HIGHLIGHTS ON HEALTH IN PORTUGAL

Spain

VIANA DO CASTELO VILA REAL BRAGA BRAGANÇA PORTO

VISEU AVEIRO

GUARDA Atlantic ocean COIMBRA

LEIRIA CASTELO MADEIRA BRANCO

SANTAREM Spain

LISBOA PORTALEGRE

EVORA AÇORES SETUBAL

BEJA

FARO

Country Highlights give an overview of the health and health-related situation in a given country and compare, where possible, its position in relation to other countries in the WHO European Region. The Highlights have been developed in collaboration with Member States for operational purposes and do not constitute a formal statistical publication. They are based on information provided by Member States and other sources as listed.

Contents

OVERVIEW ...... 3

THE COUNTRY AND ITS PEOPLE ...... 5

HEALTH STATUS ...... 9

LIFESTYLE ...... 25

ENVIRONMENT ...... 29

HEALTH SYSTEM ...... 32

REFERENCES ...... 36

WHO Regional Office for Europe European Commission

HIGHLIGHTS ON HEALTH IN PORTUGAL 1 JULY 1997 DRAFT This project to develop Highlights for the 15 EU countries received financial support from the European Commission.

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2 HIGHLIGHTS ON HEALTH IN PORTUGAL OVERVIEW

AN OVERVIEW OF THE HEALTH SITUATION

Positive trends Negative trends

Life expectancy in Portugal improved rapidly Although infant mortality in Portugal has nearly during the 1970s, and after 1980 it rose at about halved since 1980 (the largest reduction observed the same rate as the average of the countries that among the reference countries), the infant now comprise the European Union (EU). In mortality rate was still the highest in 1993. 1993, it nevertheless remained shorter than that Mortality of Portuguese men aged 15–34 years in all the reference countries.1 is more than three times higher than that of The standardized death rates (SDRs) of women in this age group. To a large extent this Portuguese men and women aged 0–64 years for excess male mortality is due to accidents and ischaemic heart disease was one of the lowest other violent deaths. among the reference countries in 1993, even though the decrease over the preceding ten years As the SDRs for all cardiovascular diseases had been less than the EU average. (CVDs), including cerebrovascular disease, have dropped by less than in most of the reference Female mortality from all cancers has been countries, the death rate for CVDs has remained declining since the early 1970s: in 1993 it was above the EU average; for cerebrovascular the fourth lowest among the reference countries. diseases the SDR is the highest. Lung cancer, and especially cancer of the breast, have on the other hand shown a rising trend Portugal is one of the few countries where during the 1980s, although these SDRs were still mortality of men aged 0–64 years from all among the lowest in 1993. cancers and cancer of the lung rose during the 1980s. However, in 1993 male SDRs for these The population’s Mediterranean nutrition causes were still among the lowest in the patterns seem fairly healthy. The proportions of reference countries. adult and adolescent female smokers are still the lowest among the reference countries. Although the SDR for road traffic accidents declined by more than in most of the reference countries, in 1993 it was still the highest.

1 The 15 countries of the European Union (EU) plus Iceland, Norway and Switzerland.

HIGHLIGHTS ON HEALTH IN PORTUGAL 3 METHODOLOGICAL REMARKS

METHODOLOGICAL REMARKS

Highlights on Health provide an overview of the health of a country’s population and the main factors related to it. Based on international comparisons, they present a summary assessment of what has been achieved so far and what could be improved in the future. In order to enlarge the basis of comparison beyond the EU, data for Iceland, Norway and Switzerland have also been included where available and relevant. A special case of comparison is when each country is given a rank order. Although useful as summary measures, ranks can be misleading and should be interpreted with caution, especially if used alone, as they are sensitive to small differences in the value of an indicator. Also, when used to give an assessment of trends (e.g. the table at the start of the Health Status section), ranks can hide quite important changes within an individual country. Therefore bar charts (to show changes over a relatively short period) or line charts (to show time trends from 1970) have also been used. Line charts present the trends for all the 15 EU countries and their averages, although only the country referred to in a specific Highlight and the EU average are identified. This makes it possible to follow the country’s evolution in relation to that of other EU countries and to recognize how it performs in relation to observable clusters and/or the main trend. In general, the average annual or 10-year percentage changes have been estimated on the basis of linear regression. This gives a clearer indication of the underlying changes than estimates based on the more simple and straightforward percentage change between two fixed points over a period. For mortality indicators, countries with small populations (e.g. Luxembourg or Iceland) can have fluctuating values, and in these cases three-year moving averages have been used. For maternal mortality, because the number of deaths is in general small, three-year moving averages have been calculated for all countries. Where possible (and where relevant for trend comparisons), data for Germany up to 1990 refer to the Federal Republic within its current territorial boundaries. To make the comparisons as valid as possible, data for each indicator have as a rule been taken from one common international source (e.g. WHO, OECD, International Labour Office) or from Eurostat (the Statistical Office of the European Communities) to ensure that they have been harmonized in a reasonably consistent way. It should also be noted that other factors (such as case ascertainment, recording and classification practices and culture and language) can influence the data at times. Unless otherwise mentioned, the source of the data used in the charts and tables is the WHO Regional Office for Europe’s HFA statistical database (June 1995, version with 1992 or 1993 data). The latest data available to WHO as of August 1996 are mentioned, as appropriate, in the text.

4 HIGHLIGHTS ON HEALTH IN PORTUGAL THE COUNTRY AND ITS PEOPLE

THE COUNTRY AND ITS PEOPLE

Portugal is a sovereign unitary republic with a written regions, municipalities and parishes) has its constitution that came into force in 1982. Executive representative body elected by direct universal power is vested in the President of the Republic, suffrage. elected for five years by universal suffrage. The Portugal has been a member of the European Union President appoints a Prime Minister and, on the (EU) since 1986.2 latter’s nomination, other members of the Council of Ministers. Legislative power is vested in the unicameral Demography Parliament, the Republic Assembly, whose members are elected by direct universal suffrage under a The population pyramid illustrates the changes in the proportional representation system. population structure between 1970 and 1994. The Since 1976 the archipelagos of the Açores and most striking feature is the decline in the younger Madeira have been autonomous regions with their age group due to lower fertility. In 1994, the total own legislatures and governments. Mainland fertility rate was only 1.4, far below replacement level Portugal is divided into 18 districts. Both regions and (Council of Europe 1995). Therefore, the proportion districts are divided into municipalities and of the population aged under 15 years has declined subdivided into parishes. Each level (autonomous to 18%. On the other hand, due to increasing

2 These introductory paragraphs are based on material from the Statesman's Year–Book (Hunter 1994, 1995)

Age pyramid (1970 and 1994)

Age group 85+ 1970 80-84 1994

75-79 Males70-74 Females

65-69

60-64

55-59

50-54 45-49 40-44 35-39

30-34

25-29

20-24 15-19 10-14 5-9 0-4

500000 400000 300000 200000 100000 0 0 100000 200000 300000 400000 500000 Population

HIGHLIGHTS ON HEALTH IN PORTUGAL 5 THE COUNTRY AND ITS PEOPLE longevity, the proportion of the population aged 65 resources available for help with housekeeping and and over is rising steadily and now accounts for 14% personal hygiene. Social exclusion may also result while those aged 85 years and over account for 1% in isolation which can threaten mental health. These of the population (Eurostat 1996). This aging process issues affect the costs and organization of health care. is even more pronounced for women. They The situation might, however, be less serious in increasingly outnumber men from as early as 30 Portugal than in other European countries, since the years, and in 1994, 70% of the population aged 85 traditional household and family composition could and over were women. have a protective effect. As a result of the low fertility, in 1994 the population growth rate was with 0.2% one of the lowest among the reference countries, due half to natural increase Migrant population and ethnic profile and half to net migration (Council of Europe 1995). Official statistics show 131 593 foreigners living in Portugal, mostly from other EU countries but also Household composition and family from Africa and Latin America. This number is structure growing fast (Council of Europe 1994). In addition, at the end of the 1980s an estimated 60 000–70 000 As in the other southern European countries, average illegal immigrants were living in Portugal household size is still comparatively high at 3.1 (Commission of the European Communities 1991). persons per private household, while the percentage This illustrates the extent of the structural and of couples without (dependent) children is the third administrative challenges facing the southern lowest in the EU. Half the population lives in European countries since the number of immigrants households consisting of a couple with dependent began to exceed the number of emigrants (during the children. past decades many Portuguese have emigrated to countries such as France and Germany). Illegal The proportion of people living in single-person immigrants are likely to be at a higher risk of ill health households, albeit growing, is the second smallest in due to poor social integration. Immigrants from ethnic the EU (Eurostat 1995d). However, single-person minorities can have specific patterns of disease and households are likely to comprise elderly women. health needs because of genetic and behavioural The health and wellbeing of elderly people living factors and exposure to different environments in alone can be significantly affected by the financial their countries of origin. Access to health care that

