas, Brotéria, 89: 12 (1969). 27 António Barreto, Portugal na periferia do centro: mudança social, 1960 a 1995, Análise Social, 30: 134 (1995); Ana Guillén, Santiago Álvarez and Pedro Adão e Silva Redesigning the Spanish and Portuguese Welfare States: The Impact of Accession into the European Union, South European Society and Politics, 8 (2003), 57-89; José António Pereirinha and Francisco Nunes, Política social em Portugal e a Europa, 20 anos depois, in António Romão, ed., A Economia portuguesa - 20 anos após a adesão (Coimbra, 2006). 9

more than state-owned ones. Another problems relayed on the various health subsystems, and the inefficient management of the existing resources, which generated social inequalities 28. A new reform was attempted in 1971 29. It aimed to assure scientific and technical improvement, effective planning, unification and multidisciplinary in the design and implementation of the Health policy. It also wished to assure healthcare to all Portuguese guaranteed by the State, innovating in the intentions of its coverage and how they should be rendered 30. This reform was a turning point, as it attributed to the State the responsibility of coordinating a health policy centralised in its conception but decentralised in the provision of services, in order to reach with similar quality and easiness all the population. The government invested in prevention and proximity. The 1971 Reform was extremely advanced for its time, especially if we take into account the national context. It anticipated the creation of a National Healthcare System and the guidelines of the 1978 International Conference of Alma-Ata. But, as expected, it does not definitively disrupt the role of private entities providing health services, in particular on what refers to the coordination between Health Centres and public and private services dispersed across the country. Although this Reform ensured a certain standardisation of the health policy in Portugal, only in 1984 it was possible to assimilate the Medical Social Welfare Services into a single healthcare system. Even so, until 1973 the role of the State in the provision of health services was accelerated by several reasons. The international conjuncture sustained the accountability of governments for ensuring to all residents access to primary care. Internally, the government was pressured by public complaints about the still high mortality and morbidity levels. In 1973 the Ministry of Health and Welfare was split, and Health became an autonomous Ministry. Nevertheless, the political conditions prevented the full realisation of the 1971 Reform objectives 31. The Revolution of 25 April 1974 provided a break with the recent past and the political impediments which previously barred the extension of universal healthcare. The Programme of the First Provisional Government declares the 28 Arnaldo Sampaio, Discurso proferido pelo Dr. Arnaldo Sampaio no acto de posse como Director-geral de Saúde, O Médico, 54: 1098 (1972), p.518. 29 Law Decree 413/71 of 27 September 30 Pedro Morais Barbosa, Política Nacional de Saúde. Arquivos do Instituto Nacional de Saúde (Lisboa, 1972), p.79; Arnaldo Sampaio, Evolução da política de saúde em Portugal depois da Guerra de 1939-45 e suas consequências. Arquivos do Instituto Nacional de Saúde (Lisboa, 1981), p.27. 31 Arnaldo Sampaio, Evolução da política de saúde em Portugal depois da Guerra de 1939-45 e suas consequências. Arquivos do Instituto Nacional de Saúde (Lisboa, 1981), p.34. 10

