In Portugal, there is a fundamental right to health protection specifically set out in the Chapter dedicated to fundamental rights in the Constitution of the Portuguese Republic. The right to health protection must be guaranteed: (1) by means of a universal and general national health service, which, with particular regard to the economic and social conditions of the citizens who use it, will tend to be free of charge; and (2) by creating economic, social, cultural and environmental conditions that particularly guarantee the protection of children, the young and the elderly; systematically improving living and working conditions, and promoting physical fitness and sport at schools and among the general population; and developing the public’s health and hygiene education and healthy living practices.2
Healthcare services in Portugal are provided through three coexisting and overlapping systems: (1) the National Health Service (SNS), (2) special health insurance schemes for certain professions (health subsystems) and (3) voluntary private health insurance.
The SNS was established in 1979 in the context of the enactment of the Constitution of the Portuguese Republic in 1976 and is managed by the Ministry of Health.
The Ministry of Health is divided into three sectors: (1) the direct administration; (2) the indirect administration; and (3) the public enterprise sector, comprising the Shared Services of the Ministry of Health (SPMS), local health units, hospital centres and public enterprise hospitals.3
The Ministry of Health is responsible for issuing the National Health Plan4 and the National Strategy for Quality in Health. Five regional health authorities (ARS) (which are public entities and part of the indirect administration of the state under the supervision of the Ministry of Health) are responsible for the implementation of the national health objectives set out in those documents and have financial responsibility for primary and hospital care.
Despite the universal coverage of the SNS, there are other forms of financing the provision of healthcare services, which are specific to particular categories of citizen. There are groups of citizens with specific sickness schemes, usually designated as ‘health subsystems’. These systems, which constitute the second component of the healthcare system in Portugal, are formed of entities of a public or private nature that, by law or under contract, provide health benefits to a group of citizens or financially reimburse them for the corresponding charges. Membership of these subsystems is based on professional categories and covers beneficiaries who are still in work, retired workers and their family members. These subsystems are financed through the beneficiaries’ contributions.
Until 2005, there were six health subsystems operating in the public sector that were integrated in that same year into the main subsystem, the Institute for Disease Protection and Disease Control (ADSE). The ADSE comes under the indirect administration of the Ministry of Health (and is also subject to financial control from the Ministry of Finance) and now covers the provision of healthcare services to all public servants and persons rendering services to public entities, under certain type of arrangements. At the end of 2016, the number of ADSE beneficiaries amounted to 1.22 million, including active staff, pensioners and family members, while as at 2020 it had slightly decreased to 1.2 million.5
Private health subsystems consist of entities of a private nature that, under contract, provide healthcare to a group of citizens or contribute financially to the corresponding charges. Such a contract is compulsory, resulting from a compulsory intra-group solidarity mechanism (with a professional or business matrix). The largest private subsystems are ACS (the health subsystem for the employees of Grupo Altice) and SAMS (the health subsystem for banking and insurance employees).
Finally, the private insurance sector, the third component of the healthcare system in Portugal,6 which is based on voluntary individual affiliation, operates under a free-market regime and is subject to the general legislation of the insurance sector. Since the early 1990s, the number of beneficiaries of health insurance has increased at a rate of more than 10 per cent per year, and in 2021, 3 million Portuguese citizens had health insurance. There are some cases where people can benefit from triple coverage: from the SNS, from a health subsystem and also under private health insurance.7
Healthcare services are also provided, on a more limited scale, by non-profit private operators with a charitable background, known as Holy Houses of Mercy.8 Anyone can access the healthcare services provided by the Holy Houses of Mercy (hospitals, clinics of physical medicine and rehabilitation, etc.), as they have agreements with both the SNS and with health subsystems and insurers. In the case of agreements with the SNS, the Holy Houses of Mercy have agreements with the Ministry of Health for the provision of healthcare services, integrating them into the national healthcare network. In the case of subsystems (e.g., the ADSE) and insurers, the user will have to be a beneficiary of one of these subsystems and the Holy Houses of Mercy must have an agreement in place with them to allow these beneficiaries to access healthcare services. There are currently 22 hospitals, 120 nursing homes, and other healthcare activities managed by the Holy Houses of Mercy.9
The healthcare economy
In addition to what is stated in the Constitution of the Portuguese Republic regarding the right to health protection, the general policy guidelines regarding the healthcare sector in Portugal are set out in Basic Law No. 95/2019 of 4 September (the Healthcare Basic Law).