Demographic trends and structure

1995a 2015b POR EU POR EU 1000s % 1000s % 1000s % 1000s %

Population 9 912 371 563 10 799 393 243 Urban populationc 35 78 Distribution by age: 0–14 years 1 784 18.0 65 423 17.6 2 108 19.5 68 389 17.4 15–64 years 6 698 67.6 249 000 67.0 7 067 65.4 255 078 69.4 65+years 1 431 14.4 57 140 15.4 1 624 15.0 69 776 17.7 85+ years 99 1.0 6 015 1.6 135 1.2 7 951 2.0 Total fertility rated 1.4 1.5 Dependency ratio 48.0 49.2 52.8 54.2

a As per 1st January 1995 (Eurostat 1996) b Forecast, Eurostat intermediate scenario c 1993 (UNDP 1996) d 1994 (Council of Europe 1995)

6 HIGHLIGHTS ON HEALTH IN PORTUGAL THE COUNTRY AND ITS PEOPLE can meet such specific needs or that is culturally and linguistically acceptable can also be difficult. Percentage of people with at least Moreover, immigrants can be at a higher risk of living secondary education (higher level), 1993 in relative poverty and being marginalized in their Women host countries, which can exacerbate their diseases. Men Illegal immigrants in particular can find it difficult to use health care, and follow-up to any care given POR EUa POR EU can be problematic. Total (25–59 years) 21 54 22 64 55–59 years old 8 35 11 52 25–29 years old 36 69 28 70 a Education Excluding Italy (data not compatible) Source: EUROSTAT 1995c The relevance of educational attainment to health has been well documented. In Europe, where primary education is universal, the proportion of the group, 15% of women obtain a higher degree against population with more than a lower secondary 9% of men (Eurostat 1995c). Another study shows education would be the appropriate indicator for that at 16–18 years 15% more girls than boys are educational achievement. A recent survey on undergoing education (Eurostat 1995d). education of the workforce in the former 12 EU countries (Eurostat 1995c) shows that in this respect As women work more frequently outside the home, Portugal still lags somewhat behind the other EU the availability of preschool facilities becomes more countries: only about 25% of the adult population and more important for children’s social integration have attained at least an upper secondary education. and mothers’ and children’s psychosocial wellbeing. The situation is, however, improving, as among the In Portugal, preschool education provided by the group aged 25–29 years, some 35% achieved an authorities up to now is not available for all children upper-secondary or higher educational level. aged 3 years until the beginning of compulsory Furthermore, there is no sign that women have had education at 6 years (Eurostat 1995d). less access to education. Indeed in the younger age

Private households by type in the EU, (1990–1991)

Couples with children Other private household One person household Single parent household Couples without children 100

80

60

40

20

0 SWE DEN DEU FIN NET AUT BEL FRA EU UNK LUX ITA IRE GRE POR SPA Source: EUROSTAT 1995e

HIGHLIGHTS ON HEALTH IN PORTUGAL 7 THE COUNTRY AND ITS PEOPLE

Economy

The economy includes both private and public Basic economic data sectors. A programme of privatization is under way. Although the economy has benefited from EU Indicator POR EU membership since 1986, Portugal is still one of the less wealthy EU countries. In the early 1990s: GNP per head (US$,1992) 7 510 20 043 • agriculture remained important, employing Real GDP per head 12% of the civilian workforce although it only (PPP US$,1992) 9 850 17 792 accounted for 6% of the GDP in 1994; Source: UNDP 1995 • industry employed 33% of the civilian workforce and represented 37% of the GDP. Industry is dominated by the manufacture of textiles and footwear; 14.5% below the EU average, 35% of all • services accounted for 61% of the GDP, em- unemployed people are under 25, which is slightly ploying 56% of the civilian workforce; with higher than the EU average. Women comprised 44% more than 20 million visitors in 1992, tour- of all people in civilian employment, which is nearly ism is important in Portugal but its seasonal 10% above the EU average (Eurostat 1995a). nature and the probable large numbers of ille- The underground economy, which involves an gal immigrants working in this area mean that estimated 17% of the active population, is a serious it is difficult to assess its impact on employ- problem (Morin 1995). ment. In 1992, Portugal spent 18% of its GDP on social Unemployment stood at nearly 7% of the workforce protection (the lowest percentage in the EU), most in 1994. While the unemployment rate among the of it on old age and sickness benefits (Eurostat 1994). active population aged less than 25 years was with

GDP (PPSa), 1992 Expenditure on social protection as percentage of GDP, 1992

Greece Greece Portugal Portugal Spain Spain Ireland Ireland Finland Finland United Kingdom United Kingdom

Sweden Sweden Netherlands Netherlands Italy Italy Denmark Denmark Germany Germany Austria Austria Belgium Belgium France France Luxembourg Luxembourg 0 5000 10000 15000 20000 25000 010203040 GDP per head Percentage

a EU unit of purchasing power parity (PPP) Source: EUROSTAT 1995a

8 HIGHLIGHTS ON HEALTH IN PORTUGAL HEALTH STATUS

HEALTH STATUS

A description of the population’s health status against • death rates for cardiovascular diseases the background of the 18 European reference (CVDs) in the population aged 0–64 years countries3 shows that, despite considerable showed one of the smallest reductions since improvements in some areas, on the whole Portugal 1980, leading to a fall in the relative position lags behind (see chart below). The comparative in 1993; positions for some key health indicators were: • as regards cancer mortality, Portugal is in dan- • life expectancy remained the lowest in 1993; ger of losing its previous advantage over the other European countries as there has been • even though infant mortality nearly halved little reduction, or even substantial increases, during the preceding ten years (the largest re- in death rates for cancer among the group aged duction observed among the reference coun- 0–64 years in recent years; in particular, male tries), Portugal still has the highest rate; mortality from all cancers and cancer of the • maternal mortality improved from the last to lung and female mortality from cancers of the the penultimate position, notwithstanding a breast and cervix rose during the 1980s; marked reduction; • mortality from road traffic accidents remained the highest; suicide rates, on the other hand,

3 See footnote 1 on page 3

Portugal relative to 18 European countries in 1980 l and latest available year (1991–1993) K BEST WORST

a b POSITION 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 POR EU Min. Max. 74.2 76.8 74.2 79.0 Life expectancy at birth (years) K 7.3 6.4 3.8 8.5 Male/female difference in life expectancy at birth (years) K 8.7 6.8 4.4 8.7 Infant mortality rate per 1000 live births K 9.2 6.5 0.0 11.7 Maternal death, all causes, per 100 000 live birthsc J l 65.3 60.1 38.5 81.7 SDRd, cardiovascular diseases, age-group 0–64 l L 24.5 31.7 14.8 56.6 SDR, ischaemic heart disease, age-group 0–64 l L 25.7 11.5 5.1 25.8 SDR, cerebrovascular disease, age-group 0–64 K 78.2 87.4 66.8 97.1 SDR, cancer, age-group 0–64 K 12.1 19.0 11.7 24.8 SDR, trachea/bronchus/lung cancer, age-group 0–64 l L 2.5 2.3 0.0 4.0 SDR, cancer of the cervix, age-group 0–64, females l L 16.9 19.8 14.6 36.1 SDR, cancer of the breast, age-group 0–64, females l L 57.7 47.0 30.6 79.3 SDR, external causes of injury and poisoning l L 9.7 13.0 6.7 23.2 SDR, motor vehicle traffic accidents K 7.4 11.7 3.7 26.5 SDR, suicide and self inflicted injury J l

J Position improved 2 (indicators) Note: a) Lowest value observed among 18 European countries. b) Highest value observed among 18 European countries. K Position unchanged 6 (indicators) c) 3 years moving averages. L Position deteriorated 6 (indicators) d) SDR: Standardized death rate.

