Portal de Periódicos da CAPES

Child Health in Portugal

2016; Elsevier BV; Volume: 177; Linguagem: Inglês

10.1016/j.jpeds.2016.04.051

1097-6833

Teresa Bandeira, Ricardo Ferreira, Inês Azevedo,

Child and Adolescent Health

Portugal has experienced rapid decline of neonatal and infant mortality in the last century, similar to that of other western European states. The joint venture of pediatricians and obstetricians with adequate top-down government commissions for maternal and child health for the decision making by health administrators and a well-defined schedule of preventive and managerial measures in the community and in hospitals are the most likely explanations for this success. Another achievement of child health care services is the registry for special diseases. Education of health care workers plays a fundamental role in improving health statistics. Portugal has a reasonable number of doctors, nurses, and health technicians per capita. Quality assurance monitoring systems and implementation of evidence-based clinical guidelines with digital records, including international coding, are essential steps to improve health care systems. Portugal has experienced rapid decline of neonatal and infant mortality in the last century, similar to that of other western European states. The joint venture of pediatricians and obstetricians with adequate top-down government commissions for maternal and child health for the decision making by health administrators and a well-defined schedule of preventive and managerial measures in the community and in hospitals are the most likely explanations for this success. Another achievement of child health care services is the registry for special diseases. Education of health care workers plays a fundamental role in improving health statistics. Portugal has a reasonable number of doctors, nurses, and health technicians per capita. Quality assurance monitoring systems and implementation of evidence-based clinical guidelines with digital records, including international coding, are essential steps to improve health care systems. Portugal is situated in Western Europe and borders with Spain in the Iberian Peninsula.1National Strategy for the Sea 2012 -2013. Government of Portugal.Google Scholar The land territory covers an area of 89 000 km2 and the Atlantic islands (Madeira and Azores) of around 3000 km.22011 Census. Census-final results. Portugal-2011. INE, Lisbon, Portugal; 2011. http://censos.ine.pt/xportal/xmain.Google Scholar Nowadays, Portugal has become an urban country.22011 Census. Census-final results. Portugal-2011. INE, Lisbon, Portugal; 2011. http://censos.ine.pt/xportal/xmain.Google Scholar The population density is 114 inhabitants per km2, and the majority of people is concentrated in big cities in coastal regions (Figure 1).3INE. https://www.ine.pt/xportal/xmain?xpgid=ine_main&xpid=INE&xlang=pt, DGS/MS (http://www.dgs.pt), PORDATA (http://www.pordata.pt). Accessed September 2015.Google Scholar Portuguese is the official language of Portugal. Although a small country in Europe, following the Portuguese overseas expansion from the 15th century, it is the most spoken language in the Southern hemisphere and the third most frequent in the Western hemisphere.4Observatory for the Portuguese language. http://observalinguaportuguesa.org/o-portugues-e-a-lingua-mais-falada-no-hemisferio-sul/. Accessed September 26, 2015.Google Scholar In the 2011 census, Portugal had a population of 10.4 million people; in 2014, the country had a birth rate of 7.9%.3INE. https://www.ine.pt/xportal/xmain?xpgid=ine_main&xpid=INE&xlang=pt, DGS/MS (http://www.dgs.pt), PORDATA (http://www.pordata.pt). Accessed September 2015.Google Scholar In 2014, there were 82 367 children born in Portugal (Figure 2), which represents a nadir for the last 50 years and has implications on the population pyramid. The natality is recovering for the second year now. (Figure 3). The gross domestic product (GDP) per capita was US $16 675 in 2014. GDP growth rate in Portugal averaged 0.39% from 1988 to 2015, reaching an all-time high of 3.3% in the fourth quarter of 1990 and a low of −2.6% in the first quarter of 1991.5Trading economics. 2015http://www.tradingeconomics.com/portugal/gdp-growthGoogle Scholar During the economic crisis between 2011 and 2013, the GDP grew much slower than other countries in the European Region, but it is slowly recovering.5Trading economics. 