Effects of the financial crisis and Troika austerity measures on health and health care access in Portugal
Introduction
Although Portugal is one of the European countries most affected by the global financial crisis, there has been much less attention to the health consequences of the crisis and subsequent austerity measures compared to countries such as Greece, Spain and Ireland. Portugal's recession started in 2008. Despite a brief recovery in 2010, it then lost more than 6% of GDP between 2011 and 2013 [1]. The crisis was accompanied by mounting deficits (9.9% of GDP in 2010) [2] and the government debt, mainly from the credit-fuelled expansion of the non-tradable sector such as retail and construction, reached 129% of GDP in 2013 [3].
In May 2011, the Portuguese Parliament rejected austerity measures and the government requested an emergency €78 billion bailout package from international lenders – the European Central Bank, the European Commission and the International Monetary Fund – known as the Troika. The Memorandum of Understanding (MoU) with the Troika included agreement to generate substantial savings, including the health care sector [4], [5], [6].
Portugal had undergone remarkable change since the 1980s. Social conditions had improved as the creation of a welfare state tackled material deprivation and increased access to healthcare [7]. Portugal's health system is primarily funded through general taxation with a mix of public and private financing. Before the financial crisis, approximately 30% of the total expenditure was private, with nearly 25% representing out-of-pocket payments. Patient co-payments have increased over time, dominated by payments for pharmaceuticals [8]. All residents have access to health care provided by the National Health Service (NHS), and a number of reforms were implemented since the 1990s to improve performance, especially primary care and pharmaceutical care delivery. Portugal had progressively increased expenditure on healthcare, particularly in the public sector. In 2008, when the financial crisis hit Portugal, expenditure for health care represented nearly 10% of GDP [8]. However, progress was reversed during the crisis; health expenditure declined by 5% per year in real terms in 2011 and 2012 [9], contrasting with an annual growth of 1.8% in the previous decade [10]. Per capita expenditure stood at 2514 US$ PPP in 2013, well below the OECD average of 3453 US$ PPP [11].
Budget cuts were achieved in several ways [6], [12], [13]. First, unit costs were forced down as the government negotiated lower prices for drugs and cut salaries of health workers. Second, more cuts were introduced in prevention, public health and research. Third, measures were implemented to reduce demand for care, mainly by increasing co-payments. Visits to primary care physicians attracted a charge of €5.00 in 2013, up from €2.25 in 2011. The corresponding increases for routine hospital visits were from €4.60 to €7.75 and for emergency visits from €9.40 to €20.60, with additional fees of up to €50 for examination and diagnosis. Increased charges have been maintained at these values through 2015, even after the termination of the MoU. The impact was, however, softened by broadening exemptions from payments to almost 56% of the population (from 4.3 million people in 2011 to 5.8 million in 2014 [14]). Exemptions are based on several criteria (family units earning less than €630 per month, the unemployed, pregnant women and children up to the age of twelve, among other groups) with the main criterion being that of economic hardship. In 2015, the Ministry of Health extended exemption from fees to youth under 18. However, criteria for exemptions for certain conditions such as chronic obstructive pulmonary disease (COPD) and chronic active hepatitis were tightened [15]. Fourth, some subsidies were removed, such as tax relief on private health insurance. Box 1 sets out a more detailed description of the austerity measures sought by the Troika in 2011.
The Portuguese government was required to commit to reducing the deficit to 3% of GDP by 2013, while “minimising impact on vulnerable groups”. Yet there have been concerns that some of these measures may have impacted adversely on access to care and on population health, not least because of awareness of what has happened in Greece [17]. So what has happened in Portugal?
Section snippets
Methods
We used the European Statistics on Income and Living Conditions (EU-SILC) [18] to analyse changes in self-reported unmet medical need before and after the introduction of the Troika's adjustment package. EU-SILC is an EU-wide representative population survey, the cross-sectional component of which contains data on perceived unmet medical need. The unmet medical need indicator is considered a proxy for barriers experienced in access to care, consistent with other studies [17], [19]. The relevant
Effects of health care budget cuts on health system and access to care
As shown in Fig. 1 and Table 2, the odds ratio (OR) of reporting unmet medical need (accounting for socio-demographic characteristics of respondents) more than doubled in the crisis year, with the greatest impact on those in employment (OR 2.82, 95% CI 2.15–3.69), followed by the unemployed (OR 2.07, 95% CI 1.32–3.24), and the retired (OR 2.00, 95% CI 1.40–2.85), and other economically inactive groups (OR 1.81, 95% CI 1.11–2.96). EU-SILC also collects the reason for not seeking care and Table 3
Discussion
This study shows that the recession, followed by the policy of austerity adopted in Portugal has been accompanied by a demonstrable worsening of self-reported access to health care, most marked among those who are not exempt from the increases in co-payments implemented as part of the austerity package. While an ecological study [23] looking at aggregated data did not find differences in emergency admissions between patients that were exempt or not-exempt from payments in 2012 compared to 2011,
Conclusions
The available evidence points to a clear deterioration in access to health care in Portugal since austerity measures imposed by the Troika came into effect in 2011, especially for vulnerable population groups not benefiting from exemptions from charges. This situation is familiar to other countries in Southern Europe, particularly Greece [17] and Spain [47], where the universality of health coverage, population health and existence of the welfare state has been challenged by austerity measures
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