From time to time, until the crisis has passed, the HEPL blog series authors will be given the opportunity to provide short updates on their country/region’s continuing response to this worldwide catastrophe and their further reflections on those responses. Each update will be labelled accordingly with the original response at the bottom of each post.

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HEPL blog series: Country Responses to the Covid19 Pandemic

Portugal’s response to the coronavirus pandemic – the August update (2020)

Céu Mateus (Lancaster University, UK)

At the time of writing (August 8), the country had 52,537 cases confirmed, 1,750 deceased, and 38,364 recovered COVID-19 cases. Further to this, there were only 33 patients in the ICU. Compared to previous reports, the number of persons that recovered, number of active cases, and the number of deceased patients has increased. In three months there was an increase of 86% in the number of new cases and an increase of 49% in the number of deaths. The number of cases confirmed as well as the number of deaths per day was decreasing until mid-May. Since then the number of cases per day has plateaued, and even presented some increase, until mid-July. The number of deaths was steadily decreasing until the third week of June. Since then there has been an increase with a peak on the 9^th of July but decreasing since and with zero deaths on the 3^rd of August. The biggest outbreaks in the last three months have taken place in Lisbon and in nursing homes around the country, with mortality in nursing homes showing a worrying pattern. Social distancing is still the norm, and no public gatherings of more than 20 people are allowed.

On the 1^st of June, nurseries, day care, and after school activities were reopened. On the same date cinemas, theatres, and concert halls were also allowed to resume activity with marked seats and reduced capacity for social distancing.

Face masks are now mandatory when coming into contact with other people in public or private services. Partial working from home with lagged schedules and ‘bubbles’ is now the norm. Public transport is working on a reduced scheduled with reduced capacity and all the passengers must wear face masks. Public services are now open, but everyone has to wear a mask and only people with scheduled appointments are allowed in. All shops have now resumed their activities, with clients and workers required to use face masks and scheduling appointments for hairdressers and activities alike.

Outside individual sports are also allowed. Football has resumed but no spectators are allowed in the stadiums. Restaurants and coffee shops are open with reduced capacity due to social distancing measures. There are restrictions on alcohol sales outside restaurants, and bars and dancing places face reduced opening hours as well.

Data availability is still a problem and the data shared with a few researchers is inaccurate in some respects. Epidemiologic models used by the government have not been shared with the research community. Between March and May there is clearly excess mortality, and its causes may be attributable to COVID-19 and to people missing necessary care. According to the Portuguese Medical Association, in the same period, there were 3 million fewer appointments in the primary care sector. There was also a reduction in the number of people going to A&E. Further to this, we need to have in mind the thousands of diagnostic and screening exams that were not performed. Most of the providers in the private sector have closed or reduced significantly their activity. This will undoubtedly impact on the health outcomes of the Portuguese population.

As in most of the countries, the economy has also come to a halt, tourism declined to practically zero, and businesses are struggling to remain operational. New relief measures to address the problems of people working in the arts (musicians, actors, technicians, film makers, and so on) have been promised but are yet to start. Information about the financial and economic impact of ongoing reforms is still very limited. The economic outlook for Portugal is worrying as the gross domestic product shrank 14.1% in the second quarter of 2020, the biggest contraction ever, due to lockdown measures imposed to contain the spread of the coronavirus. In June, the unemployment rate hit 7% from a revised 5.9% in May. In addition, there are close to 900 thousand workers on furlough, but some will see their jobs disappear when the scheme ends. As in other countries, women and those under 25 have been hit the hardest. Schools will open in September and teaching may be face to face, but plans are still vague. This is worrisome both for the families and for the teachers.

The Portuguese government had a very balanced response at the beginning of the pandemic, and this must be praised and acknowledged. However, we have since faced some inability to solve problems like data collection, data sharing, excessive bureaucracy and lack of leadership in many areas, namely in the NHS.