2015http://www.tradingeconomics.com/portugal/gdp-growthGoogle Scholar The impact of the decrease in recent years is yet to be determined.Figure 3Structure of the resident population in Portugal by age groups and years. Reprinted with permission from PORDATA (http://www.pordata.pt).3INE. https://www.ine.pt/xportal/xmain?xpgid=ine_main&xpid=INE&xlang=pt, DGS/MS (http://www.dgs.pt), PORDATA (http://www.pordata.pt). Accessed September 2015.Google ScholarView Large Image Figure ViewerDownload Hi-res image Download (PPT) Portugal has experienced rapid decline of infant mortality in this century (Figure 4). In the 1940s, infant mortality was over 104‰, one of the highest in Europe.6Levy M.L. 50 Years of pediatrics in Portugal.Acta Pediatr Port. 1999; 30: 93-99Google Scholar Health services were not available for all. The hospitals were not well prepared for the care of children; poverty had a strong negative impact on health. In 1960, the recognition of high rates of mortality by infectious diseases (mainly because of pertussis, poliomyelitis, tetanus, and diphtheria) led a team of health professionals, headed by Arnaldo Sampaio, to implement the National Vaccination Program. At the beginning, the financial support was provided by the Calouste Gulbenkian Foundation, and at present, it is funded by the Portuguese National Health System (NHS).7Servico Nacional de Saude. Direcao Geral de Saude, DGS. 50 anos Programa Nacional Vacinacao. http://www.dgs.pt/?cr=28717. Accessed June 28, 2016.Google Scholar Other interventions, such as improved nutrition, reorganization of hospital care, and implementation of a network of the health care centers, played a key role in improving child health.6Levy M.L. 50 Years of pediatrics in Portugal.Acta Pediatr Port. 1999; 30: 93-99Google Scholar In 1981, infant mortality was 21.4‰, but the neonatal mortality decreased at a much slower rate and was still high with a recording of 15.5‰.8Machado M.C.S. National Commission on child and adolescent health. 2004-2008.Report from the High Commissioner of health. 2009; Google Scholar In 1989, the First Maternal and Infantile National Commission of Health, including obstetricians and pediatricians, began a strategic health plan to decrease neonatal mortality.8Machado M.C.S. National Commission on child and adolescent health. 2004-2008.Report from the High Commissioner of health. 2009; Google Scholar Free access to health care was offered to all pregnant women and neonates. Preventive measures included the implementation of individual health booklets for both groups on growth and other developmental milestones. A well-defined schedule for prenatal diagnosis of diseases was developed, and the identification of at-risk pregnancies was followed by in utero transfer strategies. A network of well-equipped maternities was established. All of these activities explain why Portugal currently has one of the lowest infant mortality rates in Europe.9Eurostat. Infant mortality rate. http://ec.europa.eu/eurostat/documents/3217494/6975194/KS-EX-15-001-EN-N.pdf. Accessed September 27, 2015.Google Scholar In order to improve child health care in all age groups, the focus is now shifting to those political interventions that aim to reduce extreme poverty. The preventive measures include financial support and education on the risks of alcohol, tobacco, and drug consumption during pregnancy and by teenagers. Similar to other countries, education on healthy nutrition and physical activity is another preventive measure to fight the recent obesity epidemic. Another priority of multidisciplinary prevention is to reduce traffic accidents. One of the achievements of child health care services in recent years for Portugal is the registry for patients suffering from special diseases. The registry of patients with HIV is an example of success. The notification of HIV is now in digital format in an information system with the Directorate of Health. The Portuguese Society of Pediatric Infectious Diseases has strong input in the registries. In 2013, there were 196 cases of pregnancies of mothers with HIV and their 197 newborns in Portugal, which corresponds to 0.24% overall prevalence of all pregnancies. The number of pregnant women with HIV has declined in recent years.10PortugalHIV infection, AIDS and tuberculosis in numbers. Directorate General of Health, Lisboa2014Google Scholar Life expectancy for men and women in Portugal has continued to increase between 2002 and 2012, whereas crude and standardized death rates have decreased10PortugalHIV infection, AIDS and tuberculosis in numbers. Directorate General of Health, Lisboa2014Google Scholar; however, there are some geographic disparities between different coastal regions. Portugal has a tax-funded NHS that provides coverage to all residents. Public health care is shared between the central and regional governments. Both the public and the private sectors provide hospital care and community health services. In 2011, beds in public hospitals accounted for 72% of all hospital beds; in 2010, 80% of all inpatients were cared for in public hospitals.11Mateus C. Joaquim I. Nunes C. Boto P. Campos L. Portugal: Geographic variations in health care. Geographic variations in health care: what do we know and what can be done to improve health system performance?. OECD Publishing, Paris2014https://doi.org/10.1787/9789264216594-14-enCrossref Google Scholar Total health spending accounted for 10.2% of GDP in Portugal, which is above the Organization for Economic Cooperation and Development (OECD) average of 9.3%. However, Portugal ranks below the OECD average in terms