LISBON — Getting to the MRI machine at one of this city’s largest public hospitals means taking a trip through time. Plastic waiting room chairs in radiology sit amid centuries-old blue and white Azulejo tiles, while a nearby chapel glimmers with Renaissance statuary and paintings. Hospital de São José’s ambulance bays, exam rooms, and labs, after all, occupy a former college the Jesuits started building in 1579.
This recycling of a timeworn campus that somehow survived Lisbon’s devastating 1755 earthquake exemplifies Portugal’s health system: Instead of spending money on gleaming new hospitals and expensive drug therapies, the country focuses on old fashioned primary care and public health.
It’s a strategy that has served Portugal well, and one that health care experts point to as a model the United States might learn from as it confronts soaring medical costs and, by many measures, deteriorating health.
Consider these numbers: Portugal has a life expectancy nearly four years longer than the U.S. despite spending 20% of what the U.S. does on health care per person. According to the 2021 Global Security Index, which measures the ability to respond to pandemics, Portugal ranked third out of 195 countries in providing access to affordable health care. The United States ranked 183rd.
Portugal has a national health care system, entitling every resident to free or very low-cost health care. “They take care of people. If you’re poor, you still get health care. And you don’t have to have a job to get health insurance,” said Kyriakos S. Markides, a professor of aging at the University of Texas Medical Branch, Galveston. “What happens in this country? A lot of people go without.”
Portugal is not without challenges. A shortage of primary care doctors means long waits for care, and more than a million people, many of them immigrants, have no assigned physician. But STAT’s analysis, based on two weeks of reporting in Portugal and interviews with dozens of health care workers, patients, and policy experts, found their system is nimble and makes smart use of data and electronic health records to track both individual and population health in real time. It embraces innovative programs such as “social prescribing” that expand the boundaries of what is considered health care, while progressive laws on drug use and treatment have been credited with driving down overdose deaths, even as they rose in the U.S.
Central to its success is a network of primary health care clinics embedded in neighborhoods, working alongside regional public health units. Data flow freely between them to track illnesses and unmet health needs, said Gustavo Tato Borges, president of Portugal’s National Association of Public Health Doctors.
While his country may not offer the most cutting-edge, expensive medical treatments, he told STAT the focus on primary and preventive care is working — and not breaking the bank. “We have results that are way above what would be expected,” he said. “Most of us cannot even imagine what it costs to provide care in America. We in Portugal don’t want to become the U.S. We are probably more seduced by Holland and Germany.”
Portugal has come a long way in a relatively short time. In 1950, life expectancy here was closer to 60, among the lowest for developed nations. In the U.S. that year, it was 70, stellar for the time and among the highest in the world. Today, the two countries have swapped places. Why?
It’s a vexing question — and something of an indictment of the United States, a powerhouse of biomedical research that spends more on health care than any other country — in 2022, $4.5 trillion, or $13,500 per person.
“We are a sick nation,” says Stephen Bezruchka, a former emergency physician in Seattle who now researches and teaches at the University of Washington about the role inequality plays in harming health and why spending more on health care doesn’t help. If there were a “health Olympics,” he notes in his book “Inequality Kills Us All,” the United States would come in 50th.
Now at 78.5 years, life expectancy in the United States has stagnated. In 2021, it had dropped to its lowest level since 1996, according to the Centers for Disease Control and Prevention, in large part due to Covid deaths, and it is still struggling to bounce back. The country ranks about 60th among the world’s nations, closer to Turkey and Ecuador than to fellow economic powerhouses like Switzerland and Japan, where people live to about 84 years on average. In Portugal, which spends about $2,700 per person on health care annually, people live 82.3 years on average.
Americans “die the youngest and live the sickest,” according to a report comparing 10 peer nations released this year by the Commonwealth Fund. “The United States,” the report’s lead author and former foundation president David Blumenthal told STAT, “is the most innovative — and dysfunctional — health care system in the world.”
If you ask experts what’s behind that poor health performance, you’ll hear a kind of “choose your own adventure” based on the research interests of those experts. It’s gun violence. No, it’s infant and maternal mortality. No, it’s racial health disparities. No, it’s deaths of despair. No, it’s obesity. No, it’s drug overdoses.