HIGHLIGHTS ON HEALTH IN PORTUGAL 9 HEALTH STATUS

are still among the lowest. classes. A newborn baby’s chances of surviving, for Measures relating to the total population often hide example, vary markedly with its mother’s educational important differences between segments of that level (DEPS 1995: 74f). Death rates for the main population, for instance between men and women. causes of mortality, including infant mortality, also In general, women have higher morbidity but lower vary geographically between the districts and death rates than men. As a result, Portuguese autonomous regions (DEPS 1995: 70ff, 83ff). women’s life expectancy at birth (77.9 years in 1993) is 7.3 years longer than men’s (70.6 years), one of the widest gaps among the reference countries. Similar differences can be observed between social

Life expectancy at birth, males Life expectancy at birth, females

85 85

80 80

75 75

70 70

65 65

POR POR EU EU 60 60 70 72 74 76 78 80 82 84 86 88 90 92 70 72 74 76 78 80 82 84 86 88 90 92 Year Year

Life expectancy at age 65, males Life expectancy at age 65, females

25 25

20 20

15 15

POR POR EU EU 10 10 70 72 74 76 78 80 82 84 86 88 90 92 70 72 74 76 78 80 82 84 86 88 90 92 Year Year

10 HIGHLIGHTS ON HEALTH IN PORTUGAL HEALTH STATUS

Loss of life expectancy due to deaths before 65 Loss of life expectancy due to deaths before 65 years, males years, females

15 15

POR POR EU EU

10 10

5 5

0 0 70 72 74 76 78 80 82 84 86 88 90 92 70 72 74 76 78 80 82 84 86 88 90 92 Year Year

Life expectancy Main causes of death

Trends for life expectancy at birth and at 65 years Cancers are the most frequent cause of death under rose markedly for both sexes after 1970 but less the age of 65 years, followed by CVDs. However, noticeably during the 1980s, especially for men. In over all ages the situation is reversed and CVDs cause 1993, Portuguese women shared the lowest position more deaths than cancers. A more detailed analysis for life expectancy at birth (77.9 years) with Danish of age-specific mortality patterns shows that the women and for life expectancy at the age of 65 years causes of up to 80% of all deaths in each age group (17.3 years) with Irish women. Male life expectancy can be classified in three main categories: external at birth (70.6 years) is 1.5 years lower than that of causes4 (which claim the highest number of lives the next lowest (Finns), while at the age of 65 only (DEPS 1995: 76ff) until the age of 35 years), cancers men from Ireland have a somewhat lower life and CVDs. expectancy than those from Portugal (13.6 years). A comparison between countries of standardized The most recent data (1994), however, indicate a death rates (SDRs) related to these causes can indicate rapid increase of life expectancy for both sexes and how far observed mortality might be reduced. As in particular for men. almost all causes underlying these deaths are A country’s position as regards life expectancy at influenced by collective and individual habits and the age of 65 years and loss in life expectancy due to behaviour, a wide variety of health promotion and premature death (i.e. deaths before the age of 65 prevention measures can be applied to bring about years) gives some indication of the potential for changes that will reduce health risks and thus diseases improving overall life expectancy. and premature death. Although female mortality before the age of 65 years The most striking features of the Portuguese age- and showed the second largest decrease among the sex-specific death rates are the extremely high reference countries during the last ten years, women mortality of both boys and girls aged 1–14 years still have the second highest premature mortality rate compared to that in other EU countries, the very and men, having experienced only a slight marked excess male mortality between the age of 15 improvement, the highest. and 64 years, and in all age groups by far the biggest

4 This category includes all mortality due to poisoning, suicide, homicide and all types of accident.

HIGHLIGHTS ON HEALTH IN PORTUGAL 11 HEALTH STATUS

Main causes of death by age and sex group, 1992/1993 (standardized death rates per 100 000 by age and sex group)

Age 1–14 Age 15–34 60 200 Males Females Males Females

160

40 120

80 20

40

0 0 Minima POR POR Minima Minima POR POR Minima

All other Congenital anomalies All other Cardiovascular diseases Cancer Nervous/sensory system Cancer Nervous/sensory system External causes External causes

Age 35–64 Age 65+ 800 8000 Males Females Males Females

600 6000

400 4000

200 2000

0 0 Minima POR POR Minima Minima POR POR Minima

All other Cardiovascular diseases All other Digestive diseases Cancer Digestive diseases Cancer Respiratory diseases External causes Cardiovascular diseases

Minima: smallest SDR values observed in the particular group. Dashed line: lowest overall death rate observed in a single EU country.

These charts show age- and sex-specific death rates for the main causes of death in Portugal in 1993. These rates are compared with the lowest corresponding rate observed in any country of the EU, which can thus be considered as a reference value potentially attainable by other countries. The sum of these minima, however, has to be considered as an artificial value which is sensitive to different national coding practices or coding errors. The dashed lines show the smallest overall SDR observed in any one EU country.

12 HIGHLIGHTS ON HEALTH IN PORTUGAL HEALTH STATUS proportion of deaths in the category of all other • At 65 years and over, women have the highest causes, including large numbers of deaths due to age-specific overall mortality in the EU and “signs, symptoms and ill-defined conditions” (DEPS men the second highest. The SDR for CVDs 1995: 76ff). is also the highest for women and among the highest for men, whereas cancer mortality is • At 1–14 years, the total age-specific death rate the third lowest for both sexes. Men also have is by far the highest in the EU for both sexes the highest death rate for diseases of the di- and double the EU average for boys. Both boys gestive system. Both the female and male SDR and girls have the highest SDRs for accidents for the residual category of “all other causes” and second highest for cancers; boys also have are much the highest among the EU countries. the highest mortality from diseases of the di- gestive and nervous systems (including the This analysis of age-specific mortality patterns shows sensory organs). that the greatest potential for reducing mortality lies in improving the health of children and in the • At 15–34 years, both sexes still have the high- prevention of accidents and cancers among young est overall death rate of the EU countries. The people and cardiovascular and digestive diseases male overall death rate is more than three times among older people. The high mortality rates across higher than the female, and for accidents five all ages for the “signs, symptoms and ill-defined times higher. Both sexes also have the high- conditions” category, particularly in the north-east est SDRs for cancers and diseases of the di- (DEPS 1995: 84), also deserve special attention. gestive system of all people in this age group in the EU. • At 35–64 years, men still have the highest overall mortality in the EU. Whereas mortal- Cardiovascular diseases ity from cancer is below the EU average for both sexes, SDRs for CVDs are comparatively The overall trend in SDRs from CVDs in the high, especially for women. Furthermore, men population aged 0–64 years has been falling since rank third highest for accidental deaths, sec- 1970 in western Europe. This downward trend has ond highest for deaths due to diseases of the been mirrored in Portugal since the mid-1970s; in digestive system, and highest for deaths due 1993, nevertheless, the SDR for women from CVDs to respiratory diseases, although the latter are was among the highest of the reference countries and less frequent. that for men around the EU average. Despite a comparatively small reduction in mortality

Standardized death rates, cardiovascular Standardized death rates, cardiovascular diseases, males aged 0–64 diseases, females aged 0–64

350 350

POR POR EU 300 300 EU

250 250

200 200

150 150

100 100

50 50

0 0 70 72 74 76 78 80 82 84 86 88 90 92 70 72 74 76 78 80 82 84 86 88 90 92 Year Year

HIGHLIGHTS ON HEALTH IN PORTUGAL 13 HEALTH STATUS from ischaemic heart disease during the last ten years, half times higher in 1993 than the EU average. both sexes had relatively low SDRs due to this cause Moreover, for both sexes only a modest (below in 1993. A strong north-south gradient exists as average) reduction in these rates has taken place regards SDRs for people aged 0–64 years: they are during the last ten years. Geographical variations have more than twice as high in some southern regions also been observed for cerebrovascular disease, with and Lisbon (DEPS 1995: 83ff, de Sa et al. 1994). the highest SDRs in the north-west (DEPS 1995: Portuguese women and men aged 0–64 years have 83ff). particularly high mortality from cerebrovascular disease, with SDRs respectively two and two and a

Standardized death rates, cancer, Standardized death rates, cancer, males aged 0–64 females aged 0–64

150 150

POR EU

125 125

100 100

75 75

POR EU 50 50 70 72 74 76 78 80 82 84 86 88 90 92 70 72 74 76 78 80 82 84 86 88 90 92 Year Year Percentage change over most recent 10 years Percentage change over most recent 10 years

France Denmark Italy Iceland 27.5 Belgium Ireland Luxembourg United Kingdom Spain Netherlands EU Belgium Germany Luxembourg Austria Germany Portugal Austria Denmark Norway Netherlands EU United Kingdom Sweden Ireland Italy Greece Switzerland Switzerland Portugal Norway France Finland -20.5 Finland Sweden Spain Iceland Greece -20 -15 -10 -5 0 5 10 15 20 -20 -15 -10 -5 0 5 10 15 20 Percentage Percentage Rank order from country with highest SDR to country with Rank order from country with highest SDR to country with lowest SDR in 1992 lowest SDR in 1992

14 HIGHLIGHTS ON HEALTH IN PORTUGAL HEALTH STATUS

Cancer effect of an almost 5% increase during the last ten years, while in the same period the EU As in other European countries, cancer mortality in average went down by 4%. The development the population aged 064 years shows clear gender- as to lung cancer was even more pronounced: specific patterns and trends. male death rates in 1993 still ranked fourth • For men, death rates for all cancers have risen lowest but with an increase of 28% Portugal steadily over the last two decades from a very was one of the only five countries where an low position in 1970 to a medium position in upward trend has been recorded, in contrast 1993. The last SDR is still somewhat below to a 4% fall in the EU average. the EU average, but it nevertheless mirrors the • SDRs for women aged up to 64 years, how-

Standardized death rates, cancer of the Standardized death rates, cancer of the trachea/bronchus/lung, males aged 0–64 trachea/bronchus/lung, females aged 0–64