purpose to create a national health system and gathered in the Ministry of Social Affairs both health and social security. This decision, only apparently contradictory, wanted to promote the effective integration of medical and social services under the welfare state. In addition, decentralisation was attempted. The Portuguese Constitution of 1976 declares in its art.64 that Health is a universal right that should be carried out through the creation of a national system of universal, comprehensive and free care. So, the State should ensure universal access to healthcare and medical and hospital coverage nationwide. The constitutional consecration of the right to health acquires reinforced legality, imposing itself as a constitutional obligation. But it also conquers political relevance because it results from the fundamental basis of the Portuguese democracy, extended to several parties and socio-political trends. Indeed, political democratisation had become inseparable from social democratisation 32. Portugal recovers the needed political stability to build a real national health system 33. The Order of 29 July 1978 34 anticipates the National Health Service, guaranteeing to all citizens access to medical and social services regardless of their ability to pay. In 1979 the National Health Service (SNS) was established 35. Different models could have been adopted to frame the Portuguese National Health Service, but underlying its creation was the political option to ensure a universal and free SNS, where the State assumed a leading role contrary to the private sector. Broadening the coverage of services to the entire population had a positive impact on health indicators in the post-25 April 36. It was a slow process and not always linear, implying a strong public investment, in terms of staff, infrastructures and services. Although there were some variations in the priority given to health and the development of the SNS throughout the 80s, including some public 32 Ana Guillén, Santiago Álvarez and Pedro Adão e Silva Redesigning the Spanish and Portuguese Welfare States: The Impact of Accession into the European Union, South European Society and Politics, 8 (2003), 57-89. 33 Carlos Farinha dos Santos, Assistência social pp. 13-74 in Fernando Rosas and José Maria Brandão Brito, eds., Dicionário da História do Estado Novo (Lisboa, 1996). 2009). 34 António Arnaut, Serviço Nacional de Saúde (SNS). 30 Anos de Resistência (Coimbra, 35 Law 56/79 of 15 September 36 António Correia Campos, Sau de: o custo de um valor sem prec o (Lisboa, 1983), p.26; Jorge Simões, Retrato Político da Saúde. Dependência do Percurso e Inovação em Saúde (Coimbra, 2009); Paula Santana, Os ganhos em Saúde e no acesso aos serviços de Saúde: avaliação das últimas três décadas pp.57-69 in Jorge Simões, ed., Trinta anos do Serviço Nacional de Saúde. Um percurso comentado (Coimbra, 2010). 11

disinvestment between 1980 and 1983 37, measures were taken to deepen the universality of healthcare provided by the State. They focused on autonomy, formation and service s decentralization. In 1983 the Ministry of Health comes back into existence and the sector acquires a new organic relevance. Two operational aspects regarded as fundamental were strengthened, the preventive feature of health policy and the drugs regulation. The first due to the fact that our country [was] in an advanced stage of transition characterised by the dominance of infectious diseases to the prevalence of the so-called diseases of civilisation, to which primary care should respond accordingly 38. The second aimed to regulate the quality and prices of the prescript medicines. In the mid-80s the economic and financial conditions of the country improve, following its entrance in the European Economic Community (EEC). Meanwhile, arises an international vision of health sustaining the need of a deeper involvement of the private sector, and calling for a larger individual responsibility in the financing and transformation of the SNS 39. In the following years several measures to ensure the financial sustainability of the system were sanctioned, such as the introduction of user fees, and others which aimed at changing hospital management, converging with the logic of business management. The constitutional revision of 1989 changed the legal framework, assuming that healthcare should change from free to tendentiously free, although safeguarding the economic and social conditions of each citizen. Following these amendments, the SNS regulation changed in order to: ensure the regionalisation of government services; promote the development of the private health sector; ensure business management of public health units; encourage citizens to opt for private health insurances 40. The new legislative frame had also the ambitious goal of promoting the integration of primary and hospital care through health facilities, invoking the principle of indivisibility. In 1993, the Ministry of Health was reorganised, in order to regionalise health policy decision, by allocating powers and reinforcing assignments to five regional entities designated Regional Health Authority. These ones would assure the link between local Health Centres and Central Hospitals, through the creation of the Integrated Healthcare Units. 37 Jorge Simões and Óscar Domingos Lourenço, As políticas públicas de Saúde nos últimos 25 anos, in Livro de Homenagem a Augusto Mantas (APES, 2006), p.78. 38 Preamble of the Law Decree 74-C/84 of 2 March 39 Jorge Simões, Retrato Político da Saúde. Dependência do Percurso e Inovação em Saúde (Coimbra, 2009), p.98. 40 Ibid. 12

