Mitigating Health Worker Migration in Portugal: Strategies and Implications
Cristiana Monteiro MSc
Health Policy Expert | Lead Healthcare Scientist | Principal Cardiac Physiologist | EACVI Echo SIG
The Portuguese National Health Service (NHS) is the primary healthcare provider for the country’s population. Founded in 1979, it is primarily funded through general taxation. Annually, the Portuguese Ministry of Health presents plans to the Ministry of Finance, which, in turn, defines the NHS budget. Additional revenue is generated from user fees in the form of co-payments; since their introduction, family/individual health expenses have increased by 28%, potentially making healthcare access unequal. Resource allocation (funding, equipment and workforce) is yet to become needs-based.
Despite its crucial role, the NHS faces significant challenges: shortages of healthcare professionals (HCPs), long waiting lists, and an increasing number of HCPs leaving the country. Although there has been a steady increase in numbers across all professions (e.g. 60,396 doctors in 2022 vs 33,751 in 2002; 81,799 nurses in 2022 vs 41,799 in 2002), Portugal has one of the lowest numbers of HCPs per population in Europe, exacerbating the strain on the healthcare system. The ratio of nurses to physicians is also low.
The country has experienced a significant exodus of HCPs seeking opportunities in countries like the United Kingdom and Germany. The reasons for this are multifaceted, ranging from economic factors to better professional opportunities and quality of life. The 2008 global financial crisis coupled with austerity measures imposed by the European Commission, European Central Bank and International Monetary Fund, as part of a Memorandum of Understanding (MoU), in exchange for a loan of €78 billion, dealt a severe blow to Portugal's economy and public services, including healthcare. This led to budget cuts, wage freezes, and increased workloads for HCPs, prompting many to seek employment elsewhere. Other “push” factors, such as limited career advancement prospects and challenging working conditions have further incentivised HCPs to emigrate.
This article explores two strategies aimed at reducing the negative consequences of HCP migration in Portugal. The first strategy is the program “Regressar”, which seeks to encourage Portuguese HCPs abroad to return. The second strategy involves attracting international HCPs to fill the gaps in Portugal's workforce.
The program “Regressar” is a government initiative aimed at encouraging Portuguese emigrants to return by offering incentives and support for reintegration into the workforce. Under this program, emigrants may benefit from tax exemptions and financial support to facilitate their transition back to Portugal. While the program has the potential to attract skilled HCPs back to the country, its effectiveness in addressing the workforce shortage remains questionable.
A benefit of the program is the provision of a five-year exemption from paying income tax on 50% of earnings from the moment participants become professionally active in Portugal. Further support is given in the first year upon return (between 2,402.15€ and 3,363.00€), compounded by 25% should the individual return to an under-serviced region. An extra 1,441.29€ per household is also given to aid with travel expenses.
However, there are limitations to the program. Firstly, while the tax and financial incentives may be appealing, they may not be sufficient to offset the lower salaries and limited career opportunities available. Many returning professionals may find it difficult to reintegrate into a system that has faced years of underfunding and staff shortages, especially if they can enjoy higher salaries and better working conditions elsewhere. Moreover, the program does not address the issues driving HCP migration, e.g. limited career opportunities and working conditions, which will be challenging for those who have established successful careers abroad. Although some careers have been unfrozen, offering HCPs the prospect of further advancement, those returning to the NHS do not fulfil the criteria for roles at a similar seniority level to that they would have been performing elsewhere; their experience and achievements are therefore ignored, and HCPs find themselves restarting their careers. Another limitation is that the program does not address the low number of vacancies within the NHS. While the program may attract some, it is unlikely to stem the overall tide of emigration without comprehensive reforms to improve the NHS's attractiveness.