60 60 POR EU POR EU 50 50

40 40

30 30

20 20

10 10

0 0 70 72 74 76 78 80 82 84 86 88 90 92 70 72 74 76 78 80 82 84 86 88 90 92 Year Year

Percentage change over most recent 10 years Percentage change over most recent 10 years

Belgium Denmark Italy Iceland France United Kingdom Luxembourg Netherlands Netherlands Ireland Greece Norway EU Sweden Spain Switzerland Germany Austria Austria EU Denmark Germany United Kingdom Belgium Switzerland Luxembourg Finland Italy Ireland Greece Portugal Finland Norway France Sweden Portugal Iceland Spain -60 -30 0 30 60 90 -60 -30 0 30 60 90 Percentage Percentage Rank order from country with highest SDR to country with Rank order from country with highest SDR to country with lowest SDR in 1992 lowest SDR in 1992

HIGHLIGHTS ON HEALTH IN PORTUGAL 15 HEALTH STATUS

ever, followed the main trends in SDRs for Portuguese women has been rising faster than women in western Europe, with a slight de- the EU average (see also the section on wom- crease for all cancers and increase for cancer en’s health page 21). of the lung over the last ten years. In 1993, the Cancer mortality also varies between the regions, country kept its good position for overall can- with relatively low rates in the north-east and the cer mortality as well as its second lowest po- highest rates in Viana Castelo, Oporto, Beja, Lisbon sition for cancer of the bronchus and lung. On and Setúbal (DEPS 1995: 83f). the other hand, the trend for mortality from cervical cancer moved in the opposite direc- tion to the EU average, rising slightly during the last decade, and breast cancer mortality in

Standardized death rates, external causes Standardized death rates, external causes of injury and poisoning of injury and poisoning, total population

200 Finland France POR, males POR, females 175 Luxembourg EU, males EU, females Denmark Portugal 150 Belgium Switzerland 125 Austria Norway 100 EU Germany 75 Italy Spain Sweden 50 Iceland Ireland

25 Greece 1980 Netherlands 1991/93 0 United Kingdom 70 72 74 76 78 80 82 84 86 88 90 92 0 20406080100 Year Deaths per 100 000

Standardized death rates, Standardized death rates, motor vehicle motor vehicle traffic accidents traffic accidents, total population

80 Portugal POR, males POR, females Luxembourg 70 EU, males EU, females Spain Greece 60 Belgium Italy France 50 Austria EU 40 Ireland Germany 30 Denmark Switzerland 20 Finland Netherlands Iceland 10 United Kingdom 1980 Sweden 1991/93 0 Norway 70 72 74 76 78 80 82 84 86 88 90 92 0102030 Year Deaths per 100 000

16 HIGHLIGHTS ON HEALTH IN PORTUGAL HEALTH STATUS

External causes of death and injury Psychosocial and mental health

This category covers all deaths that are not due to Although mental and psychosocial wellbeing are somatic deficiencies such as illness but mainly to important aspects of health-related quality of life, too accidents, (accidental) poisoning, violent acts little information is generally available to allow a (homicide) and suicide. The trend within the EU for reliable description of this very important dimension mortality from these factors, and in particular from of the population’s health. Suicide can be used as an road traffic accidents (which contribute the biggest indirect measure of mental disorder or lack of proportion of all deaths due to external causes), has psychosocial wellbeing. been falling since 1970. In contrast, a rising trend While women are more likely to attempt suicide, the was observed for Portuguese men and women until rate of Portuguese men actually committing suicide the early 1980s, when it began to fall. SDRs for all is three and a half times higher than that of women external causes are thus among the highest in men (12.2 against 3.4 per 100 000). Traditionally Portugal and average in women. has been among the countries with very low SDRs The risk of dying in a road traffic accident dropped for suicide, and during the last ten years the decreases by 16% over the last ten years but is still at the highest for both sexes were greater than the EU average. In level among the reference countries. Moreover, the 1993, women ranked third lowest and men fifth risk of being injured in such an accident has gone up lowest among the reference countries. by almost 70% and was the third highest at the beginning of the 1990s (706 per 100 000 against an EU average of 477). A reduction in both injury and AIDS death due to motor vehicle accidents seems possible if the appropriate measures are taken to improve safety on the roads and the chances of survival after The acquired immunodeficiency syndrome (AIDS) this type of accident. is essentially a sexually transmitted disease which can also be transmitted through blood (through the transfusion of infected blood or blood products and use of non-sterile injection equipment). There is a delay of about ten years or more between initial infection with the human immunodeficiency virus (HIV) and development of the clinical illness of

Standardized death rates, mortality from Standardized death rates, suicide and suicide and self–inflicted injury self–inflicted injury, total population

60 Finland Denmark POR, males POR, females Austria 50 EU, males EU, females France Switzerland Belgium 40 Luxembourg Sweden Norway 30 Germanyª EU Iceland 20 Ireland Netherlands United Kingdom Portugal 10 Spain 1980 Italy 1991/93 Greece 0 70 72 74 76 78 80 82 84 86 88 90 92 0 5 10 15 20 25 30 35 Deaths per 100 000 Year ª 1980 Federal Republic of Germany only

HIGHLIGHTS ON HEALTH IN PORTUGAL 17 HEALTH STATUS

AIDS. The number of notified cases of AIDS is rising Incidence of AIDS, 1987 and 1994 all over western and northern Europe, although (adjusted for reporting delays, 1992–1994) annual rates of new cases are far higher in the south. Taking into account reporting delays, Portugal had Spain an incidence rate of 6.7 cases per 100 000 population France in 1994, placing the country just below the EU Italy Switzerland average. EU By the end of March 1995, a total of some 2400 AIDS Portugal cases had been reported in Portugal and it is predicted Denmark Luxembourg that 800–1000 new cases per year could be expected United Kingdom after the mid-1990s (European Centre for the Netherlands Epidemiological Monitoring of AIDS 1994 and Belgium 1995). In the cases reported up to the beginning of Germany 1995, transmission by homo/bisexual contact and by Sweden injecting drug use accounted for 31% each, while in Austria Norway 27% of all notified AIDS cases the virus was Ireland 1987 contracted through heterosexual contact. Greece 1994 However, the very long incubation period means that Iceland these figures do not necessarily reflect the actual Finland 048121620 extent of the epidemic or the currently prevailing New cases per 100 000 modes of transmission. As no data about the incidence Source: European Centre for the Epidemiological of infections are available, the prevalence of HIV- Monitoring of AIDS 1995 positive people can only be estimated. According to

Numbers and distribution of HIV cases in adults and adolescents, by country and mode of transmission, estimated by back–calculation (Dec. 1991)

Homo/bisexual (male) Other Estimated Injecting drug use Heterosexual contact number of cases,1993 United Kingdom 33 351

Germany 22 353

Netherlands 6 727

Denmark 3 600

Greece 3 735

Belgium 3 937

Sweden 2 570

France 102 874

Switzerland 6 240

Austria 4 872

Ireland 1 737

Portugal 14 794

Italy 96 753

Spain 150 523 0 20 40 60 80 100 Percentage Source: European Centre for the Epidemiological Monitoring of AIDS 1994

18 HIGHLIGHTS ON HEALTH IN PORTUGAL HEALTH STATUS recent estimates (European Centre for the 60 years of age on the lists of disability pension funds. Epidemiological Monitoring of AIDS 1994), there According to this estimate, Portugal has the second were almost 15 000 HIV-positive people in Portugal lowest proportion of disabled people among the EU at the end of 1993. There is also likely to have been countries for which this information has been a shift in the distribution of HIV cases as to the compiled and markedly below the average of 11.5%. transmission mode. While elsewhere in Europe the As the study points out, it cannot be excluded that a largest increases are recorded in the heterosexual bias has been introduced by this method of estimation contact group, in Portugal transmission appears to because a relatively high degree of disability is be more through injecting drug use than through required for entitlement to a disability pension. homosexual contact. Based on back-calculated Although this has been taken into consideration, the prevalence estimates, at the end of 1991 injecting estimated proportion might be too low. drug-users accounted for 45% of all seropositive A comparison of the rates of disability pensioners cases in Portugal, followed by heterosexuals (25%) aged under 60 years shows that Portugal is in an and homo/bisexual men (22%). upper-medium position, with a rate of 5.4% compared Some 14% of diagnosed cases up to 1993 were in to an average of 4.7% in the EU. women. The epidemic is mostly concentrated in the According to a national health survey carried out in three biggest cities, with more than half of all cases 1990–1991 in the north and 1991–1992 in the south notified in Lisbon (DEPS 1995: 51ff). (the Alentejo region), the following chronic conditions and long-term illnesses are the most prevalent (DEPS 1994): Disability • diseases of the musculoskeletal system (19% in the north, 21% in the south); The prevalence of long-term illness and disability is an important criterion of a population’s health-related • diseases of the circulatory system (10% in the quality of life. However, such data are not generally north, 16% in the south); available. A recent comparative study (Eurostat • diseases of the respiratory system (6% in the 1995b) estimated that in 1992, 9.5% of the population north, 4% in the south). suffered from disabilities resulting in a handicap in social or socioeconomic terms. As no representative data from a health survey are available, this figure has been derived from the number of people under

