A tale of loss of privilege, resilience and change: the impact of the economic crisis on physicians and medical services in Portugal
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.
Section snippets
Background
The Portuguese health care system is broadly organised into three overlapping sub-systems; the National Health Service (NHS), the private-public subsystems linked to individual employers and professions, and the private health care insurances. The Ministry of Health coordinates provision of services across the three subsystems, and consumers can opt to belong to more than one system at the same time. Healthcare is funded through general taxation, by subsystem specific payments, by premiums for
Methods
We drew from the economic theory to understand the possible impact of the economic crisis on physicians and on markets for medical services. We also drew from the medical and psychological literature to explore individuals’ resilience, particularly doctors’ burnout and their ability to resist stress and wearing workloads [23], [24], [25]. We asked physicians about changes in their public and private sector working hours between 2010 and 2015, and at their intentions to migrate, under the
Study findings
Drawing from the study’s methodological approach for understanding the impact of the crisis, findings are organised into direct changes brought in by the crisis in physicians’ work, their perceptions on the general impact of the crisis on the wider market for medical services, and finally, physicians’ adaptation and coping strategies developed in the face of the above changes.
Discussion
According to those interviewed, the economic crisis appears to have brought considerable changes for physicians in Portugal in terms of salary cuts, working routines and loss of privileges, as well as for the country’s market for medical services. Physicians reported to be grudgingly adapting to such changes, with few considering leaving the public sector or the country, and a flurry of very diverse coping strategies emerging for different employment institutions and levels of seniority. As we
Conclusions
We used an economic approach to interview physicians, policy-makers and health managers in Portugal to gain a perspective on the impact of the economic crisis on physicians and on the market for medical services in the country. Our findings show that the crisis has indeed brought changes for physicians as well as for the country’s market for medical services, but that physicians are reported to be adapting to such changes, with few considering leaving the public sector or the country, and a
Acknowledgments
The present paper is based on the findings from a wider study funded through a Banco Santanter Totta unrestricted research grant.
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