Another strategy has been to encourage HCP immigration from other countries to fill the gaps in the workforce. This involves implementing policies and initiatives to facilitate the recruitment and integration of foreign HCPs into the Portuguese NHS. The numbers of foreign HCPs have been increasing since the establishment of bilateral agreements between Portugal and Cuba (2009), Uruguay (2008), Costa Rica and Colombia (2011). As of 2016, the Portuguese NHS employed nearly 2000 foreign physicians, and over 1200 other HCPs.
A benefit of attracting HCPs from other countries is the potential to acutely alleviate staffing shortages and waiting lists. By tapping into the global pool of HCPs, Portugal can access a diverse range of skills and expertise to complement its workforce. This influx of talent can fill vacancies in areas experiencing critical shortages. Additionally, recruiting HCPs from other countries can bring fresh perspectives and approaches to patient care, enriching the quality of healthcare delivery. Cultural diversity within the workforce can also enhance patient satisfaction and promote inclusivity. However, there are ethical considerations when it comes to the immigration of HCPs.
One concern is the potential impact on the healthcare of sourcing countries, particularly those facing their own HCP shortages, exacerbating them, worsening inequalities and hindering efforts to improve outcomes globally. Job search visas were introduced in 2022 and include all job types; citizens from the Community of Portuguese Speaking Countries (Angola, Brazil, Cape Verde, East Timor, Guinea-Bissau, Mozambique and S?o Tomé e Príncipe) have access to easier pathways. Although lower than the European Union (EU) average, as of 2019, Portugal had a rate of 5.6 physicians and 7.1 nurses per 1,000 inhabitants; some of the sourcing countries have significantly lower rates of available HCPs per 1,000 inhabitants (e.g. Angola: 0.2 physicians and 0.4 nurses/1,000 persons; Mozambique: 0.1 physicians and 0.6 nurses/1,000 persons; Guinea-Bissau 0.2 physicians and 1.1 nurses/1,000 persons; Brazil: 2.1 physicians and 5.5 nurses/1,000 persons). This migration also occurs within the EU, with 33% of foreign nurses in Portugal being of Spanish origin.
Furthermore, there may be challenges associated with integrating foreign HCPs, including language barriers, and cultural and training differences. Effective support must be in place to facilitate the transition and integration of foreign HCPs into the workforce. In 2023, a further 300 physicians have been recruited by the Portuguese government; however, not all are practising, as the accreditation system in place is highly complex, posing significant challenges to international HCPs wanting to migrate to Portugal. Additionally, relying on immigration to fill workforce gaps does not address underlying issues: low wages, limited career opportunities, and challenging working conditions.
Another concern is one of image; international HCPs are supported through free accommodation and meal subsidies. This is not offered to national HCPs, leading to a sense of unfairness and drawing significant criticism, and potentially pushing them out.
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The major goal of a health system is to improve the health of its users; for this, there must be an appropriately trained workforce with high enough numbers sustaining it. Human resources (HR) influence the service efficiency, supporting the delivery of fair and equitable healthcare; practising HCPs in Portugal feel there has been a worsening of the quality of care delivered since 2008.
So to understand the reasons behind the HCP migration from Portugal, we must look into “push” and “pull” factors. The training of high numbers of HCPs that does not match available vacancies drives unemployment; simultaneously, those in employment are lowly remunerated, having to work several jobs. Poor working conditions, high workloads and limited access to career advancements are additional “push” factors driving HCPs abroad.
These factors led to a resurgence in emigration from 2001, and have been aggravated by the 2008 global economic crisis. The Economic and Financial Adjustment Programme implemented within the 2011 MoU included measures targeting the cost-efficiency of the public sector. NHS expenditure was reduced by 10% between 2010 and 2014, through mergers between public sector hospitals, investments in health promotion, changes to the financing system (adding co-payments), cutting salaries and overtime rates, freezing careers, limiting recruitment (thus increasing unemployment) and increasing working hours from 35 to 40/week.