Proportion of disabled, by age group (1992) Estimated proportion of population aged <60, receiving disability pension, 1991

0-4 Denmark 5-9 POR EUª 10-14 Luxembourg 15-19 Netherlands 20-24 25-29 Belgium 30-34 Portugal 35-39 40-44 Germany 45-49 Italy

Age group Age 50-54 55-59 France 60-64 Ireland 65-69 70-74 Greece 75-79 Spain 80+ 0 20406080 United Kingdom Percentage 02468 a) Unweighted average Percentage Source: EUROSTAT 1995b Source: EUROSTAT 1995b

HIGHLIGHTS ON HEALTH IN PORTUGAL 19 HEALTH STATUS

Health of children and adolescents under 2500 g. The sudden infant death syndrome is the main cause The first year of life is one of the most critical phases of death in the postneonatal period. Madeira has the as regards mortality; only after the age of 55 years highest postneonatal rate, almost double the national do death rates return to the same level as in the average. A 20% reduction in infant mortality neonatal (during the first 28 days after birth) and attributed to congenital anomalies was observed postneonatal (from 28 days to 1 year after birth) between 1989 and 1993 (DGS 1995). periods. Decreasing on average by almost 35% over the last 10 years, infant mortality rates (IMR) have The three major causes of death in the group aged converged throughout the EU. The Portuguese rate 114 years are accidents, neoplasms and congenital fell by over 45% to 8.7 per 1000 live births in 1993 anomalies. For both boys and girls, Portugal has the (7.9 in 1994), the greatest improvement in the highest mortality rates among the reference countries reference countries during this period. Even so it from most causes of death. remains the highest rate among the reference Immunization coverage of children against most countries and nearly 30% higher than the EU average. childhood and communicable diseases, such as Between 1989 and 1994 the IMR for the whole diphtheria, tetanus, pertussis, measles and country decreased by roughly 35%, the neonatal poliomyelitis, has continued to rise, reaching over mortality rate by 41% and the postneonatal mortality 95% and for measles over 90% in 1994. Children’s rate by 31%. The rates in the north are approximately oral health has also improved, contributing to long- 10% above the national average, in the centre and term benefits for general health, especially the areas around Lisbon just under the national average, functioning of the digestive system. In 1990, 12-year- and in the Algarve and Alentejo 10–20% below the old children had an average of 3.2 decayed, missing national average. They are highest of all in the Azores or filled teeth, about average in the reference and Madeira: 10.8 and 14.1 per 1000, respectively, countries. in 1993 (DGS 1995). Neonatal deaths contribute to Adolescence is characterized by efforts to take on approximately two thirds of all infant deaths, and adult roles. This transition involves experimentation most often occur in very low-birth-weight babies. In and imitation, which can make young people 1994, 6.1% of newborn babies in Portugal weighed

Infant mortality per 1000 live births DMFTa index for 12 year-olds

Portugal Greece Around 1980 Belgium Spain 1990 Greece Austria Italy Germany Spain Italy Luxembourg Iceland France Portugal EU United Kingdom Ireland France United Kingdom Luxembourg Austria Norway Netherlands Ireland Norway Belgium Germany Switzerland Switzerland Sweden Denmark 1980 Netherlands Sweden Denmark 1991/93 Iceland Finland Finland 0246810 0 5 10 15 20 25 DMFT a Decayed, missing or filled teeth Deaths

20 HIGHLIGHTS ON HEALTH IN PORTUGAL HEALTH STATUS vulnerable to damage to their health. Acute health Women’s health problems can result from accidents, experiments with drugs, unsafe sex or unwanted pregnancies. In the After age, the second strongest correlate of mortality longer run, the adoption of specific lifestyle patterns is gender. Women generally live longer than men and can lead to chronic degenerative diseases. Tobacco have lower mortality rates for all causes of death in consumption, for instance, remains a serious the EU. However, women have higher reported rates problem: 45% of young people aged 15–24 years of morbidity and utilization of health care services were regular smokers and the rate is rising among (especially around childbirth), and can be indirectly young women (Andrade e Silva 1991). Adolescence more affected by population and other social welfare is also the phase when social insecurity can be policies. Women in Portugal have the lowest life compounded by, for example, unemployment – about expectancy, both at birth and at age 65, among the one in three unemployed people are aged under 25 reference countries. This is reflected in the country’s years (Eurostat 1995a). overall mortality rate for women under the age of 65, which is the second highest. Specifically, the One of the few routinely available indicators of death rate due to CVD is close to 25% higher than adolescents’ sexual health and behaviour is the the EU average, and the death rate due to frequency of teenage pregnancies, which can reflect cerebrovascular disease (the highest among the social factors as well as access to and use of reference countries) is more than twice as high as contraceptive methods. The number of births to the EU average. In contrast, mortality from cancer, young women aged 15–19 years has been falling in including lung, breast and cervical cancers, is lower almost all the reference countries since 1980. In than the EU average, although the SDR for breast Portugal, the reported fertility rate for women in this cancer showed a comparatively high increase (14%) age group is the third highest in the EU at 22.6 per over the past ten years. 1000, corresponding to a rate about four times higher than the lowest rates found in 1992 among the In addition to relatively higher overall female reference countries (Council of Europe 1995). A case mortality levels, the country had the second highest control study found that teenage mothers who do not maternal mortality recorded among the reference receive specialized care are likely to make fewer countries, with an average of 9.2 maternal deaths per antenatal visits and give birth to infants that weigh 100 000 live births between 1991 and 1993 (3-year on average some 200 g less than the babies of teenage moving average). However, the maternal mortality mothers who do receive such care (Silva et al. 1993). rate has improved considerably, decreasing by half

Live births per 1000 women aged 15–19 Maternal deathsa per 100 000 live births

United Kingdom France Iceland Portugal Austria United Kingdom Portugal EU Netherlands Greece Germany Ireland Norway Norway Italy Germany Denmark Sweden Ireland Luxembourg Austria Finland Belgium Belgiumª Finland Spain Switzerland Denmark Spain France Greece Sweden Italy 1980 1980 Luxembourg Netherlands 1990/92 1992 Iceland Switzerland 0 5 10 15 20 25 0 102030405060 ª 1990 Births Deaths Source: Council of Europe 1995 a 3-year moving averages

HIGHLIGHTS ON HEALTH IN PORTUGAL 21 HEALTH STATUS over the past ten years to 8.4 maternal deaths per (gonorrhoea, syphilis and chancroid) has declined, 100 000 live births in 1995. new bacterial and viral syndromes associated with Sexually transmitted diseases (STDs) are more Chlamydia trachomatis, the human herpes virus, the difficult to diagnose in women (many STDs occur human papilloma virus (HPV) and HIV have become without recognizable symptoms in women) and they prominent in western Europe. These agents are often suffer more severe sequelae than men (Fathalla more difficult to identify, treat and control and can 1994). While the occurrence of traditional STDs cause serious complications often resulting in chronic

Standardized death rates, cancer of the Standardized death rates, cancer of the breast, females aged 0–64 cervix, females aged 0–64

12 POR EU POR 30 EU 10

8

20

6

4 10

2

0 0 70 72 74 76 78 80 82 84 86 88 90 92 70 72 74 76 78 80 82 84 86 88 90 92 Year Year

Percentage change over most recent 10 years Percentage change over most recent 10 years

Iceland 83.6 Norway Luxembourg United Kingdom Ireland Denmark Belgium Ireland United Kingdom Germany Netherlands Austria Denmark Portugal Germany Switzerland EU EU Switzerland Belgium Italy Sweden Austria Luxembourg France Netherlands Spain Spain Portugal France Sweden Greece Norway Finland Italy Finland Iceland Greece -60 -40 -20 0 20 40 60 -100 10203040 Percentage Percentage

Rank order from country with highest SDR to country with Rank order from country with highest SDR to country with lowest SDR in 1992 lowest SDR in 1992

22 HIGHLIGHTS ON HEALTH IN PORTUGAL HEALTH STATUS ill health, disability, infertility or death. A community- in particular women (von Wowern et al. 1994). In based study of over 1000 women attending primary western Europe hip fractures are common in elderly health care centres nationwide found the prevalence people, affecting one in four women up to the age of of candida albicans (the most common genital 90 years, twice the rate for men (Armstrong/Wallace candidosis) at over 10% (de Oliveira 1993). 1994). Other female health problems are not limited to Violence against women has in general received women’s reproductive function or reproductive age. limited attention as a public health issue. Data on The cessation of ovarian function at menopause puts the occurrence and type of such violence are lacking women at special risks, notably of osteoporosis due but recent World Bank estimates indicate that in to bone loss. Osteoporosis-related morbidity, established market economies gender-based including pain, loss of mobility, periodontal disease victimization is responsible for one out of every five and tooth loss, and fractures of the hip, vertebrae healthy days of life lost to women of reproductive and wrist, is affecting increasing numbers of people, age (Heise 1994). In Portugal, mortality rates from homicide and intentional injury have increased by almost 35% for women over the past ten years, the most significant increase among the reference countries.

