uma visão baseada em conversas várias:
ANALYSIS-Portugal ponders political price of good health
9:11 AM CDT, March 29, 2012
* On health costs, Lisbon holds up mirror to other economies
* Future of basically free, universal access model at stake
* Euro crisis is dry run for future health budget battles
By Alan Wheatley and Daniel Alvarenga
LISBON, March 29 (Reuters) – To get an idea of the enormous
financial strains on Europe’s health care sector, put yourself
in the shoes of Professor Joao Alvaro Correia da Cunha.
As head of North Lisbon hospital centre, one of Portugal’s
largest, da Cunha has already slashed salaries by 20 percent and
shed 150 staff as part of cuts demanded by international lenders
in return for bailing out the government to the tune of 78
billion euros. He is under orders to keep cutting.
Yet da Cunha, a doctor for 43 years, is not ready to
compromise on his calling to heal the sick. In February he spent
1 million euros to treat a woman with a complex blood disease
and will soon prescribe a new drug for 25 people with a fatal
degenerative nerve disorder endemic in northern Portugal. The
cost will be perhaps 200,000 euros a year per patient.
Portugal’s taxpayer-funded national health service (NHS)
provides universal access, more or less free at the point of
delivery, and da Cunha is proud that his hospital has never had
to turn away a patient. He finds rationing of health care
anathema. Yet times are tough.
“If it comes to the point when it’s necessary to decide
whether we can treat a patient or not, then that decision will
not be mine. I’d rather retire,” he said. “And you shouldn’t
have to look in your pocket to see if you can afford to be
treated. But I agree we’re reaching the limit: we have no money.
The country is in crisis.”
Portugal is in particularly dire straits because it is in
hock to its lenders, with terms dictated by officials from the
“troika” of the International Monetary Fund, the European
Commission and the European Central Bank.
But the financial pressure that its medical system faces is
replicated across the continent. Spain, for instance, is bracing
for health cuts as part of an austerity budget promised by new
Prime Minister Mariano Rajoy.
The debate on the scope of health care spending may have
been triggered by the euro zone’s debt drama, but it will not go
away when the crisis ebbs.
“It will be unavoidable to rethink the resource allocation
mechanism. Of course, in health most countries don’t want to
talk about explicit rationing. The political cost is too high,”
said Professor Monica Oliveira, an expert in health finance at
the Technical University of Lisbon.
GOOD HEALTH, FINANCIAL PAIN
Standard & Poor’s, a credit ratings agency, recently warned
that health bills, compounded by the cost of caring for ageing
populations, were likely to become unaffordable for the Group of
20 major economies unless governments changed their social
Total health care spending has risen by more than 70 percent
in real terms in the OECD area since the early 1990s. Public
spending on health absorbs more than 6 percent of GDP and could
increase by another 3.5 to 6 percentage points by 2050,
estimates the Organisation for Economic Cooperation and
Development, a Paris-based forum of 34 mature economies.
People are living longer, while medical technology and
treatments are improving all the time. This is forcing
governments – and voters – to make unpalatable financing
choices. Is it possible to put a price on health? How much are
we prepared to pay to extend a life by a few weeks or months?
Seen in that light, today’s cost-cutting in Portugal is only
a dry run for a more fundamental reassessment of how the country
should pay for health care. Public and private spending on
health totalled 10.1 percent of GDP in 2009, well short of the
U.S. level of 17.4 percent but above the OECD average of 9.6
“We cannot undertake financing reforms when we are going
through a troika programme. But as soon as we’re through it,
we’ll have to start discussing financing. If not, the system
will be unsustainable. This is something that everybody has to
understand,” said Fernando Leal da Costa, a secretary of state
in the health ministry.
Like several experts interviewed for this report, da Costa
said he expected a mixed system to evolve in Portugal; the state
would continue to fund core services, but people would be asked
over time to pay more out of their own pocket.
“If we don’t try to do things smoothly now, we’ll probably
not avoid a catastrophe,” da Costa said.
With the troika’s bean counters bearing down, things are
currently far from smooth. The government is desperate for more
people to seek treatment in primary care centres instead of in
hospitals, which are more expensive. It also needs to close some
old hospitals to increase efficiency but has been shy of
offending local interests by shutting wards that are surplus to
“The government is in the emergency room. They’re trying to
keep the patient alive,” said Isabel Vaz, chief executive of
Espirito Santo Health, a private hospital group. “They’re making
a huge effort to control costs, but I don’t know how they’re
going to put in place all the reforms they need without money.”
In the longer term, Vaz said Portugal needed to reduce
duplication: around two million people or about 20 percent of
the population have access to private medical care – which is
subsidised for civil servants – as well as the NHS. This “double
coverage” is not efficient economically because it means paying
twice to cover the same risk, she argued.
Vaz advocated the sort of model used in Germany and the
Netherlands. “We’d have a social package so that everyone has
access to basic care and people would have to top up,” Vaz said.
“But that of course means a different way of looking at the
Talk of tampering with the NHS is heresy to many Portuguese,
who cherish the system as a symbol of the country’s transition
to democracy after the overthrow of its dictatorship in 1974. It
is no accident that Britain’s health service, set up after World
War Two and generally held in similarly high esteem, served as a
model for that in Portugal.