Within the same timeframe, the main country of choice for Portuguese HCPs, the United Kingdom (UK), also underwent changes to its healthcare market. These would become major “pull” factors. Although there is no centralised database, migration trends from Portugal to the UK are similar across all HCPs; e.g. the number of Portuguese nurses registered to work in the UK increased from 20 to 550 between 2006/2007 and 2011/2012. Easier access to employment, better working conditions and salaries, training and career growth opportunities have pulled HCPs into the country.
Visa and professional requirements in the UK were tightened in 2006, and EU states became important sources of HCPs in comparison to former colonies. Preceding this, in 2005, mutual recognition of diplomas was implemented in the EU, facilitating worker mobility. Without an ethical code regarding international recruitment, health agencies flooded the Portuguese market, actively recruiting candidates from the pool of unsatisfied and/or unemployed HCPs. Despite the creation of a Global Code of Practice on the International Recruitment of Health Personnel by the World Health Organisation, its adherence is voluntary.
There is a consensus that the development of the healthcare workforce is key to retaining professionals and accelerate work towards universal healthcare. However, Portugal has not learned from its challenges in the beginning of the millennium and such HR reforms are yet to be thought out and implemented. There are other measures that could be explored.
One solution would the implementation of task-shifting, redistributing healthcare responsibilities and alleviating physician workloads. By delegating tasks to nurses and allied health professionals, doctors can focus on more complex cases, improving efficiency and patient outcomes. This would prove effective in the development of new avenues for professional advancement, offering national HCPs prospects for growth, improving job motivation. However, such initiatives face regulatory barriers, particularly regarding the legal definition of medical acts ("ato médico"). Current regulations restrict the scope of practice for non-physicians, limiting their ability to take on additional responsibilities. This has been challenged by the Organisation for Economic Co-operation and Development but not yet acted on, due to opposition by medical lobbyists and unions. Addressing such barriers and promoting interdisciplinary collaboration is essential to realising the potential benefits of task-shifting in the Portuguese NHS.
A further measure documented to increase staff retention is the introduction of new technology, e.g. robots and artificial intelligence. Not only would the deployment of these tools improve HCPs’ workloads, it would also increase professional development and learning opportunities.
Finally, to support with long-term HR planning, a monitoring system for migrating HCPs is recommended, through which capacity and demand planning can occur. This system, by documenting reasons for the HCP outflow, can inform sustainable policy actions regarding the healthcare workforce in Portugal.
HCP migration poses significant challenges to the Portuguese NHS, and the strategies so far designed to overcome them have proved inefficient and controversial; their effectiveness depends on addressing economic and structural factors. Comprehensive reforms to improve the attractiveness and sustainability of the Portuguese NHS are necessary for sustainable, long-term change. As of 2016, the National Health Plan did not address the issue of HCP migration, signalling that this may not be seen as a result of policy failures. It is only by addressing the underlying factors and implementing targeted interventions that Portugal can build a resilient and sustainable workforce that meets the growing needs of its population.
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Health information officer at Tafo government hospital
2 个月Thanks for sharing this I am a health information manager in Ghana and I would love to practice in Portugal What are the requirements and the steps to take?
Chief Cardiac Physiologist, BSc (Hons) in Cardiac physiology Specialized in adult echocardiography and Valve Clinic
10 个月Great insights
Senior Clinical Vascular Scientist at Imperial College Healthcare NHS Trust
10 个月Hi Cristiana, Thank you for sharing this insight into the Portuguese Healthcare System. Truly enjoyed the reading and fully agree on the need for major reforms. These changes seemed to be in the horizon until very recently, but there’s some uncertainty at the moment because the most senior policy-makers can’t agree on a long-term strategy. As you highlighted, adequate Human Resources and and clear allocation of responsabilities for each professional group are absolutely vital. Despite the tax relief, the program “Regrassar” does not seem to be attractive because healthcare professionals do not feel they are returning to a system that supports or values their continuous professional development, as it happens in other European countries. The exodus of nurses and physiologists is widely known, but doctors are also departing from the country in great numbers. Portugal, a country that exports high quality healthcare but has no economic return for the education and training of the younger generations. Thank you again.