The BVS and PubMed search (April 2015) identified 909 and 930 documents, respectively, for a total of 1426 documents after the exclusion of duplicates. The application of the inclusion criteria reduced the list of selected documents for full reading to 47, and six studies identified by key informants and other sources were added; Additional file 2: Figure S2 shows the process of selection of peer-reviewed article search. The website search identified 49 documents, of which 16 are policy documents and 33 are technical reports. The search of online newspapers identified 1454 potentially relevant articles, and 94 were selected for analysis. The full list of 155 analysed documents is available on request.
Most the articles identified in this documentary search (nine out of 12 documents) report that the authors did not have access to external financial support or did not mention any.
Geographical access to physicians in the Portuguese National Health Service
The challenges faced by decision-makers to ensure access to physicians at the national level were identified as (a) a forecasted shortage of physicians, (b) geographical imbalances and (c) maldistribution by level of care.
Shortage of physicians?
Although the number of physicians in Portugal per 1000 habitants has been above the European Union (EU) 27 countries’ average between 1995 and 2013 [33], a shortage of physicians has been forecasted, particularly of general practitioners/family physicians (GPs) and of public health physicians in three scientific research documents, three political documents and one policy analysis document [13, 14, 19, 21, 34–36]. This was attributed to the low numerus clausus policy limiting entry in medical schools between 1979 to 2000, combined with the planned retirement of large numbers of physicians in the coming years [14, 19, 21, 25, 37–39]. In 1979, the numerus clausus was 805; in 1985, it dropped to 272; and in 2001, it was increased to 945 [40].
No analysis other than forecasting the numbers of future graduates and future retirees has been found. There is no monitoring of outflows to the private sector, to other sectors other than health or to other countries; dual practice is not monitored either [12, 23, 39, 41, 42]. Emigration flows are estimated by proxy indicators such as cancellation or suspension of registration and requests of Certificates of Good Standing [43, 44], which rose from 191 in 2009 to 650 requests in 2012 only in the South Regional Session of the Portuguese Medical Council [43]. In 2014, the total number of requests was approximately 1100 for the whole country [45], and between January and May 2016, there were another 226 requests [46].
Geographical imbalances
The geographical maldistribution of physicians is acknowledged in Portugal; it is discussed in six scientific research documents, four political documents and nine policy analysis documents [8–26]. The distribution of physicians favours the three main urban areas of Oporto, Coimbra and Lisbon [8, 11, 22, 47, 48] (Fig. 2) where the most advanced technology and the oldest medical schools and teaching hospitals are found [10, 48]. In 2011, the Northern and the Lisbon/Vale do Tejo (LVT) regions, where 65% of the population resides, had 74% of NHS physicians; the Central region had 18%, Alentejo 4% and Algarve 4%, whereas they had 23, 7.5 and 4.5% of the population respectively [47, 49]. Portuguese private practitioners also tend to concentrate in the richer urban areas, as is the case in most Organisation for Economic Co-operation and Development (OECD) countries [50].
The maldistribution has been attributed to the lower supply of NHS beds and to the population’s lower purchasing power [8, 10] in disadvantaged regions. Another factor is the possibility of multiple employment in urban areas where the private sector offers additional remuneration opportunities [10].
Maldistribution by level of care
Another challenge identified in the documentation under review is the imbalanced distribution of physicians between primary care (PC) and hospital services; it is discussed in five scientific research documents and 11 policy analysis documents [11–16, 24, 34, 37, 42, 48, 51–55]; this is in spite of a stated policy to promote Family Health Care [11, 52, 54, 56], which includes the creation of Family Health Units [57, 58] consisting in multi-professional units which have organizational, technical and functional autonomy and that provide personalized health care to a given population [59, 60]. The first ones were implemented in 2007, and in late 2016, there are 459 covering 53% of the population.
The reason for the maldistribution was attributed to the low prestige of PC, to the lack of planning and to the limited number of internship places in family medicine as training capacity had not been developed in health centres [14, 34, 37, 52]. The problem is compounded by the ageing of the medical profession specially affecting GPs [42, 61–63], 75% of whom were above 50 years of age in 2011 [49], and by a wave of early retirements provoked by the austerity measures implemented after 2011 in the NHS [37, 49, 64].
Strategies to address health workforce imbalances
A first attempt to define a strategy for the development of the health workforce was the publication, in 2001, of a “Strategic Plan to Education and Training in The Health Areas” [11, 19, 65]. It drew the attention to geographical and level of care imbalances and predicted a shortage of physicians in the coming years. In the context of political instability prevalent at that time, there was no follow-up [11].
The National Health Plan 2004–2010 [22, 66] represented a second planning effort. It raised the issue of skill mix and new competencies needs, but did not go “much beyond a call for a more explicit strategy” [11]. In 2012, the National Health Plan 2012–2016 [67], following recommendations of the World Health Organization [25, 42], included the objective of designing and implementing a HRH policy [23]. However, the targets set in the Plan were restricted to numbers of physicians per inhabitant, from 3.83 physicians per 1000 habitants in 2009 to 4.51 in 2016 [23, 68].
To date, no HRH policy has been formulated [23, 25, 42], in spite of numerous policy documents and reports stating that it is needed. On the other hand, various isolated and ad hoc strategies have been adopted.
Strategies to address shortage included an increase in the numerus clausus, the opening of new medical schools and programmes, an increase of residency places and the re-hiring physicians who had retired from the NHS. This last strategy was also intended to reduce the level of care maldistribution of physicians.
