Policy models [13, 5]

Organised intervention of the Portuguese State (albeit ineffectively) in public assistance dates back to the 19^th century. Until then and during many years this role had been played by charitable organisations, mainly the Catholic Church and private individuals as a mean of redeeming their sins and gaining a place in heaven. The spiritual advantages of donating probably also contributed to the maintenance of a cycle of poverty and in this way, the existence of this solidarity lead to the prevention of the establishment of social security as a right. To face the danger of massive social unrest due to poverty, the state would provide assistance to the disabled, instruction and work to others, and repress those who were unwilling to work. During these times of classical liberalism, the concept of public assistance was not universally accepted: in this perspective it was considered as merchandise and even a violation of economic science. One argument was that this would lead to an excessive birth rate and would ultimately produce more poverty. During the second half of the 19^th century, mutuality, an associative movement for mutual care in which health related expenditures of a member were shared by the group, developed in the urban industrialised areas side by side with a weak and poorly organised public assistance.

And that was the way that, until the beginning of the century, the access to benefits was much more a result of a voluntary obligation of mercy and charity than a universal right extended to the whole national community. It was then recognised that the welfare and public assistance that existed by that time were only slightly more than a rudimental structure, consequently assuming that poverty wouldn’t disappear with the welfare and that mendicancy couldn't be resolved simply promulgating a law. The solutions then descried, while trying to link public action to private assistance, pointed towards producing more wealth with a more equitable distribution and to a public assistance more adequate to the real beggars. Transposing the logic of the private insurance, but with non-profit purposes and a potential that only the state could accomplish, assistance and mutuality, twenty five years after UK and five after France, came to give place to the compulsory social insurance. Social care began to live from private contributions and / or public funding, the compulsory social insurance relying in a premium paid by the insured or his employer(s). A legal right for the individual to demand some kind of service from a public entity was born, though restricted to the registered members of the system. Nevertheless, due to incapacity or insufficiency, measures taken were once more far from desirable, pragmatically resulting in an almost absolute failure.

In the Second World War period, revealing a trend to dismiss the individual, Social Providence has been formed integrating the Caixas. These, in turn, absorbed in some way the mutuality organisations and compulsory social insurance. This gave origin immediately after the war to a Social Assistance Statute that comes to recognise the function of public assistance as supplemental to the private initiative, meanwhile reserving to the state the role of orientation, guardianship, and to favour that private assistance. But only 20 year later came to press the legal framework for those health and social assistance policies. These also had a final balance much less than desirable: fragmentation and lack of co-ordination of the health, social care and providence activities, insufficient protection to be found in public assistance, and a principle of universality never to be reached. However, within the medical-social services, the state organised health care through its own services, or else with a collaboration of private third part. The organic structure of the first Ministry of Health and Social Care only saw the light in 1971, panorama that finally began to change significantly in the second half of the seventies.

Under the 1976 Constitution a National Health Service is born (to only be ordinarily legislated in 1979), later reformed in 1990. For the first time health legislation is more than administrative legislation applied to the health; for the first time the Portuguese state was deeply committed with health care. State health services are financed through taxes and although constricted by availability of human, technical, and financial resources, the law grants all the citizens access to it and recognises their right to demand health care as needed - universal -; in a first time coverage is also free of charges. Recently, with the 1990 reform (regulated in 1993), due to serious financial restraints and quality erosion, three core principles were at stake. Namely, (1) health protection relying exclusively within state responsibility; (2) gratuity only to be broken by moderator taxes; and (3) the universal right to access health care in public services or other, exceptionally, while and whenever impossible within public services. Hurt in its institutional and functional identity, the National Health System it probably will disappear giving place to a new system of superimposed cell with no centralised obedience. In effect joint responsibility in health protection will probably lead the state to draw back to a merely supplemental function. The responsibility of health cost coming to rely upon the user according to its socio-economical status, also points at a return of the old assistance model when everybody could gain access to public services, and he wouldn’t be charged if it was a case of poverty. Finally, conventions and management arrangements will probably strike the system functioning as a global unit.

Changing the basements of solidarity, social scope and financing, a real social security regime also came after 1974 to substitute the compulsory social insurance. The system used to be restricted to a group of compulsory social insurance policies, limited to the workers, and financed from their wages with the workers and businesses quotations. The new system, financed by national community, also included compulsory social insurance, but became broader also protecting non-workers and successively covering more risks. It also has progressively loosed access to it and increased accounts rendered. All this aggravated with demographic evolution and no political compensation comes to account for the present situation in social care. Nowadays differences when compared to other countries are not juridical, but mainly economical.

Under this settlement, key players and decision-makers are the Parliament and the Government as well as Unions and Professional Associations.

While the responsibilities for defining health care policies and supervising its implementation reside within the Ministry of Health, the responsibility for Social Care Delivery is shared between the Ministry of Health and the Ministry of Solidarity and Social Security and is co-ordinated by the Government. That is to say that articulation between health and social care as well as social security is carried out almost only at Government level.

Última actualização = 06/Abril/97