HIGHLIGHTS ON HEALTH IN PORTUGAL 23

LIFESTYLE

LIFESTYLE

Among the wide variety of factors influencing health priority has been given to reducing it as a primary (genetic disposition, the physical and social prevention measure for hypertension (Carrageta et environment, etc.), behaviour has a major impact on al. 1994). each individual’s and the population’s health and wellbeing. Lifestyle patterns such as nutritional habits, (lack of) physical activity, smoking and heavy Nutrition drinking of alcohol play an important role in premature mortality, mainly from CVDs and cancers. Nutritional habits are deeply rooted in cultural These diseases alone are responsible for the largest traditions and agricultural production. Nevertheless, number of deaths under the age of 65 years in in recent decades changes have occurred as food Portugal. Unhealthy behaviour also contributes to a markets have opened up, transport has become more wide range of chronic illnesses and thus affects the rapid and new and efficient techniques of food quality of life, especially in older age. Lifestyle, conservation have been developed. As a result the however, is also influenced by collective behavioural highly different nutrition patterns of northern and patterns, common to a person’s social group, and by southern Europe are tending to converge, with the more general socioeconomic conditions. In most Portugal following the southern trends typically European countries, improvements in lifestyles have referred to as the Mediterranean diet, which is largely been confined to the more socially and particularly low in saturated fatty acids. However, economically privileged middle classes, who are the intake of vegetables and fruits has only recently better placed to live healthy lives (WHO 1993). increased towards the average for the southern European countries. The average proportion of energy derived from overall fat intake has increased Somatic risk factors over the past decade to 34% of total energy but remains the lowest level found in the EU. The extent to which lifestyle is likely to influence morbidity and mortality in a population can be approximated by the prevalence of well known Alcohol consumption medical risk factors such as raised blood pressure, high cholesterol level or overweight. These are some In the EU as a whole, the consumption of alcoholic of the most common determinants associated with beverages has steadily declined since 1980 following cardiovascular diseases. an increase in the 1970s, with Portugal following this In Portugal almost no information is available on the trend. Many European countries are tending towards prevalence of raised blood pressure, high serum a “homogenization” of drinking patterns and cholesterol levels or overweight. The very few diversification of beverages. Thus, in Portugal the insights result from specific local studies, for instance consumption of traditional beverages such as wine the clinical record review of adults attending clinics decreased substantially (by over 30%) between 1980 in the district of Lisbon. According to this and 1993, while at the same time beer intake more investigation, less than half (41%) of the people aged than doubled from less than 40 to 80 litres per head 45–64 years who met the criteria of having annually and the consumption of distilled spirits hypertension were receiving treatment (Baltazar/ remained almost stable. As a result of this process of Natario 1993). Salt is widely consumed and since substitution, the reduction in the amount of alcohol excess salt consumption is considered to have an consumed was about average and the country kept important role in the pathogenesis of hypertension, its fifth highest position among the reference

HIGHLIGHTS ON HEALTH IN PORTUGAL 25 LIFESTYLE

Changing patterns of food consumption in Europe, 1970–1990

a b POR NORTH SOUTH

Cereals Animal fats Vegetables and fruits Sugar 175 25 350 55

300 50 20 150 250 45

15 200 40

125

Kg per head Kg per 150 Kg per head Kg per

Kg per head Kg per 35 10 head Kg per

100 30 100 5

50 25

75 0 0 20 70 72 74 76 78 80 82 84 86 88 90 70 72 74 76 78 80 82 84 86 88 90 70 72 74 76 78 80 82 84 86 88 90 70 72 74 76 78 80 82 84 86 88 90 Year Year Year Year Source: FAO/WHO, Nutrition PC database a) Denmark, Finland, Iceland, Norway, Sweden. b) Greece, Italy, Portugal, Spain. countries. In 1993, total consumption of pure alcohol As in 1980, in 1993 the death rate from cirrhosis and was 10.4 litres per head (almost 13 litres per head of other liver diseases was the highest among the the population aged 15 years and over) compared to reference countries and 60% above the EU average. 11 litres in 1980 (Produktschap voor Gedistilleerde There is nevertheless a promising trend, as this rate Dranken 1994). has dropped over the past decade by 24% for women and 22% for men.

Annual alcohol consumption (litres of pure Percentage change over most recent 10 years alcohol per head), 1993

Luxembourgª Luxembourg France France Austria Austria Germany Germany Portugal Portugal Denmark Denmark Spain Spain Switzerland Switzerland EU EU Greece Greece Belgium Belgium Italy Italy Ireland Ireland Netherlands Netherlands United Kingdom United Kingdom Finland Finland Sweden Sweden Norway Norway Icelandª Iceland 03691215 -40 -20 0 20 40 ª1992 data Consumption (litres) Percentage Source: Produktschap voor Gedistilleerde Dranken 1994

26 HIGHLIGHTS ON HEALTH IN PORTUGAL LIFESTYLE

Tobacco consumption approximately 26%. This low rate is primarily due to the lowest prevalence of female smoking in the Despite the increase in the per capita cigarette EU, even though more women smoked regularly in consumption for the population aged 15 years and 1994 than in 1987. Bans on advertising introduced over between 1985 and 1992, Portugal has the lowest in 1983 may have substantially contributed to the overall smoking prevalence found in the EU, relatively low female smoking rates (BASP 1994).

Percentage of daily smokers among adolescents by sex and age, 1990 (N=4 538) Males Females

Spain Denmark

Germanyª Great Britain

Portugal Spain

France Netherlands

EU Germanyª

Denmark EU

Belgium Belgium

Netherlands Ireland

Great Britain France

Ireland Portugal

Greece 14 years Greece 14 years 15 years 15 years Italy Italy

0 5 10 15 20 0 5 10 15 20 Daily smokers (%) Daily smokers (%) ª As per territorial boundaries before 3/10/90 ª As per territorial boundaries before 3/10/90

Source: Van Reek and Adriaanse 1995

Percentage of smokers among adult population aged 15+ Males Females

Netherlands Denmark

France Netherlands

Greece France

Spain United Kingdom

Denmark Luxembourg

Germanyª Greece

EU EU

Belgium Belgium

Portugal Germanyª

Italy Spain

Ireland Ireland

United Kingdom 1987/88 Italy 1987/88 1994 Luxembourg 1994 Portugal

0 102030405060 0 102030405060 Smokers (%) Smokers (%) ª 1987/88 as per territorial boundaries before 3/10/90 ª 1987/88 as per territorial boundaries before 3/10/90 Source: BASP 1994

HIGHLIGHTS ON HEALTH IN PORTUGAL 27 LIFESTYLE

Tobacco-related deaths in 1990 were estimated at by an estimated 5000 people but appears to be 6800, but only male deaths were recorded given the becoming more popular and is often used together extremely low prevalence of women smokers during with heroin. In 1993, close to 4900 people (49.6 per the 1960s and the three or four decade delay between 100 000 population) sought treatment for drug starting to smoke and the occurrence of lethal effects dependence for the first time at public facilities, a related to it (BASP 1994). Although the death rates 16% increase. In about 95% of all cases of people due to lung cancer and other tobacco-related cancers seeking treatment, heroin is the main drug used. Of are some of the lowest found in the EU, over the past those who enter drug treatment centres, half are aged decade the rate has increased by 28% for men and 35 years or over and about 19% are aged under 15 8% for women. years. The number of deaths from drug overdose increased from a reported 22 in 1987 to 155 in 1992 Between the ages of 14 and 15 years, the prevalence and has been fluctuating since then. The increase in of daily smoking nearly triples for boys to 13% drug-related AIDS cases was much larger than the whereas girls are only beginning to smoke at this total increase in AIDS cases between 1991 and 1994. age. Thus, 7% of the 15-year-old girls smoke daily (Van Reek/Adriaanse 1995). The percentage of A national representative sample survey of students adolescents and young adults aged 15–24 years attending state schools in the 7th, 8th or 9th grades smoking daily decreased for young men but more in 1989 found that the lifetime prevalence of any than doubled for young women between 1977 and illicit drug use was 2.5%. A survey of the greater 1988, to 45% and 31%, respectively. More recent Lisbon area in 1992 found a lifetime prevalence for surveys confirm this trend (BASP 1994). the same group of 5.6%, with cannabis by far the most usual drug tried. According to these surveys, the prevalence of drug use within the previous 30 days was 0.7% in 1989 for the whole country and Illicit drug use 2.6% in 1992 for the greater Lisbon area (DEPS 1994). In 1992, heroin was most widely used by the In the early 1990s, 60 000–70 000 people were group aged 25–29 years and cannabis by the 20–24- recorded as being addicted to heroin, although year-olds. Women make up about 20% of the users cannabis remains the most common drug, used by of both drugs. over 100 000 people (WHO 1995a). Cocaine is used