Portugal’s Response to the Coronavirus Pandemic – Update (May 2020)

Céu Mateus (Lancaster University, UK)

The Portuguese strategy to tackle the coronavirus outbreak seems to have worked out well. At the time of writing (May 13), the country has had 28,132 cases confirmed, 1,175 deceased, and 3,182 recovered COVID-19 cases. Moreover, there were 26,278 persons in surveillance, 602 inpatients and 103 patients in the ICU. Compared to last month the number of persons that recovered, number of active cases, and the number of deceased patients has increased. The number of cases confirmed as well as the number of deaths per day has been decreasing in the last week. The two biggest outbreaks of the disease are around the two main cities: Lisbon and Porto.

Portugal was on lockdown until the 2^nd of May when some measures were eased. Social distance is still the norm, no public gatherings of more than 10 people are allowed and home confinement as much as possible is still in place. Only very close family members are allowed at funerals. Wearing a face mask is now mandatory when coming into contact with other people in public places. Whenever possible working from home is still the norm. Public transport is resuming normal activity but can only transport passengers up to 2/3 of their capacity and all the passengers must wear face masks. Some public services are now open but everyone has to wear a mask and only people with appointments scheduled are allowed. Small street shops (up to 200m²), hairdressers, barbers, and nail shops have resumed their activities, with clients and workers required to use face masks. Libraries reopened on the 4^th of May. Outside individual sports are also allowed.

The plan for lifting the lockdown has three phases: 4^th of May, 18^th of May and 1^st of June. Reassessment of the measures adopted will take place every fortnight.

As in most countries, the economy also has come to a halt, tourism declined to practically zero, and businesses are struggling to remain operational. The package of relief measures to anticipate and mitigate the impacts of the lockdown on citizens and employers has been extended in order to cover more people in dire situations. The number of people reaching out to food banks increased dramatically.

There are still concerns about the availability of timely data and about the accuracy of the epidemiologic models (not yet made publicly available). There is no information about the financial and economic impact of ongoing reforms.

The Portuguese health care services and professionals have been able to deal with the increase in the demand for their services and the value placed on the Portuguese NHS is very high.

Portugal’s Response to the Coronavirus Pandemic – Original post (April 2020)

Céu Mateus (Lancaster University, UK) and Mónica Oliveira (IST, Universidade de Lisboa, PT)

Portugal’s Response to the Coronavirus Pandemic
The first Portuguese COVID-19 patient was diagnosed on March 2 and the first death occurred on March 16. As the number of cases steadily increased in the first weeks of March, the Portuguese government prepared a set of preventive measures while working on health capacity enhancement. On March 13 the Ministers of Internal Affairs and of Health issued a joint declaration of an alerted state for the whole territory and decided to recall police and civil protection services to support public health operations. Mass public gatherings were suspended, dancing places, schools and non-essential shops closed, as well as non-essential movement banned and land borders closed from March 16. On March 18 the President of the Republic declared a state of emergency for two weeks, which was afterwards renewed until April 17.

Preventive measures, testing and response to the epidemic
Social distancing measures have been in place since March 19. People returning to Portugal have been asked to quarantine since mid-March, and since March 23 people arriving by plane are controlled and airports will be reduced to minimum activity over Easter. Restaurants, shopping centres, sports facilities, shops and businesses have been closed since mid-March; access for visitors to hospitals and nursing homes is very restricted; dentists only perform acute treatments; and prisons are closed to new prisoners and visitors.

Since March 16 all non-critical public sector employees have been working from home, private sector firms were asked to work-at-home whenever possible, and childcare facilities, schools, universities and other educational institutions have been closed (sometimes using online/digital teaching). Also the Portuguese border with Spain has been closed, with legal exceptions applying.

On March 13 the government released a package of 30 relief measures to anticipate and mitigate the impacts of the lockdown on citizens and employers. Social security, taxes, and mortgage payments can all be delayed in specific situations for up to 3 months, and lay off legislation has been passed to support private businesses left without any activity (accounting for stringent difficulties in several sectors, including tourism). That package has now been revised/adjusted.