It’s all of those and more, said Stephen Woolf, a professor of family medicine and population health at Virginia Commonwealth University, who has analyzed such trends for decades and says the lives lost due to America’s failing health system dwarfs those lost in the pandemic. In his analyses, every body system, age group, racial group, and social class in the United States is doing more poorly on average than it should — even white, college-educated Americans who should be thriving.
It’s not just a handful of diseases that are to blame, either. In addition to Covid-19 — which curbed U.S. life expectancy far more than in many other countries — Woolf has found that 35 different causes of death have increased in recent decades.
“In every single domain, we found problems in the U.S. … It’s systemic,” Woolf said. “In Portugal, they are not experiencing those systemic problems.”
Portugal’s stellar progress comes as no surprise to Atul Gawande, a physician-writer who serves as assistant administrator for global health at the U.S. Agency for International Development. As a journalist, he chronicled the success of another country, Costa Rica, which also spends far less than the U.S. on health care yet achieves outsized results because of its similar focus on primary care and public health.
Thailand, he said, is another nation that dramatically boosted health outcomes by providing citizens with access to low-cost health care, assigning them primary care physicians, and creating an army of community health workers. In just two decades, he said, the country has shifted from seeing 35% of its population die before 50 to gaining 10 years in life expectancy; it’s now near 80.
“This is part of the story of Portugal,” he said in an interview with STAT. And it could be a story in the U.S. as well, international experts say, if we altered our health system to center less on expensive hospital and specialty care, and mended the yawning gulf that exists between public health and primary care.
“Those countries that have built around their primary health care centers,” Gawande said at the recent STAT Summit, “have gotten phenomenal results at a much lower cost.”
Portugal’s focus is unapologetically on primary care. The backbone of its health system are “family health units,” clinics pioneered in 2006 and sprinkled throughout the country. Their care teams become part of the community. They include doctors, nurses, social workers, and often most critically, front desk staff who calmly work to help coordinate appointments and keep streams of patients flowing.
On a recent day at the Baixa Family Health Unit, in Lisbon’s lively historic center, patients of all ages from a panoply of nations flowed through, receiving what truly is family care. “We follow the whole family, from pregnancy until they’re dead,” said Martino Gliozzi, the physician who coordinates the center. His oldest patient is 104.
While part of a national health system, clinic directors have considerable autonomy. When Gliozzi took charge in 2016, patients frequently lined up in the early morning to be seen by a doctor. He put an end to the lines with a system that distributed appointments throughout the day and allowed more patients to be seen.
For those who can’t get to the clinic, doctors see patients at home. Gliozzi stays fit by negotiating Lisbon’s steep hills and apartment staircases, as do his clinic’s nurses. “We have older ladies who live on the third floor. They cannot do anything by themselves. For them it’s really important we go there,” said Tânia Meneses, one of the clinic nurses.
Gliozzi, a native of Italy who has worked in Mozambique and Brazil, came to Lisbon for his residency in 2009 and feels right at home in the health unit, where a dozen languages might be spoken in a day. Staff use Google Translate on their phones, pointing at pictures, waving their arms, and using broken English to communicate with the many immigrants they serve. Patients who don’t have health records or aren’t sure if they’ve received vaccines are urged to get shots, especially for measles and tuberculosis. “Better safe than sorry,” Meneses said.
The clinic embraces what Gliozzi calls “out of the box” ideas, like Walk with a Doc: Early in the evening, physicians stroll city streets with patients to encourage exercise. (Portugal, like the U.S., faces an obesity crisis despite its much healthier seafood-forward Atlantic diet — think Mediterranean diet but with more clams.)
Under the leadership of another young doctor, Cristiano Figueiredo, the clinic was the first in the country to embrace “social prescribing” — using patient visits to ask about social issues affecting their health and start to address them by linking patients with the community resources they need. The practice is now spreading widely across Europe.
At one appointment, a young man in his 30s, who asked that his name not be used to protect his privacy, came in with itchy red hands, the skin peeling off in strips. The rash was painful, keeping him from his on-and-off job helping build temporary exhibition spaces. Figueiredo determined the man had impetigo and prescribed an antibiotic cream. But rather than rushing him out the door and moving to the next case, Figueiredo spent time reading the patient’s health records, and noticed he hadn’t seen a physician in the previous four years. Electronic health records follow a patient regardless of how often or where they move within Portugal.