28 HIGHLIGHTS ON HEALTH IN PORTUGAL ENVIRONMENT

ENVIRONMENT AND HEALTH

Environmental conditions affect humans through acute, short-term and long-term exposure to noxious factors. In the long run the main concern is to promote Carbon dioxide emissions from fossil fuels, sustainable development compatible with good health tonnes per head and, in particular, to preserve the food chain (water, Luxembourg 40 34 agricultural production) from contamination by Denmark hazardous substances. Short-term environmental Germany protection means avoiding or at least reducing Belgium Finland potentially harmful situations, bearing in mind that Netherlands people are not exposed equally to adverse United Kingdom environmental conditions and not all people and Ireland social groups are equally vulnerable to them. Thus, EU (12) Austria children, pregnant women, elderly or ill people are Iceland more likely to be affected by polluted air or Norway contaminated food. Also, adverse environmental Greece conditions tend to accumulate for specific segments Italy France of the population. Low income, for instance, is often Switzerland associated with exposure to environmental hazards Sweden 1980 at work (noxious substances, risk of accidents) and Spain 1991 poor housing conditions (crowding, air pollution, Portugal noise, etc.). These situations may affect health and 0 5 10 15 20 Tonnes per head wellbeing either directly or indirectly by causing Source: EUROSTAT 1994 discomfort and stress, giving rise to unhealthy coping behaviour such as the use of medical drugs or heavy drinking. Water and sanitation

Water resources are abundant but unevenly Air quality distributed over the country and quality is an important issue. In the early 1990s, some 11% of urban and 14% of rural dwellings were not connected So far, air pollution does not seem to be a major to a water supply system, in other words about 20% concern in Portugal. Emission levels of the main of the population have no running water at home pollutants are significantly below the EU average: at (DEPS 1994). Some 58% of the water supplied comes the beginning of the 1990s emissions per head of from surface water and 42% from groundwater. In sulfur dioxide were 60% of this average and those of 1990, 21% of the population were served by a sewage carbon dioxide and nitrogen oxide were less than half. treatment plant. (Eurostat 1995a: 356). Although However, the increasing trend observed during the this is by far the lowest percentage in the EU, it has last decade, which has reached over 60% as regards gone up ten fold since 1981. Systems have been set carbon dioxide from fossil fuels (Eurostat 1994: up to monitor the quality of recreational (bathing) 351ff), may indicate that problems lie ahead. The and drinking-water as well as for the collection and situation is also likely to be much more critical in treatment of industrial effluents and household areas with a high degree of urbanization and sewage. concentration of industrial sites.

HIGHLIGHTS ON HEALTH IN PORTUGAL 29 ENVIRONMENT

Waste a part in their becoming homeless. In Portugal it was estimated in the early 1990s that 3000 people were Increasing quantities of waste are being generated in homeless on any one day of the year or 4000 over almost all countries with serious implications for the course of a year, i.e. 3–4 per 10 000 population, health from the resulting pollution of the air, water the second lowest rate in the EU (Avramov 1995: and soil. The average amount of municipal waste 92). However, the proportion of people living in generated in the EU during the 1980s went up by emergency accommodation is estimated to be about 20% to reach 350 kg per head in 1990. This trend 1% (DEPS 1994). was duplicated in Portugal, although here the figure In the early 1990s, 18% of homes had no inside toilet only reached some 260 kg per head, the lowest and the proportion of households with no bath or quantity among the EU countries. The proportion of shower varied between 5% in urban and 22% in rural paper and cardboard recovered has remained fairly areas (DEPS 1994). Some 23% of the population stable since the mid-1970s at around 40% of the were estimated to live in dwellings which did not material used, while the recycling rate for glass rose meet national criteria of good quality (Avramov 1995: from 10% to 30% between 1985 and 1990. The 113). respective maxima recorded among the reference countries are 51% and 67% (Eurostat 1995d: 194). Increasing urbanization and road and air traffic has brought to the fore the issue of noise and its effects on health. In Portugal it represents a health threat for about half the urban population, since in 1991 one in Generation of municipal waste, kg per head five people found the noise level at home unbearable and an additional 29% were seriously disturbed. Finland Netherlands Denmark Norway Proportion of the urban population disturbed Luxembourg by road traffic noise, 1991 Switzerland Sweden EU (12) Italy Italy Greece United Kingdom Luxembourg Belgium Germany Spain France Belgium Austria Spain EU (12) Iceland Netherlands Ireland 1980 Germany Greece 1990 Portugal Portugal

0 100 200 300 400 500 600 700 France Kg per head Source: EUROSTAT 1994 United Kingdom Ireland Unbearable Hardly bearable Denmark Housing 0 20 40 60 80 100 Percentage Source: EUROBAROMETER 1991 Housing conditions generally have an impact on people’s health and wellbeing, but the health situation of homeless people is particularly critical: they often suffer from health problems typically associated with Safety at home and during leisure-time activities, poverty (malnutrition, infectious diseases, sports and so on is not well documented. No data are psychosocial stress caused by solitude and insecurity, available about the incidence of such accidents and etc.), and they may be more vulnerable to health their health consequences, but a study in the EU problems than the rest of the population owing to countries comparing cases treated by health care traumatic events or personality traits which may play services between 1990 and 1992 showed that for the

30 HIGHLIGHTS ON HEALTH IN PORTUGAL ENVIRONMENT

Portuguese population aged over 45 years the Occupational accident death rates frequency of this type of accident is higher than the per 100 000 population and EU average (EHLASS 1995). total number, 1991/1993 Number of fatal accidents Luxembourg 18 Occupational health and safety Germanyª 2660 Italy 1937 Spain 1116 Exposure to health risks at the workplace is still an EU 7949 important cause of ill health and death. However, Austria 171 France 1082 information about exposure in terms of type, Switzerland 130 frequency, intensity of hazardous conditions and the Ireland 64 number of workplaces or people affected is scarce. Portugal 168 The incidence rates of recognized occupational Norway 61 Belgium 138 diseases attracting disablement benefit awards Finland 64 provide an estimate of risk levels, although such Denmark 61 figures are generally lower than the actual number Sweden 81 Greece 88 of cases. Usually, only a small proportion of reported United Kingdom 258 cases are recognized, although delays between Netherlands 43 reporting and recognition may be considerable. 012345 Deaths per 100 000 The death rates in Portugal for occupational accidents ª As per territorial boundaries before 3/10/90 are about average for the EU, but the risk of being Source: ILO 1994 injured at work is third highest among the reference countries. In 1993, 168 people were killed in work- related accidents (1.7 per 100 000 population) and as regards fatal cases (258 people killed in accidents5, some 244 000 people were injured. This represents corresponding to a rate of 2.6 per 100 000 a risk of 2467 per 100 000 population, which is 45% population), while cases of injury (roughly 234 000) above the EU average of 1700 per 100 000. Data for dropped somewhat. 1994 indicate a marked worsening of the situation

5 Defined as deaths occurring at point of accident and not including deaths occurring subsequently.

HIGHLIGHTS ON HEALTH IN PORTUGAL 31 HEALTH SYSTEM

HEALTH SYSTEM

Institutional structures and and the 350 primary health care centres. Diagnostic resources tests at primary health care level are usually done privately but co-payments are made by the SNS. Since 1979 a nationwide network of hospitals and The number of practising physicians is slightly above health centres has been established under the National the EU average but there is a serious shortage of Health Service (Serviço Nacional de Saúde – SNS). dentists and nurses, despite a doubling of nursing The SNS is financed from tax revenues and provides staff in the last 12 years. Moreover, there are wide free access to primary health care and hospital care. geographical variations in the availability of health Drugs and medications on an approved list are free personnel and some districts are clearly understaffed or subject to co-payments. However, in some (DEPS 1995). About 60% of health professionals situations there is also rationing of supply and a work in Lisbon, 17.6% in Oporto and 9% in Coimbra, private sector is developing to meet the remaining leaving the rest of the country with comparatively demand (Berthod-Wurmser 1994). few staff (OECD 1994). The SNS provides universal coverage, but civil servants and their dependants (13.6% of the population) are covered by their own scheme based Primary health care on co-payments and financed by the Government plus 2.5% of employees’ salaries. Separate contributory Primary health care is provided by integrated primary schemes also cover people working in banking, health centres providing a wide range of services, insurance and some public enterprises (OECD 1994). including health promotion and protection, as well The SNS is centralized: responsibility for its as prevention, diagnosis and treatment. Some 74% functioning, organization and management is shared of all physicians in the health centres are general between the Ministry of Health and the five regional practitioners (GPs). Other medical disciplines authorities. The SNS manages all public hospitals represented include public health, gynaecology, paediatrics and stomatology. Only some of the health centres are equipped for carrying out X-rays and laboratory diagnostic tests, and patients are frequently Health personnel per 1000 population referred to private practices for these procedures. Primary care is also provided by more than 1800 POR EU extensions or health posts. In sparsely populated areas 1992–93 % of 1991–93a % of physicians sometimes serve more than one post 1980 1980 (Boerma et al. 1993). Physicians 2.9 145 2.7 143 Dentists 0.2 200 0.6 125 General practitioners Nurses 3.1 135 6.0 129 General practitioners have a dominant role in health a Or latest available year centres as the providers of primary care. People are Source: OECD 1995 free to choose their doctor and GPs have lists of at