National guidelines for triage and referral of COVID-19 patients have been enforced: emergency and phoneline calls are the main entry point, with patients asked not to visit health providers directly; persons with mild symptoms are generally advised to stay at home until symptom free for 48 hours; and those with severe symptoms are referred to testing in a hospital setting. Following disagreements among medical experts, attempts were made to increase the testing capacity by using military personnel and allowing alternative testing protocols.

Special measures for illegal immigrants, victims of domestic violence and prisoners have been put in place, so as to eliminate barriers to care and to prevent disease transmission among the weakest.

Government attempts were made towards a heavy use of digital technologies in the delivery of public services, with an app/website with all measures and supporting software being quickly created.

Treatment capacity
Elective surgeries were postponed if considered as non-urgent. Whenever possible patients were discharged to free beds and staff, and to reduce the risk of infection. External consultations were postponed or started being done over the phone or via telehealth to avoid contact. These measures allowed NHS hospitals to free up capacity to deal with COVID-19 related services. The hospital network was reorganized so that some hospitals were put at the forefront for COVID-19 patients and one hospital will be fully dedicated to the treatment of COVID-19 patients from the second week of April onwards. By early April (April 6) there is still enough hospital capacity, although the pressure is increasing with slightly over 1,000 COVID-19 patients being admitted. So far ICU capacity is sufficient for critical patients, with the stock of ventilators being increased and more being arriving from China.

The private sector has been supporting the NHS for non-elective care when adequate, field hospitals have been erected in some strategic locations, and primary care services have been adapted to the new context.

As in many other countries, there have been shortages in protective equipment (e.g. masks, personal protective equipment, hand sanitizer), with mobilisation of the Portuguese society contributing to alleviate this (for instance using 3D printers and productive textile capacity).

Workforce
Measures to re-organize health care personnel were put in place before the situation became critical. The government requested all personnel with ties to the NHS to only work in the NHS, and given the low number of nurses, a special hiring program was implemented. GPs have been trained to carry out distinct activities, and military lab professionals requested to perform diagnostic tests. Emergency childcare facilities were reorganized to allow critical workers to stay at work, and home care professionals were given support.

A low number of anaesthesiologists, together with a low number of ICU beds and ventilators are recognised as critical weaknesses in the Portuguese NHS.

Reflection on COVID-19 response in Portugal
Political parties in Portugal have been united towards the response to the COVID-19 crisis. Interpreting its own context and the situation in Spain and Italy, Portugal was the first country in Europe to issue a coherent package of 30 measures ranging from health, education, social distancing, fiscal policy, unemployment, social security and so on. That package was designed to be inclusive and protect the most severely affected by the epidemic and has been revised afterwards to address identified pitfalls and to improve incentives.

Regarding the response context, on the positive side Portugal had before the crisis finally recovered from the effects of 2008 financial crisis and from the Troika intervention in 2011, with the first surplus in public accounts under democracy being observed in 2019, and with the economic situation improving and low unemployment being achieved. Nevertheless, the Portuguese economy is highly exposed to tourism, highly relies on international funding of public debt, there being limited space for allocating further public resources to the crisis. This is a major concern, as it is unlikely that the approved policy package will be enough to secure the economy.

Given severe budgetary constraints in the NHS since 2011, health care providers face enormous challenges in answering to the new demands, lacking resources, good information systems and collaborative tools, but are doing their best to adjust and reorganize. So far, the number of visits to A&E departments has decreased but an increase in mortality unrelated to COVID-19 has been observed, with these issues deserving monitoring and analyses.

Government policy-making and its communication strategy regarding the crisis suggest control, but debilities in data collection and publication have been exposed and concerns were raised about the availability of timely data and about the accuracy of the epidemiologic models used (not made publicly available). There is no information about the financial and economic impact of the ongoing reforms.

With the crisis, digital technologies are being boosted, there being nevertheless fears concerning bureaucracy and about the capacity of the public sector to quickly deliver the reform package.

Although there seems to be positive signs on the trajectory of the pandemic, it is too early to judge the impact of the reforms, and the government has yet to announce any plans for a gradual easing of the shut down and for tackling postponed health care services.

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