The attachment to the NHS, founded in 1979, is not just
sentimental. People see the results of big investments in
health. In 1970, Portugal, western Europe’s poorest country,
recorded a shocking 55.5 infant deaths per 1,000, twice as many
as in neighbouring Spain. By 2009, the rate was down to 3.6.
Over the same period, life expectancy at birth improved from
67.1 to 79.5, the OECD average.
No one is more devoted to the NHS than Antonio Arnaut, a
lawyer who set up the system when he was minister of social
“Today, everyone is equal when it comes to disease. Health
is a right, not a privilege of those who can pay, as it used to
be and is still the case in the United States, for example,” he
said in an interview in his office in Coimbra, a university town
north of Lisbon.
A founding member of Portugal’s Socialist Party, which is
now in opposition, Arnaut is not against private health
insurance and acknowledges there is a lot of scope to reduce
waste. But he says the debate is less about financing and more
about the political will to preserve what has become, in his
eyes, a fundamental right.
“If the government cuts so much that the NHS loses its
character, there’ll be a popular revolt, because only revolt can
recompense for the humiliation of the oppressed,” Arnaut, who is
also a poet and essayist, said.
SPREADING THE PAIN
Most Portuguese seem inured to the need for belt-tightening
to cut the government’s budget deficit to the EU threshold of 3
percent of GDP next year, but there is no doubt that the pain of
the health cuts is being felt widely.
Da Cunha, the Lisbon hospital head, is planning to reduce
his bill for drugs and medical consumables by another 10 percent
this year, but the mean salary of his 6,700 professional staff,
including three chaplains, has already fallen 20 percent over
two years to 1,200 euros a month.
“We can’t reduce our salaries any further,” he said simply.
Portuguese have had to pay more for consultations and
prescriptions since the start of the year, and patients in rural
Portugal no longer automatically enjoy free transport if they
have to go to the city for treatment.
Apolinario Eduardo, 36, who has just landed a job as a taxi
driver in Coimbra, said he feared people would be deterred from
going to the doctor’s.
“For the last two years only my wife was employed and not
earning much. If we needed to go to the hospital today, a
co-payment of 20 euros, instead of 2 euros as it was before,
plus the price of the drugs would take out a huge chunk of our
monthly family income,” he said.
Hospital executives and government officials brandish
statistics to rebut media reports that the death rate has
already started to climb because people can no longer afford all
the tablets and medicines they need.
But Pedro Pita Barros, an economics professor at the Nova
School of Business and Economics in Lisbon, said Portugal was
probably at the limit of how much patients could be expected to
pay out of their own pocket.
“You have people easily paying 40, 50, 60 percent of the
cost of their drugs, and some of these will be chronic
patients,” he said. “The only thing that has helped them is a
steep fall in price because of competition from generics;
otherwise they’d have faced a hard time.”
The government is expanding the use of cheaper generic drugs
at the behest of the troika. By the end of 2012, Portugal’s
pharmaceuticals bill will have dropped 20 percent, or 525
million euros, in two years to 1.25 percent of GDP, according to
Joao Almeida Lopes, chairman of Apifarma, the Portuguese
IN PORTUGAL’S GENETIC CODE
A brighter result of the debt crisis for the pharmaceutical
industry is that the government, again at the troika’s prodding,
finally intends to start paying next month about 3 billion euros
of arrears built up over the past decade or more in the NHS.
“When you work with public hospitals, you’re lucky to get
paid after a year,” said Ricardo Matos, an account manager at
Alere Inc, a U.S. medical diagnostics developer.
Apifarma says pharmaceutical providers alone were owed 1.39
billion euros at the end of February, with payments taking an
average of 500 days to come through. Some companies that were
owed money and starved of credit have had to close, Lopes said.
“Our greatest enemy is the systematic underbudgeting of the
health system in Portugal,” he said. “In terms of health care,
we should be careful not to go beyond what has been agreed with
the troika and is in the budget for 2012.”
That sounds self-serving, but Barros with the Nova School
said the government’s goal of cutting 1 billion euros from this
year’s budget of about 7.5 billion euros was probably too
Weighed against that judgment, the IMF has identified health
costs as the largest potential source of medium- and long-term
fiscal pressure for Portugal. In today’s money, the Fund
estimates the country’s future related health costs at 116
percent of GDP, dwarfing the average for advanced economies of
In other ways, though, Portugal is better placed than many
others. An OECD analysis of health efficiency in 30 of its
member states reckoned that only five countries had greater
potential than Portugal for savings in public health spending.
Portugal ranked above Denmark and Finland for efficiency in its
Portugal has also grasped the nettle of pension reform by
linking payments to longevity. Moreover, its demographic profile
is less severe than that of many of its neighbours. As a result,
it faces one of the smallest rises in projected ageing costs in
the EU – 4 percentage points of GDP or less – between 2007 and
2060, according to a European Commission study.
As such, the task of caring for the old will be more a
matter of organisation than spending ever greater sums, said
Barros: “More elderly people living alone with chronic
conditions will require more health care in the community than
Still, the coming years will test health policymakers and
finance ministers, especially in countries such as Portugal
where the benefits of publicly-funded universal access to
medical care are taken for granted.
Jose Martins Nunes, head of a cluster of seven hospitals in
Coimbra, said asking the better-off to pay more would undo the
very fabric of the national health service.
“The situation is tough, but the NHS is part of Portugal’s
genetic code. We will do everything within our means to maintain
the model as it is,” he said.
(editing by David Stamp)
Copyright © 2012, Reuters