In addition to a network of public hospitals and primary healthcare facilities covering the entire Portuguese territory, there is a broad range of private healthcare services offered in Portugal, including private clinics of varying dimensions and private hospitals. There are several private entities in Portugal, both for profit and non-profit, operating networks of multiple private hospitals and clinics.
ii The role of health insurance
As mentioned in Section I, there is no obligation for users of healthcare services to acquire healthcare insurance. This activity is governed by law and other instruments regulating insurance in Portugal. The insurance sector in Portugal is governed by the Authority for the Supervision of Insurance and Pension Funds.
iii Funding and payment for specific services
Pursuant to the Healthcare Basic Law, the SNS is financed primarily through transfers from the Portuguese state budget. Furthermore, in this regard, there are provisions of the Healthcare Basic Law, the Statutes of the SNS approved by Decree-Law No. 11/93 of 15 January, as amended, and Decree-Law No. 113/2011 of 29 November, as amended, that regulate access to the SNS services on the basis of moderating fees. Healthcare units of the SNS may also receive the following income:
- payment of healthcare services provided in particular rooms or other types or services not available for the majority of users;
- payment of healthcare services by third parties that have the legal or contractual responsibility to pay for healthcare such as healthcare subsystems or insurers;
- payment of healthcare services provided to non-beneficiaries of the SNS;
- donations; and
- moderating fees paid by users.
Moderating fees are charged to SNS users (with some exceptions applicable to certain categories of users as well as to certain types of healthcare services10) with a view to incentivising a rational use of SNS resources and the control of public expenditure. These fees are governed primarily by Decree-Law No. 113/2011 and by Ministerial Order No. 306-A/2011 of 20 December, as amended, setting a fixed fee for consultations (primary care and hospital outpatient visits), emergency visits, home visits, diagnostic testing and therapeutic procedures. Moderating fees are only due in ambulatory care.
Moderating fees will ideally be charged upon the provision of healthcare services, unless the user is unable to pay as a consequence of his or her health situation or a lack of financial means. Whenever the fees are not paid immediately, the user will be instructed to pay the relevant amount within 10 days. Non-payment of moderating fees is not grounds for refusing healthcare services.
Owing to mismatches between supply and demand, waiting lists in the SNS for surgery or consultations for certain medical specialties are often long. The SNS’s offering of dental services is also limited, although Ministerial Order No. 301/2009 of 24 March introduced the National Oral Health Promotion Programme,11 pursuant to which certain categories of patients are entitled to vouchers that are exchangeable for dentistry services. For these reasons there is strong demand for private-sector services in certain areas (e.g., dentistry or medical specialties).
Wellness services, alternative therapies and opticians are usually funded by individuals, with the possibility of co-funding by private insurers or health subsystems. Some types of beneficiaries (e.g., infants and adolescents, pregnant women, the elderly, and AIDS and HIV patients) are entitled to certain specific additional benefits. In the specific case of the elderly, this group of beneficiaries can access additional benefits, such as co-funding for glasses up to a specified limit (under the Solidarity Supplement for the Elderly12 or exemption from payment of moderating fees). Furthermore, the Holy Houses of Mercy – in the context of the National Network of Integrated Continuous Care13 – provide the elderly with a set of mechanisms to give them adequate care, such as residential structures, day centres, home support services and continuous care units.
Primary/family medicine, hospitals and social care
Primary care is currently organised in Portugal on a geographical basis. The Group of Healthcare Centres (ACES), introduced under Decree-Law No. 28/2008 of 22 February, as amended,14 was created as a decentralised service of the ARS (which has directive powers over it) as a new way to guarantee improved direct access to healthcare for Portuguese citizens, which was previously assured by the healthcare centres regime, enacted by Decree-Law No. 60/2003 of 1 April (no longer in force). The ACES is made up of healthcare providers with administrative autonomy, which agglomerate one or more healthcare centres. They are responsible for providing primary healthcare to the population of a specific geographic area. Although the ACES is intended to be the primary source of healthcare services, hospitals continue to be citizens’ first choice.
It is also possible to receive basic primary healthcare through the local healthcare systems (SLSs), introduced by Decree-Law No. 156/99 of 10 May, which are made up of healthcare centres, hospitals and any other healthcare service providers or institutions, whether public or private in nature, that operate within a certain local region. The SLSs are created by means of an administrative order from the Minister of Health, following a proposal from the ARS and consultation with the local authorities.
Despite the international financial crisis in 2007, which limited public expenditure in the healthcare system, the private sector managed to find a way to keep its market share within the healthcare sector. One of the most important reforms within the hospital sector in Portugal in recent years was the development of public–private partnerships, enacted by Decree-Law No. 111/2012 of 23 May, as amended. Although the investment and operation of these healthcare units is private, they are nevertheless integrated into the SNS, which means that all SNS users have the same rights and duties as in any other public hospital or healthcare unit. Currently, there are three hospitals under this regime.15