A Time of Difficult Options A new stage begins in 1995, characterised by political stability and by a tendency of State s disengagement in health. It was a time of containment, as in many other European countries. This phenomenon was also attended by the upgrading of social systems to changing realities, such as the demographic ageing phenomenon and falling of economic growth, and focused on three main topics: re-commercialization, cost reduction and re-calibration 41. Portugal was no exception to this trend, and in the second half of the 90s began a process of adjustment 42, worsened by the lack of maturation of its Welfare State. Thus the adjustment to new realities gradually became more difficult and inevitable 43. It was a period of major legislative profusion in the field of health, some of which are still in force. Multiple structures were created and new regimes were tested. From the political and social consensus on the urgent need to strengthen the SNS and to rationalise its management, the measures adopted aimed at making such rationalisation without jeopardising the principles of the system 44. Thus, measures to create a contractual model between payers and providers, to modernise public health administration and reform the salaries of professionals according to their performance were adopted. In 1999, the SNS was restructured to include regional and local levels of territorial activity. At the regional level, to Health Centres were assigned the functions of planning, coordination and definition of strategies for technical assistance. At the local level, and endowed with a flexible organisation, the Portuguese people could count with the Public Health Units of Local Health Systems and the Operative Units of Public Health of the Health Centres. The turn of the century corresponded to new legislative acts, which proposed, among other things, permanent and exclusive contracts for physicians, the enlargement of the number of professionals, the regulation of pharmacy and medicines, the establishment of public-public partnerships (based on public 41 Paul Pierson, Coping with permanent austerity, in Paul Pierson, ed., The new politics of the Welfare (OUP, 2006), p.25. 42 António Barreto, Mudança social em Portugal, 1960-2000 pp.46-78 in António Costa Pinto, ed., Portugal contemporâneo (Lisboa, 2005). 43 Paul Pierson, Coping with permanent austerity, in Paul Pierson, ed., The new politics of the Welfare (OUP, 2006); Fernanda Rodrigues, Assistência social: uma política reticente em tempo de globalização, in Pedro Hespanha and Graça Carapinheiro, eds., Risco social e incerteza: pode o Estado recuar mais? (Porto, 2002); Pedro Adão e Silva, O Modelo de Welfare da Europa do Sul Reflexões sobre a utilidade do conceito, Sociologia, Problemas e Práticas, 38 (2002), 76-96. 44 Pedro Pita Barros, As políticas de Saúde em Portugal nos últimos 25 anos: evolução da prestação na década 1987 1996 (Lisboa, 1999). 13

sector partners), public-private partnerships (combining public financing with private capital), and partnerships within the social sector 45. With the new political cycle (Social Democracy) the spirit of the national health system changed. Portugal moves from a model primarily funded in SNS to another one, where coexist both public and private initiatives. This change in the design of the national health system implies relevant discontinuities 46, and changed the philosophy on the provision of primary care. The creation of a Continuing Care Network was envisaged, comprising public, private and social entities, thus fulfilling the growing need of assuring healthcare and maintain the quality of life, welfare and comfort of needy citizens. This issue has gained particular prominence due to the ageing population and the social-familiar changes. The network was rebuilt in 2006 under the name of National Network of Integrated Continued Care, taking advantage of EU funds to finance its execution, and to include palliative care. The need to adapt the services to the rapidly changing demographic structure had already influenced the design of various plans that guided health policy in this period, namely the 2004-2010 National Health Plan, the National Programme for the Health of Elderly People and the National Palliative Care Programme 47. In 2005, after the Socialist Party returned to power, a wave of transfers of Hospital-companies to the state s business sector took place. However this innovation in the public control of the hospitals did not reverse the previous trend of health corporatization, although it incorporated the purpose of concentrating hospital units. The goal of the Government was to enable economies of scale, productive specialisation, quality, and executive autonomy 48. This principle of concentration was also applied to Health Centres. In 2006 a Normative Order regulated and established the Family Health Units (USF), described as basic organisational cells to provide individual and family healthcare, consisting of a multidisciplinary team with organisational, functional and technical autonomy, integrated in a network with other functional units of the health centre. Continuing the legislative production which aimed to ensure seniors quality of life, Normative Order 30/2006 of March 31 instituted the rules for the implementation of establishments corresponding to nursing homes, i.e. structures built with similar objectives to those of nursing homes, yet different, in what regards its capacity, scope and organisation model and profit. 45 Resolution of the Council of Ministers 162/2001, of 16 November 46 Pedro Pita Barros, Análises da saúde (Lisboa, 2007), p.115. 47 Suzete Gonçalves, Cuidados Continuados Integrados pp.23-47 in Jorge Simões, ed., Trinta anos do Serviço Nacional De Saúde. Um Percurso Comentado (Coimbra, 2011). 48 António Correia Campos, Reformas da saúde: o fio condutor (Coimbra, 2008), p.42. 14