of health spending per capita (US $2619 in 2011, compared with the OECD average of around US $3300). The share of hospital spending in Portugal in 2011 was 27% and, thus, slightly lower than the OECD average of 29%. Health spending per capita in Portugal increased in real terms by 1.8% on average between 2000 and 2009, and grew at a similar rate of 2% during 2009 to 2010. However, health spending per capita fell by 6.3% during 2010 to 2011. Several other OECD countries also experienced a reduction in health spending after 2010, following the international economic recession and the need for fiscal consolidation.11Mateus C. Joaquim I. Nunes C. Boto P. Campos L. Portugal: Geographic variations in health care. Geographic variations in health care: what do we know and what can be done to improve health system performance?. OECD Publishing, Paris2014https://doi.org/10.1787/9789264216594-14-enCrossref Google Scholar Education of health care workers also played a fundamental role in improving health statistics. Portugal has a relatively high number of doctors, nurses, and health technicians per capita (252, 398, and 76 per 100 000 inhabitants in 2012, respectively).22011 Census. Census-final results. Portugal-2011. INE, Lisbon, Portugal; 2011. http://censos.ine.pt/xportal/xmain.Google Scholar In 2011, there were 43 247 physicians working in Portugal, 54% of whom were older than 50 years of age.12Santana P, Peixoto H, Loureiro A, Costa C, Nunes C, Duarte N. Study of prospective Developments of Doctors in the National Health System. Portugal: Coimbra University Press; 2013 (following data from the Portuguese Medical Association and Central Administration of Health).Google Scholar The country's universities provide the public and private sectors with enough physicians, but the situation may change as a consequence of the financial crisis. Teaching pediatrics at medical schools was approved by the Reform of 1911; pediatric lectures and seminars then were held in the fourth year. This curriculum has changed in recent years, with some medical schools offering an extended pediatric curriculum that teaches pediatrics during the first years and before starting clinical courses.6Levy M.L. 50 Years of pediatrics in Portugal.Acta Pediatr Port. 1999; 30: 93-99Google Scholar The government has developed electronic health record programs for some areas such as immunization, as well as the administration of medical care in hospitals and ambulatory clinics. Coding of diagnoses is based on the International Classification of Diseases, Ninth Revision, applied as an obligatory tool throughout the health system. The National Program for the Health of the Child and Youth started in 1992 and has since been regularly updated, the last amendments dating from June 2012 as a result of a workup by a large team of professionals. The primary child health care program must be implemented for all children living in Portugal either by public services or at the level of public health centers, mostly offered by general practitioners (GPs) (approximately 70% of patients) or by pediatricians (caring for approximately 30% of children). There are an estimated number of children that are followed by both GPs and pediatricians. Secondary or tertiary child health are offered by pediatricians who work in public hospitals or in private clinics or hospitals.13Child and youth health: Action type Program. DGS 2011.Google Scholar Services include screening and detection of diseases, immunization of children, and mother and child health care. All Portuguese children are born in maternity units. Each child is given an identification number at birth, which is linked with that of the mother and father, and includes information on chronic health conditions. Obstetricians register the birth of a child. The relevant perinatal information is transferred in the personal health record from neonatologists to the primary care physician. A standardized program for regular health checkups, including growth, development, and standardized physical examinations, is performed by all practitioners who care for children's health.13Child and youth health: Action type Program. DGS 2011.Google Scholar Vaccinations, as well a primary child health care until adulthood, are organized by public health units. There is a national registry using electronic records to register the individual paper version of the health booklet. The parents can change their assigned primary care provider and choose to be tracked by a private pediatrician. There are only a few pediatricians who work in the public health centers. In 2011, there were 1752 pediatricians working in Portugal, which represents 1 pediatrician per 1087 children less than 18 years of age. Sixty-seven percent of pediatricians were women, and 60.2% of all pediatricians were older than 50 years of age. In 2013, 1138 were specialists, and 508 were residents in pediatrics.14The training programme of residencies in Pediatrics. Health Ministry Ordinance 616/96, Diário da República —I Série-B 