Since 1999, there has been a gradual rise in the numerus clausus; in 2010, it was 2.5 times higher than 15 years before [69], whereas population growth during that period was 3.5% [47]. Until 1999, Portugal had five medical schools, two in Lisbon, two in Oporto and one in Coimbra offering a total of 566 places [14, 70]. Two new medical programmes were opened in 2001 in universities of the interior of the country [9, 14]. Additionally, a course exclusively for students holding a bachelor´s degree opened in 2009 in Algarve to attract young professionals to the south of the country [70]. In 2004/2005, basic courses were created in Azores and Madeira Islands; students complete the first 3 years of medical education there and the remaining years at the University of Coimbra [10, 70].
There was also an increase in the number of residency slots for specialization, after the compulsory post-graduation of general internship that includes a total of 6 months involving general practice and public health and a year of hospital-based training. It is followed by a period of 4 to 6 years of training for a medical specialty [14, 37, 69]. There are three medical career streams: hospital-based practice (45 specialties), public health and general practice [10, 71]. The MoH defines the number of residency places in consultation with the Medical Council, depending on the available training capacity in recognized provider organizations [40, 69]. The number of residency places grew from 894 in 2006 [69] to 1569 in 2015 [72].
The re-hiring of retirees for a period of 3 years was authorized in June 2010 [35]. It aimed to overcome the shortage of physicians [37, 73, 74], particularly of GPs [35, 73]. In 2013, this strategy was extended for another 3 years [21, 74]. It is applicable to any retired physician, including those who anticipated their retirement. The benefits include the accumulation of the pension with a third of the remuneration according to contracted hours [73].
We identified four strategies addressing the geographical maldistribution of physicians: reserved vacancies, the “partial mobility of professionals”, financial and non-financial incentives during a 5-year period to work in an underserved area and four bilateral agreements to recruit physicians from other countries to work in PC in underserved areas.
In 1975, a strategy referred to as the “Medical Service in Peripheries” introduced a 1-year compulsory service outside urban areas [75, 76]. This was implemented until 1982. In 2009, financial incentives were introduced for resident physicians who commit to work in an underserved area or specialty after graduation during a period equal to their specialist medical training programme; this policy was referred to as “reserved vacancies” [40, 77, 78]. It consisted in a monthly residency grant of €750, paid by the municipality where the physician committed to work [79]. In case of failure to fulfil the obligation, the resident had to repay the grant [77]. No evaluation of this measure has been identified. This strategy is now restricted to the Azores and Madeira Islands.
The “partial mobility of physicians” regulation, approved in 1998 and updated in 2015 [80], is a special arrangement that provides for a daily allowance and transport subsidy (€200 per day) accessible to physicians who work part-time in two or more public services more than 60 km apart; it is particularly used in the region of Algarve, which experiences important seasonal variations in its resident population [73, 80].
In 2015, a new law created a set of financial and non-financial incentives to attract and retain physicians in poor and underserved areas [20]. These incentives target physicians working in a NHS establishment in an underserved area [20]. Under this scheme, physicians who accept a 5-year contract receive an additional €1000 for the first 6 months, then €500 for the next 6 months and €250 per month for the remaining 4 years [20]. Additional incentives are available, such as child’s school transfer guarantee, support to spouse employment and an extra 2 days of annual leave [20, 73]. Penalties and reimbursement are imposed in case of non-compliance [20].
Since 2008, the MoH has used an “emergency measure” in the form of the recruitment of foreign physicians through bilateral agreements with Latin American countries [10, 23, 25, 57, 81]. This option was chosen because attracting workers from other European countries proved difficult as Portugal could not offer conditions competing with those offered by countries like Germany or England [82]. The first bilateral agreement was signed with the government of Uruguay in 2008; 15 physicians came to work for the National Institute of Medical Emergencies [83–85]. In 2009, another one was signed with Cuba, and 44 physicians arrived to work in five health centres in Algarve, nine in Alentejo and one in LVT [86–88]. They returned to Cuba in 2012 and were replaced by another cohort [89, 90]. Another replacement took place in 2014 [91–93]. In 2011, bilateral agreements with Colombia and Costa Rica brought 82 and nine physicians, respectively, to health centres in the LVT and Central regions [85, 94–97]. Foreign medical degrees were validated by the Faculty of Medicine of Porto, and registration with the Medical Council followed [83, 95, 98, 99]. Prior to arrival, the physicians attended a Portuguese language course [83, 95, 100]. They also had a 2-week period for adaptation/integration into the services [95]. There has been no evaluation of the efficiency or effectiveness of these recruitments. A study that assessed the foreign physicians’ cultural competencies concluded that these health professionals performed in a culturally competent manner and contributed positively to improving access to health services [81].
Four strategies aimed at changing the distribution of physicians by level of care. First, the PC reform was designed as a strategy to increase the recognition of GPs’ career and to improve accessibility to primary level services. Second, in 2007, a quota of 25% of residency places for GPs was established [37, 40, 101]. Over the years, this has contributed to augmenting the number of GPs, but it has not been sufficient to extend PC coverage to the whole population [54, 102, 103]. In 2015, 12% of the population was still without access to a GP, ranging from 3.3% in the North to 25.8% in Algarve [104]. Third, the bilateral agreements to recruit foreign physicians aimed at addressing, at the same time, geographical and level of care maldistribution as they concerned only family practitioners, and finally, there was the re-hiring of retired physicians which focused on family physicians. The interventions to address supply, geographic and level of care maldistribution by area of political intervention are presented in Additional file 3: Table S2.