In the same year the Ministry of Health was reorganised, and introduced a new organisational model based on structures rationalisation, the strengthening and homogenisation of strategic and support functions to governance, the closeness of citizens and the devolution of powers to the local or regional level 49. The Central Administration of the Health System was founded to ensure integrated management of the SNS resources. The issue was to dissolve, merge, restructure government services and rationalise human resources. Some of its measures led to the extinction of health centres extensions and to the fusion of hospitals and health centres. In 2007 and 2008 additional attempts of hospital and health centres union took place, justified by the need to consolidate a flexible organisation, following the recommendations of the European Union. The emergency units were reorganised and structured groups of health centres. Measures to solve other immediate problems were also taken in 2008, to solve the problem of long waiting lists for surgery, and improve quality of services. The Lisbon Treaty (2007) highlights in Title XIV, Art. 168 the importance of health for the EU. Along with the International Health Regulations (2005) they were the basis for change in national decision making, namely to the National Institute of Medical Emergency, the definition of the emergency network and hospital emergencies, the definition and improvement of surveillance, alert and response mechanisms, the increase in primary care. In 2009 a restructuring of health services takes place, aiming to establish better operational services, a technical and flexible organisational model, and ensure a swift and effective protection of collective health 50. The operation of the services would go through two levels of activity: regional, functioning as a structure of surveillance and health monitoring, in a comprehensive perspective of epidemiologic surveillance, health planning and formulation of regional strategies; and local, acting as a structure for surveillance and monitoring. In June, the National Strategy for Quality in Healthcare was published. But in 2009, investment in health tended to be non-existent, except with regard to the expansion of the National Network of Integrated Continued Care, particularly those provided under the 2007-2016 National Mental Health Plan and the improvement of primary care. The same reform created the Shared Services of the Ministry of Health, EPE, to manage the provision of services, avoiding duplication in support activities and the multiplication of costs. The economic crisis experienced since 2008 instructs decision-makers to reduce and contain costs. The government required to all services to draw up a plan to reduce expenditure for 2010, except the support to the elderly. Still, the 49 Law Decree 212/2006 of 27 October 50 Law Decree 81/2009 of 2 April 15