3835, 30–10-1996.Google Scholar A pediatrician is certified by the Section of Pediatrics of the Portuguese Medical Association after completing a 5-year postgraduate training period, of which the first 3 years are in general pediatrics, including neonatal care, and the last 2 are in more specialized areas, some of which are mandatory. In practice, the training in pediatrics is acquired mostly in large hospitals, with at least 12 months spent in a secondary care unit and 6 months in primary care.15Training programme in the area of specialization of General and family practitioners. Diário da Republica n. 45/2015de 20 de fevereiro.Google Scholar Since 1979, the specialization of pediatrics into different subspecialties began to develop in university hospitals. There are 4 pediatric specialties recognized by Ordem dos Médicos (pediatrics, pediatric cardiology, pediatric surgery, and mental health for children and adolescents) and 7 subspecialties (pediatric intensive care, gastroenterology, nephrology, neonatology, neuropediatrics, oncology, and orthopedics). GPs must complete a 4-year postgraduate training of which 2 months must be performed at child and youth health facilities.16User Portal. Developed by SPMS-shared services of the Ministry of Health; 2014.Google Scholar Primary child health care is provided by both the NHS and private settings. At the NHS, child health care is almost exclusively provided by GPs. Pediatricians work mainly at hospitals, either in secondary or tertiary care facilities, but are also providers for primary child health at private clinics or hospitals. Digital platforms of the Portuguese registry and data bank had significant implications on the quality of child health care. An infant who is born in Portugal will be registered in the Project Nascer Utente (born health care consumer), which allows for the registration of the newborn in the NHS even before hospital discharge. At this point, the newborn is automatically registered to a health care center and associated with his/her mother's GP.17Directorate of HealthDespacho 03 janeiro, 2012.https://www.dgs.pt/programas-de-saude-prioritarios.aspxGoogle Scholar Nearly all health services in Portugal have access to the Internet. Thus, the physician examining the newborn will be able to enter his findings into the digital medical booklet. The GPs or other primary care providers will refer the child to pediatric specialists in secondary or tertiary care hospitals whenever a severe or long-term condition is suspected. Health care indicators have improved over the years (Table). General health education of the population has improved in recent years leading to an increased awareness of warning signals for common diseases. Together with a flexible first contact care for acute problems in the hospital pediatric emergency departments, the adoption of a specific triage system and a well- organized transfer of critically ill young patients contributed positively to the decrease in child mortality and improved quality of life of Portuguese children in the last decade.TableHealth care indicators of Portugal199019952000200520102012Mortality rate, infant per 1000 live births)11.67.55.73.73.12.9Mortality rate, infant, female (per 1000 live births)10.3-5.1-2.82.7Mortality rate, infant, male (per 1000 live births)12.8-6.2-3.33.2Mortality rate, neonatal (per 1000 live births)6.9463.62.31.91.8Mortality rate, under-5 (per 1000 live births)14.89.87.44.73.83.6Mortality rate, under age 5-y, female (per 1000)13.0-6.7-3.53.3Mortality rate, under age 5-y, male (per 1000)16.4-8.2-4.24.0Perinatal deaths (per 1000 births)10.57.25.13.62.93.6Postneonatal deaths (per 1000 live births)4.02.82.1---Number of stillborn fetuses with a birth weight of 1000 g or more758.0530.0444.0306.0241.0249.0Number of early neonatal deaths with a birth weight of 1000 g or more472.0242.0163.091.055.070.0Number of live births with a birth weight of 1000 g or more116 140.0106 511.0119 233.0108 701.0100 951.089 442.0Immunization, measles (% of children ages 12-23 mo)85.094.087.093.096.097.0Immunization, DPT (% of children ages 12-23 mo)89.093.096.093.098.098.0Hospital beds (per 1000 people)4.13.93.83.73.4-Nurses and midwives (per 1000 people)---4.65.3-Physicians (per 1000 people)2.82.93.23.43.9-GDP (constant 2005 US $) (in billion)137.4149.6184.1191.8197.2188.4GDP growth (annual %)4.04.33.90.81.9−3.2GDP per capita (constant 2005 US $)13 767.414 916.917 891.418 265.418 647.817 919.4Health expenditure per capita (current US $)-874.91069.61886.42323.71904.8Health expenditure, total (% of GDP)-7.59.310.410.89.4Employment to population ratio, ages 15-24, total (%) (modeled ILO estimate)-36.041.835.828.623.4Unemployment, youth total (% of total labor force ages 15-24 y) (modeled ILO estimate)-16.18.616.122.337.7Unemployment, youth total (% of total labor force ages 15-24 y) (national estimate)10.116.18.616.122.337.6Life expectancy at birth, total (y)74.075.376.378.179.080.4Fertility rate, total (births per woman)1.61.41.61.41.41.3Population, total (in million)9.910.010.310.510.610.5Population ages 0-14 y (% of total)20.617.816.215.615.114.9Population density (people per km2 of land area)109.1109.6112.5114.8115.6115.0Population growth (annual %)−0.20.30.70.20.0−0.4Rural population (in million)5.24.94.74.54.24.0Rural population (% of total population)52.148.945.642.439.538.4Adolescent fertility rate (births per 1000 women ages 15-19 y)24.521.320.418.114.312.6Birth rate, crude (per 1000 people)11.710.711.710.49.68.5ILO, International Labor Organization. Open table in a new tab ILO, International Labor Organization. Recognizing the growing importance of noncommunicable diseases and chronic complex diseases and deficiencies, the NHS established 8 priority programs for health care for diabetes, HIV/AIDS, prevention and control of tobacco smoking, promotion of healthy nutrition, mental health, malignant diseases, respiratory diseases, and cerebrovascular diseases.18Early diagnosis. National Program. Public health center Dr. Gonçalves Ferreira. National Institute of health Doutor Ricardo Jorge. http://www.diagnosticoprecoce.org/historia.htm. Accessed September 27, 2015.Google Scholar The Child and Youth Health Care Program is a continuous program that includes growth, development, and anticipatory care and in some cases also integrates some priority programs. The neonatal screening program began in 1979. Currently, it includes the screening of endocrine and metabolic diseases. The system informs the public about its importance. Individual results, as well as the information about all Portuguese specialized centers for the screened diseases,19ELI - Local team of intervention. The National Association of early intervention. ANIP, http://anip.net/index.php/quem-somos/sobre-anip.Google Scholar may be accessed online. Since 2014, neonatal screening also is available for cystic fibrosis. The government finances all programs for the diagnosis and treatment of these long-term conditions. Based on the international availability of high technology diagnostics for molecular genetic testing, genetic counseling, and prenatal diagnosis are offered to all patients. The Abortion Law 6/84 allows for the legal interruption of a pregnancy if there is a risk to the mother's life, fetal malformation, or pregnancy because of rape. In addition, since 2007, Law 16/2007 allows for the voluntary interruption of pregnancy until the 10th week. The social and financial burden of having a child with a long-term disabling condition is high. There are existing networks of support for health and educational needs for most families. However, in many regions of the country, there are still unmet needs and imprecise registries for the majority of chronic diseases and deficiencies in children. There are some nongovernmental organizations, namely in the area of early intervention, on the development of diagnostic and therapeutic areas, which are in line with governmental initiatives.20National system of early intervention in childhood (SNIPI). Decreto-Lei nº 281/2009 de 6 de outubro.Google Scholar, 21Nigel C. A future for health. We all have a role to play. Calouste Gulbenkian Foundation; 2014.Google Scholar The training of pediatricians and GPs in the diagnosis and management of disabling conditions, as well as socioeconomic improvement, contributed substantially to reach a sustainable and realistic progress in achieving good health care for Portuguese children and to reduce and maintain infant mortality at very low levels. A future investment must be spent for organizing a more patient-centered approach (such as palliative care), defining a network of highly specialized pediatric centers of competence. Considering that many diseases of adults may have an unspectacular early origin during childhood and that the early diagnosis will influence the further outcome and well-being later in adult life, the early diagnosis and follow-up of children's health must be considered a priority. The recognition of this life-cycle model of diseases is fundamental if Portuguese pediatricians want to improve child health care in order to reach the high standards of Northern European countries.20National system of early intervention in childhood (SNIPI). Decreto-Lei nº 281/2009 de 6 de outubro.Google Scholar, 21Nigel C. A future for health. We all have a role to play. Calouste Gulbenkian Foundation; 2014.Google Scholar Portugal has a well-established Child and Youth Health Program and one of the best vaccination rates in Europe. Infant mortality is one of the lowest in Europe, and Portugal is on its way to control the burden caused by noncommunicable diseases. Surveillance programs and chronic disease registries are used efficiently to plan and implement specific measures, including preventive, curative, and palliative care. Quality assurance monitoring systems and implementation of evidence-based clinical guidelines with digital records, including international coding, are already recognized essential steps to improve health care systems in Portugal.