He saw the man had been smoking since he was 17 and had tried to quit a few times. Figueiredo gently brought this up. “I think it’s very important for you because your father passed away from lung cancer,” he said. “Do you want to try quitting?” The patient was willing to try smoking cessation drugs; even though they’d cost him 80 to 90 euros out-of-pocket, they were cheaper than tobacco. He was also willing to do the STD scan Figueiredo suggested.
“This patient had very low contact with the NHS. We take the opportunity to do a bit of preventive medicine,” Figueiredo explained after the patient left. He remained concerned the man hadn’t finished college and worked irregularly. It was something he planned to discuss with him when he returned for a follow-up visit. “It was my instinct, it wasn’t time,” he said. “Maybe next time.”
This country’s health statistics are all the more remarkable given its dismal circumstances just a half-century ago. An authoritarian regime in power from 1933 to 1974 had left the country with the lowest per capita income and literacy rates in Western Europe. Infant mortality in 1975 was a devastating 45 deaths per 1,000 births and life expectancy hovered around 60.
During those years, noted Carlos Cortes, president of the Portuguese Medical Association, “we had a health system mostly for the rich — people who were rich could go abroad.”
That all changed when the country was remade into a democracy 50 years ago and a national health system was created, modeled on Britain’s. The right to health care was enshrined into Portugal’s new constitution.
“We put everyone on the same level,” said Cortes. Life expectancy rose by about 10 years. ”Very quickly, Portugal went from not having a system to being one of the best. It was one of the biggest jumps forward in the world.”
How far Portugal has come became clear during the Covid pandemic. In the United States, efforts to deploy the vaccines that it had created in a dazzling feat of technical prowess were disappointing to many public health leaders. Less than 70% of U.S. adults are fully vaccinated, compared with nearly 90% in Portugal.
Vaccine hesitancy is minimal, thanks to the country’s decades-long focus on childhood and adult vaccination programs, but the Covid vaccine campaign got off to a rocky start. Early efforts were marred by people with connections jumping the line and the spread of misinformation. To keep the situation from spiraling out of control, the government handed the reins of the vaccination project to Admiral Henrique Gouveia e Melo, an imposing former submarine squadron commander.
Wearing military fatigues meant to inspire trust, he appeared frequently on television to calm and encourage a frightened population. He approached the campaign as he would a battle, he told STAT, in an interview in expansive offices overlooking the Atlantic Ocean and graced with hand-painted tiles depicting naval triumphs when Portugal commanded the world’s seas.
“I am a submariner. I don’t know how to defend. I only know how to attack,” said Gouveia e Melo, now chief of the naval staff. “We had to make this like D-Day.”
He deployed military mathematicians to optimize vaccine delivery, partnered with mayors and village leaders, and commandeered iconic soccer stadiums for mass vaccination sites. Harnessing contact information from national health service records, his 300-person team contacted residents to come in for appointments, sometimes badgering people with three texts per day, and leading Portugal to quickly become, to the surprise of many, one of the world’s most vaccinated countries.
Such successes are something the Portuguese are rightfully proud of. “We came from misery to a medium position in Europe,” Adelberto Campos Fernandes, who served as the country’s health minister from 2015-18, told STAT, noting Portugal’s integrated networks of primary care, high vaccine uptake, and impressive infant and maternal health statistics.
It’s not all tied to money, he notes. Despite ranking 40th economically, Portugal ranks 14th among European nations in health metrics, and in many of those metrics, surpasses the U.S. Fernandes said he doesn’t see life expectancy and other health indicators improving in the U.S. unless politicians address inequalities that allow the wealthy and well-insured to choose among top hospitals to have elective procedures while others don’t receive even basic care.
“At the same time,” he said, “you have the best care in the world, and the worst.”
Portugal’s health care system is far from perfect. It’s a perennial issue in elections, and doctors’ and nurses’ strikes are common. Headlines ominously warn of “an imminent breakdown,” while a critical shortage of physicians has left nearly 1.6 million of the country’s 10 million residents with no family doctor, meaning they often wait weeks or months for an appointment.
The doctor shortage is partly a problem of demographics, as those who started their careers at the dawn of the country’s health system retire and aren’t replaced. It’s also a problem of low pay, particularly in Lisbon and coastal Nazaré, expensive regions where physicians often have difficulty affording homes. Many doctors and nurses have taken jobs in higher-paying Northern European countries. It may also be a problem of low efficiency and how many patients each physician sees.