situation became untenable, due to the unsettled political situation that led to a new governmental change. In late 2010 all health professions had their courses with the Bachelor level and adequate to the Bologna Process, with the possibility to follow for Masters and PhD and competencies of excellence detained, impressing high quality standards in the provision of health care. The assessment made by the World Health Organisation on the implementation of the 2004-2010 National Health Plan was positive in most factors, but warned to the need to achieve the goals set out in the 2011-2016 National Health Plan in respect to equity in access to healthcare and the quality of services 51. Crisis, Restructuring, Sustainability and Reductions In May 2011 Portugal lost some autonomy, bound to the achievement of goals set by external institutions. Decisions of restrictive character predominate in health sector, although less pronounced in primary and in continuing and palliative care. A deep restructuring of departments and agencies within the National Health Service and the Ministry of Health takes place. The number of health facilities and human resources is reduced and mega health units are created by merging/grouping health centres and hospitals. There is an increase in healthcare costs for users. This phase is represented by the use of the words and expressions Crisis, Restructuring, Sustainability of the National Health Service and reductions. It is also a period of State s disinvestment in health and of civil society dissatisfaction. The restructuring of health facilities continued, the recruitment of health professionals diminished, although preventing the possibility of hiring specialists in general and family medicine that should work 42 hours week (7 more hours than before). This situation is replicated to all healthcare professionals and all services. The prescription of Complementary Diagnostic Tests and Therapy in hospitals became more difficult. In what concerns primary care, the design of health local support changed, reducing the number of Clusters of Health Centres and abolishing the rule that limited at a maximum of 200 000 users the number of users in each Cluster and allowing to incorporate larger areas of territory, essentially in inland areas with lower population density 51 Ministério da Saúde, História do Serviço Nacional de Saúde, Portal da Saúde. Retrieved from: <http://www.min-saude.pt/portal/conteudos/a%2bsaude%2bem%2b portugal/servico%2bnacional%2bde%2bsaude/historia%2bdo%2bsns/historiadosns.htm> [Accessed in 23 July 2014]. 16

increasing the relative distance to the health services and decreasing the users accessibility. State budgets approved for 2012 and 2013 show widespread contention in what concerns remuneration, career progression, reduction of workers, reaching human resources and health expenditure. Still, in what concerns the sector of health, the elderly benefited from some measures, such as residential facilities or medicine prescription prices (adoption of generics), non-emergency transport of patients, and home care services. In May 2013 was published the final version of the new 2012-2016 National Health Plan 52, aiming to be the foundation for the health system of the 21 st Century. It applies to four strategic axes: 1. Citizenship in Health. 2. Equity and Access to proper Healthcare. 3. Quality in Healthcare. 4. Healthy Policies. In October 2013, the articulation procedures between the Ministry of Health and the institutions and services of the National Health Service, with private institutions of social solidarity were defined 53. In the context of economic constraint and fusion and concentration of health services, this legislative document may generate uncertainties. It reflects a backlash against the prevailing trend since the implementation of democracy in Portugal. The document institutes the return of the hospitals object of the measures provided in Law Decrees of 1974 and 1975, currently managed by establishments or services of the SNS, to the Misericórdias. This decision involves a clear danger concerning a return to the past. Conclusions In the previous pages we tried to describe the evolution of the most relevant measures taken by policy makers with regard to health and assistance in the Portuguese context, since the beginning of the twentieth century until the present day. As we pointed out, Portugal progressed from an understanding of healthcare provision linked to charitable assistance to a universal approach. Throughout the article, divided into several subchapters, the strength lines of the different chronological periods were analyzed, highlighting the relation between political stability, resources and welfare state. 52 Direção-Geral de Saúde, Plano Nacional de Saúde 2012-2016. Retrieved from: <http://pns.dgs.pt/pns-versao-completa> [Accessed on 23 July 2014]. 53 Law Decree 138/2013 of 9 October 2013 17