32 HIGHLIGHTS ON HEALTH IN PORTUGAL HEALTH SYSTEM least 1500 patients. They are state-employed, Central hospitals are located in the Lisbon, Oporto salaried, and have a gatekeeping function with respect and Coimbra areas and there is a district hospital, at to secondary care (Boerma et al. 1993). General least, in the main town of every district. Secondary practice is a young specialty in Portugal. It is not yet care should only be available upon referral by a GP. completely accepted by the population and GPs The hospital network includes some specialized experience a high level of professional dissatisfaction psychiatric, oncology, maternity and rehabilitation related to working conditions, low salaries, lack of hospitals. There is a clear shortage of geriatric and professional incentives, and the problems of the nursing beds for the growing number of elderly health system. It is not a popular choice for young people, who have to rely on informal family care physicians starting vocational training (European (Boerma et al. 1993). However, some private old Union of General Practitioners 1995). people’s homes are available for the wealthiest part Formally, secondary care is only available after of the population (OECD 1994). referral by a GP, but people often use hospital emergency departments to gain access to their preferred option of hospital care. Private sector

Primary dental care The recent development of a private sector in order There is a serious shortage of dentists so that only a to meet unmet needs has created a growing problem limited dental service can be provided at the dental of equity. In particular, as mentioned above, those clinics and integrated health centres. In 1988, there few old people’s homes that exist are in the private was one dentist per 30 461 population (OECD 1994). sector and very expensive (OECD 1994). Patients sometimes have to pay private practitioners Primary health care nurses themselves. Private health insurance is a new Primary health care nursing is scarcely developed, phenomenon which is still developing. Foreign given the small ratio of nurses per inhabitant (with insurance companies are active in this market 3.1/100 000 about half the average in the EU (Boerma et al. 1993). Despite important countries) and the relative concentration of health developments in this area in the 1980s, and despite professionals in the bigger cities. the fact that private insurance contributions are partially tax-deductible, only 10% of Portuguese have private insurance (Berthod-Wurmser 1994). The Community pharmacists relationship with the private sector is settled by Community pharmacies are subject to a numerus contracts or agreements. clausus. Drug prices are decided centrally by comparison with neighbouring countries. Pharmacists are allowed a profit margin of 20% on the product sold. In general, drugs are subject to a Health expenditure state contribution of 30–60%, but for the treatment of certain diseases the state’s contribution may rise International comparisons of health care indicators to 100%. Co-payments for retired patients vary are extremely difficult because the definitions between 15% and 45% but may be as much as 100%. underlying health statistics as well as accounting practices vary from one country to another. A recent comprehensive study (Schneider et al. 1995) tried to improve comparability by presenting a set of Hospital care indicators based on adjusted national data. According to this study, Portugal spent 6.6% of its GDP on health Some 83% of all hospital beds are in the public sector. in 1992 (7% according to OECD), the second lowest Hospitals are run by management boards and have percentage in the EU. Portugal managed to keep administrative and financial autonomy. Technically, hospital costs down and to remain in the lowest they have to follow guidelines laid down by the position as regards the proportion of GDP spent on General Directorate of Health, part of the Ministry inpatient care. The proportion spent on nursing also of Health (HOPE 1993). remained almost stable at the second lowest in 1992. Rising by less than the EU average, the proportion

HIGHLIGHTS ON HEALTH IN PORTUGAL 33 HEALTH SYSTEM of GDP spent on medication dropped from second A breakdown of total health expenditure by services highest in 1980 to just above the EU average in 1992, and goods provided also reveals the comparatively while that spent on ambulatory medical care rose large segments of Portugal’s health budget spent on from below to above average. medication and ambulatory medical care, while the proportion dedicated to nursing is rather small.

Health care expenditure (as percentage of GDP) by group of services/goods: comparison between 14 countriesa of the EU

1980 1992 Total health expenditure Hospital care Greece Portugal Portugal Greece Spain Belgium Belgium Germany United Kingdom Spain Denmark EU Austria United Kingdom Netherlands Luxembourg EU Italy Italy Sweden Ireland Netherlands Luxembourg Denmark Germany Austria France France Sweden Ireland 0246810 0123456 Percent of GDP Percent of GDP

Ambulatory medical care Nursing care Denmark Greece Netherlands Portugal United Kingdom Luxembourg Sweden France Spain Spain Greece Italy Ireland Belgium Belgium Germany EU EU Portugal Ireland France Austria Austria Netherlands Germany Sweden Italy United Kingdom Luxembourg Denmark 0 0.3 0.6 0.9 1.2 1.5 1.8 0 0.3 0.6 0.9 1.2 1.5 1.8 Percent of GDP Percent of GDP Medication Dental care Denmark Ireland Austria United Kingdom Sweden Denmark Netherlands Italy United Kingdom Netherlands Ireland Greece Belgium Portugal Greece Spain EU France Portugal EU Spain Belgium Luxembourg Luxembourg Germany Austria Italy Sweden France Germany 0 0.3 0.6 0.9 1.2 1.5 1.8 0 0.3 0.6 0.9 1.2 1.5 1.8 Percent of GDP Percent of GDP

Source: Schneider et al. 1995 a Data for Finland not available

34 HIGHLIGHTS ON HEALTH IN PORTUGAL HEALTH SYSTEM

Health care expenditure by group of services/goods, Portugal and EU averagea, 1992 POR EU

Other 10 % Other Ambulatory 12.7% Ambulatory medical care medical care 16 % 20.5% Dental Dental care care 7 % 6.4%

Medication 16 %

Medication 21% Hospital care 42%

Hospital care 33.9% Nursing Nursing care 9 % 5.5%

a 12 EU countries in 1992 Source: Schneider et al. 1995

Health care reforms

The law of January 1993 established five health insured person, private insurers would receive from regions with maximum autonomy. Under the new the Government part payment of the premium regions, health centres are to be grouped together according to the age, sex and income of the insured with hospitals to form health units. In addition, the at a rate below the average cost per head of the SNS. law allows full-time salaried physicians to engage in The insurers would decide with which providers to private practice provided this does not interfere with make contracts and how to pay them, but free choice their SNS duties. It is intended that co-payments will of health care provider will be an exception and lead vary according to the income of the patient or the to higher co-payment. It is hoped that group practices family. The law also provides for public services to will be formed to provide out-of-hospital care. be managed or provided by other organizations Insurance would be lifelong and the insurance (public or private) under contract. companies would not be able to cancel it. There would The provision stated in the January 1993 law is be no age or health limitations on joining (OECD somewhat controversial as regards the incentive to 1994). move from public to private insurance. For each

HIGHLIGHTS ON HEALTH IN PORTUGAL 35 REFERENCES

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HIGHLIGHTS ON HEALTH IN PORTUGAL 37 GLOSSARY

GLOSSARY

Cardiovascular diseases (CVDs): all diseases of the number of years that could be added to life circulatory system, including coronary heart disease expectancy at birth if all deaths before the age of 65 and cerebrovascular diseases. were eliminated. Dependency ratio: The ratio of the population Prevalence rate: the total number of people in a defined as dependent (those under 15 and those over population who have a disease or any other attribute 64 years of life) to the working-age population, aged at a given time or during a specified period per 15-64 years. 100 000 of that population. Incidence rate: the number of new cases of a disease Purchasing power parity (PPP): a “standardized” occurring in a population during a specified period measure of the purchasing power of a country’s (usually a year) per 100 000 of that population. currency, based on a comparison of the number of units of that currency required to purchase the same Infant mortality rate (IMR): the yearly number of representative basket of goods and services in a deaths of children aged less than one year per 1000 reference country and its currency (usually US$). The live births. EU unit of PPP is PPS (purchasing power standard). Life expectancy at birth: An estimate of the average Standardized death rate (SDR): a death rate number of years a newborn can expect to live (usually per 100 000 population) adjusted to the age provided that the prevailing age-specific patterns of structure of a standard European population. mortality at the time of birth were to stay the same throughout the child’s life. Total fertility rate (TFR): the average number of children that would be born alive per woman during Loss of life expectancy due to deaths before the age her lifetime, if she were to bear children at each age of 65 years: describes the effect of premature death in accord with prevailing age-specific birth rates. on life expectancy, and it measures the potential

38 HIGHLIGHTS ON HEALTH IN PORTUGAL