In its essence the NHS still is a hierarchical structure administered by the Ministry of Health and its Health Secretary of State. It has three main branches, which hardly communicate to each other and also are reflected in the health care professional's careers: (1) primary care, (2) secondary care, and (3) public heath. Health administration is further divided into three main Health Regional Administrations - North, Centre, and South - that account for the hospitals on one hand, and for Health Centres (primary care) on the other. Mental Health, in turn, also divided into three Centres - North, Centre and South Zones -, depends upon the General Direction of Health, one among other departments directly linked to the Ministry. Another of these is the Department of the Health Human Resources, the entity responsible by Nursing Schools and other.

Depending on the Ministry of Solidarity and Social Security is, on one hand, the Secretary of State for Social Security, and on the other hand, the Secretary of State for Social Insertion upon whom the National Council for the Third Age Policy. Social Security administration is also further divided into three main Regional Centres - North, Centre, and South -. While the Centre for the National Pensions Fund, among other departments, depends upon Secretary of State of Social Security, one of the departments depending on the Secretary of State for Social Insertion is the National Secretary for the Rehabilitation and Integration of Disabled Persons.

As previously stated, NHS funding comes directly from the budget (taxes), while the Social Security is also funded through a separate contribution that comes from employers and employees. Distribution of resources allocated to health and social care follows the policies set by the Government in general and the respective Ministry in particular.

The 1990 revision / 1993 regulation entrusted a trend to hold the user responsible for the health costs according to its own social and economical situation. In what concerns welfare, old age and disability pensions [15] are the most representative benefits due to the main importance of their costs. The basis to determine the statutory pension is 2% of a reference wage, with no less than half of the minimum mensal wages legally granted. This is determined within the last fifteen years with acknowledged wages, from the annual (14 months) average wages falling upon the best ten years with at least 120 days of contributions. Pensions result from a periodic actualisation of the statutory pension according with current prices at consumer level, thus preventing erosion due to inflation; this revision is obviously conditioned by financial availability [5]. Considering that old persons are a significant part of the 20% of the population (2 million persons) living in poverty - with an income inferior to the Minimum National Pay -, there is also an annually updated Social Pension (PTE 21000$ a month) to benefit those citizens who never made deductions to Social Security [16]. Furthermore the amount for the recently created Secure Minimum Income [17] is determined in reference to that Social Pension.

Other benefits besides pensions, with their own regulations, are the illness, death and unemployment subsidies.

Accountability [13, 5]

With a significant growth from 1970 to 1975, the health public services come to represent as much as 60% of all services: 1% of GDP in 1960, and 2% in 1970, give place to 4.6% in 1992. This means to spend 21 times more, and an annual average growth of 10%. Total spending in health care in 1994 was 938 PPP$ (value per capita at current prices), public spending representing 55.8% of this amount.

Looking into the number of physician per thousand persons, Portugal has not very favourable statistics among other EU countries. However this human health resource not only turned four times bigger than in the sixties (annual average grow of 4.5%), as it places it quantitatively in a rather fair position. This reflects in some way the expansion of the health intervention of the state. However, when compared to the physicians situation, the growing in the number of nurses is in a bad position (annual average grow of 4.5%), seeming like this is a less attractive profession.

As with human resources, the greatest increase of as much as 123% in welfare and public health expenditure can be observed in the 1970-1975 period. The same goes to health and social services with 162%. In 1975 these services even superseded for the first time the police and public health budget, what is understandable considering that health and social services grew from the 1960 coverage of 1.4 million people, to the 5.2 million during 1970.

When looking into the current expenses, personnel expenses stand out since 1980 in as much as 53%. The trend is to lower the expenses with medicaments and other services from the private sector.

While the Autonomous Central Services and other have only little importance in relation with others, and the lowering expenses with Psychiatry are also of irrelevant economic expression, the hospitals take as much as 50% of the total expenses, as do the Health Regional Administrations, both summing up circa 95%.

Although the active population growth is relatively slower, global income of Social Security grows significantly with the GDP at a 4.2%/year rate. At 1992 current prices the annual growth is 8.4% when GDP increases annually by 4.4%. This is mainly due to a larger coverage - from 1.2 million (1960) to 4.2 million (1992) -, but also as a result of the aggravation of social contribution taxes: from 23.5% of the wages in 1970 to the present 35%. The variation in the transference's merely reflect political reaction to the systems financing needs when contributions become insufficient to cover the level of expenditure. Mainly referred to interests, the other under the current source of revenue tends to drop quickly as the capitalisation system is abandoned.

With a much slower rate of growth, the National Providence Fund (Caixa) as compared with the private Social Security is much smaller. In fact, it only covers civil servants at a central, regional and local level, and its financial volume (not included in table 9.1) only represents one fifth of the whole Social Security.

The global growth of social security expenditure is very accentuated but at a different pace and with a completely different expression in the whole for different types of expenses. Pensions absorbed 0.29% of GDP in 1960 and as much as 6.41% in 1992 as a result of a huge growth in the number of pensioners: around 15% a year but differently in different periods. 187 thousand in 1970 increased in 1980 to 1.7 million. Subsidy of unemployment is also growing and probably will keep on growing considered the structural nature of unemployment. The limited capacity to collect income and the heavy burden of pensions and unemployment subsidy will probably reduce availability for the other supporting subsidies, family included. Although the tendencies observed in Social Security can also be seen In the Providence National Fund (caixa), while the number of pensioner increased almost 40 times (1960-1992) for the first system, for the second that increase was merely 4.5 times. Nevertheless an average 7% /year growth will soon impose new financing forms relying on the state as employer: through transferences and/or quotations of public entities.

Main features of the training and education of key professional groups

Depending upon the Ministry of Education, the training of health personnel is nevertheless carried out within the structures of the NHS. Nurses have a theoretical preparation of three years in nursing schools, followed by two years of training. Physicians have a 6-year degree of licentiate: three years in basic science and three more in clinical disciplines; it is then necessarily followed by a year and a half walk of the hospitals which entitles for practice as General Practitioner. Specialisation comes next, lasting for three years in the case of Generalists / Family Doctors. Internists, specialised in Internal Medicine, have a five-year residency; however formal training in Geriatrics is not available. The Neurology residency lasts 5 years and the Psychiatry takes four years. Although there is a Portuguese Gerontopsychiatry Association [20, 21], psychogeriatrics is not yet recognised and is only available as part of the Neurology residency.

Social Workers, in turn, have a 5-year degree of licentiate: three years in basic science - Psychology, Sociology, Economics, Law, etc - and two more as a period of practical training in Health Institutions, Social Security Organisations, Autarchies, Tribunals and/or Private Institutions of Social Solidarity intervened by Social Security.

Última actualização = 06/Abril/97