Over the years, the topic of health has gain importance and in this scenario, state played a key role, which has influence over the articulation of providers, the breadth and quality of services. In this sense, the analysis of the legislation is a crucial task because the legislation allows the identification of the main options of the central government in terms of health and it is an evidence of the choices and perceptions about the most suitable health policy in a given historical moment. We study the primary legislation of the health sector between 1910 and 2013 and we show that occurs an evolution in terms of health policies, which suffer several constraints, being influenced by the configuration and resources of the state. Table 2 presents the most relevant legislation on this subject, some of it not mentioned directly in the article, but implied in shaping the global framework Portuguese Health policies. With this study becomes easier to understand how evolve the government options in the field of public health in Portugal. Despite the improvements of all demographic and health indicators of the population, today Portugal is a country marked by great constraints in the health policies sector. What consequences can be drawn from these directives in what concerns the future of health support for the Portuguese population? The future remains an incognita... Table 2. Main legislation in the Health sector (1926-2013) Law 1998/44 of 15 May of 1944 Social s Assistance Statute Law Decree 35108/45 of 7 November 1945 Trigo Negreiros Reform Law 2011/46 of 2 April of 1946 Hospital Organisation Law 2120/63 of 19 July of 1963 Estado Novo Statute on Health and Welfare Law Decree 413/71 of 27 September of 1971 Ministry of Health and Assistance Organic Law Services organics based on Law 2120/63 Gonçalves Ferreira Reform Law Decree 414/71 of 27 September of 1971 Professional careers of the Ministry of Health and Welfare I and II Republic Constitution of 1976 18

Constitutional Gov. (1976/1978, Prime Minister Mário Soares) V Constitutional Gov. (1979/1980, Prime Minister Maria Lurdes Pintassilgo) VIII Constitutional Gov. (1981/1983, Prime Minister Pinto Balsemão) IX Constitutional Gov. (1983/1985, Prime Minister Mário Soares) All citizens have the right to health. Universal, general and free health. Law Decree 129/77 of 2 April of 1977 Hospital Organic Law with the overall objective of making possible the creation of the National Health Service Arnaut 54 Ministerial Ruling (Despacho) of 29 july of 1978 Allows access to healthcare for all citizens anticipating the National Health Service Law 56/79 of 15 September of 1979 National Health Service Law Decree 254/82 of 29 June of 1982 Creates the Regional Health Administration erected for the purpose of decentralization of decision-making on health Law Decree 119/83 of 25 February of 1983. Formalized Private Institutions of Social Solidarity which provide health care to the population Legislative Order 97/83 of 22 April of 1983 Second generation Health Centres Which are integrated health units, in accordance with the principles of regionalization and taking into account the careers of health professionals Law Decree 344-A/83 of 25 July of 1983 Created the Ministry of Health Law Decree 68/84 of 27 February of 1984 Established the system of state contribution in the price of medications Law Decree 74-C/84 of 2 March of 1984 Created General Directorate of Primary Health Care Law Decree 103-A/84 of 30 March of 1984 Created the Directorate General of Pharmaceutical 54 António Arnaut - Minister of Social Affairs. 19

X Constitutional Gov. (1985/1987, Prime Minister Cavaco Silva) XI Constitutional Gov. (1987/1991, Prime Minister Cavaco Silva) XII Constitutional Gov. (1991-1995, Prime Minister Cavaco Silva) XIII Constitutional Gov. (1995-1999, Prime Minister António Guterres) XIV Constitutional Gov. (1999-2002, Prime Minister António Guterres) XV Constitutional Gov. (2002-2004, Durão Barroso) Affairs Law Decree 57/86 of 20 March of 1986 Introduction of user fees in health services Law Decree 19/88 of 21 January of 1988 Hospital Management Law which introduced principles of corporate nature Second constitutional revision of 1989 Transformed the provision of health care in "tendentiously free" Law 48/90 of 24 August of 1990 Law on Health Law Decree 11/93 of 15 January Statute of the National Health Service Law Decree 151/98 of 5 June of 1998 New hospital statute adopted with private management practices in public institutions. Law Decree 157/99 of 10 May Third generation Health Centres Health Centers with greater autonomy and centrality in health care Resolution of Council of Ministers 162/2001 of 16 November of 2001 Management of health services. Which provided for the existence of public-public partnerships (based on public sector partners), publicprivate partnerships (combining public financing with private capital), and even partnerships with the social sector. Law 27/2002 of 8 November of 2002. Approves the new regime of hospital management. Management model enterprise type. Law Decree 60/2003 of 1 April Creation of the primary health care network. 20