A tale of loss of privilege, resilience and change: the impact of the economic crisis on physicians and medical services in Portugal

Highlights

• We explored physicians’ perceptions of the impact of economic crisis and austerity measures in Portugal.

• Few physicians considered leaving the public sector and the country despite the loss of privileges.

• Diverse coping strategies are emerging depending on employment institutions and seniority.

• The crisis may have consolidated the private sector by shifting demand from public to the private.

• Physicians’ responses and resilience need better understanding before designing policies to retain them.

Abstract

That the current economic crisis is having an impact on population health and healthcare utilisation across Europe is fairly established; how national health systems and markets are reacting is however still poorly understood. Drawing from the economic literature we conducted 21 interviews with physicians, policy-makers and healthcare managers in Portugal, to explore their perceptions on the impact of the crisis on the country’s market medical services, on physicians’ motivation, and the ensuing coping strategies. Interviews were recorded, transcribed and analysed using NVivo software. We show that despite the crisis, few physicians reported considering leaving the public sector and the country, and very diverse coping strategies are emerging, depending on the respective employment institutions and seniority. In spite of the changes in patient case-mix, demand for medical services may not have necessarily increased, having shifted from public to private, with many highlighting the contribution of the current crisis in consolidating the private sector. In order to maintain their pre-crisis living standards amidst deteriorating salaries and increasing controls, hospital physicians have resorted to strategies such as shifting hours to the private, and primary care ones to anticipating their retirement. Migration was reported to be an option only for the younger and older doctors. Our study suggests the existence of resilience among Portuguese physicians and in the country’s market for medical services, which, if corroborated by further research, will need to be taken into account by national health policies.

Introduction

The current economic and financial crisis is widely expected to have an impact on the health of the Europeans [1], [2]. Because of the combination of decrease in consumers’ disposable income, raising unemployment and austerity measures introduced by governments, there are signs that population health status, demand for health care and health policies are beginning to be affected in hard-hit countries like Greece [3], Italy [4], Spain [5] and Ireland [6]. Recent work has also focussed on the resilience of health systems under economic duress [7], [8].

Physicians’ availability, performance and satisfaction are widely considered as key health system issues for any country, with substantial public health implications [9]. Physicians are arguably the most pivotal and expensive resource in any health systems in high-income countries; although it is fairly established that economic expansion drives up physicians supply and utilisation [10], it is unclear what happens to these in the case of economic recession, with some models predicting a lesser impact on the physician labour market [11]. On the other hand, lack of employment opportunities and salary differentials have been proved to be key factors behind physicians migration [12], [13].

In Portugal, substantial cuts in drug expenditures, hospital budgets, workforce wages, and increase in user charges (though coupled with an increase of people exempted from their payment), were some of the austerity measures introduced by the government in the health sector between 2011 and 2013. Although it is still unclear to what extent some of these measures will truly affect the poor in Portugal [14], evidence exists that the crisis will have an impoverishing effect on the Portuguese [15], and that it is already affecting their utilisation of hospital services [16]. Reports exist of physicians’ dissatisfaction with current working conditions and their ensuing intention to leave the country, but to our best knowledge no thorough exploration has been conducted of physicians’ adaptation to the crisis.

The present paper is part of a wider study on the impact of the economic crisis on the Portuguese health market [18]. Here we specifically explore physicians’ perceptions of the changes brought on by the crisis and associated austerity measures to the market for medical services, as well as to their working routines, remuneration and intention to leave the sector. The research ultimate objective is to generate hypotheses on the impact of the crisis on provision of medical services and on physicians’ labour market to be later tested quantitatively, thus providing an evidence base to design policies to protect population’s access to medical services.