The result is lines. Lines to get elective surgeries, and lines snaking out clinic doors. Early one recent cold and foggy morning, about two dozen people were already queued up outside a clinic in Amadora, a largely immigrant neighborhood about halfway between Lisbon and the palace-studded former royal sanctuary of Sintra. They were hoping to snag a scarce appointment when the clinic opened its doors.
One woman who asked that her name not be used, was wearing a bright blue wool coat over a bulky sweatshirt, and coughing miserably. The 67-year-old had been in line since 4 a.m. She’s gotten used to waiting, she said, though it has left her frustrated and angry. She shook her head as she looked at a photo on the phone of another patient that showed a line wrapping around the building during flu season.
Her strategy worked. Once patients were let in at 8 a.m., she was out in less than an hour, having gotten treatment for her cough. She lost her family doctor a few years ago for reasons she doesn’t fully understand because her husband still has a doctor. She earns little working for a private charity and said she can’t afford private insurance or to pay to see private doctors.
“I’ve always paid taxes. I’ve been working since I was 14 and I still work, but I don’t have enough money,” she said in Portuguese through an interpreter. “How can you expect me to pay for tests and consultations?”
She left then, to pick up her prescription cough medicine, and to rest. But she returned a few minutes later, concerned about what would happen if something negative was written. “Please don’t terminate the National Health Service,” she told STAT. “It’s the only chance the poor people get.”
Even those with family doctors must wait for some services such as elective surgeries. Mohammed, 53, a patient at the Baixa clinic who moved to Portugal from Bangladesh about five years ago, has been dealing with the discomfort of a fistula for months. He was given a waiting time of nine months since his case was not deemed urgent. Carrying an organized sheaf of medical records in a clear plastic folder, he told his physician, Figueiredo, that he’d visited two hospitals hoping to be seen sooner but was told no.
Some middle-class and wealthier Portuguese have elected to pay for private insurance, partly to bypass the waits for surgery. (Some public employees get private health insurance as well.) The private hospitals they can go to are often new and gleaming. A walk through one in Lisbon revealed sleek waiting rooms filled with Scandinavian style furniture, giant video screens, walls of plants, and escalators that whispered as they carried patients between floors. But it also felt impersonal, like a Department of Motor Vehicles waiting room, with dozens of patient numbers slowly scrolling by on screens.
Some private providers, according to patients and National Health Service physicians, are eager to perform simpler procedures that result in quick profits, like hip replacements, but less eager to take on more complex, time-consuming issues or high-risk maternity cases. That can lead insured patients to return to the public system for care, adding to the financial pressures it faces.
“Across the region, private providers take the easy cases because they are there to make money,” said Jon Cylus, a senior health economist at the World Health Organization and a researcher at the European Observatory on Health Systems and Policies who formerly worked for the U.S. Centers for Medicare and Medicaid Services. “Often it erodes the public system. It’s a vicious downward cycle.”
Phe U.S. has a critical lack of primary care physicians as well. About 100 million Americans — one third of the population — face barriers accessing primary care, with the problem only worsening with time and with no real solution in sight. In Portugal, they are working on answers, some of them quite unorthodox.
Family health physician Alexandra Fernandes and nurse Olívia Matos had comfortable jobs providing care at a family health unit in Fernão Ferro, a suburb outside of Lisbon. But they were so upset by the lines of patients that they proposed opening a new health center to serve solely patients with no assigned doctor.
The center is in Seixal (pronounced say-SHAHL), just across the Tagus River from Lisbon, where nearly 50,000 residents, many of them immigrants, have no family doctor.
The clinic takes its name, Via Verde Seixal, from a device — invented in Portugal — that allows cars to pay tolls quickly without stopping. At the clinic, priority patients bypass lines to get immediate appointments. These are babies and children up to 2, pregnant women, people needing immunizations, and those with acute problems such as trauma or urinary tract infections that need immediate care. The team sees at least 100 patients a day.
“Before people would be waiting in line at 3 a.m. We saw pregnant women delivering without ever having seen a doctor,” Fernandes said. In addition to serving immigrants, the clinic increasingly sees long-time Portuguese residents as their doctors retire and they aren’t assigned new ones. “You have to be almost dead to have priority to have a family doctor,” Fernandes said.
The clinic operates on a shoestring budget. Fernandes and other doctors take half the pay they’d make at a family health unit. She relies heavily on specialist nurses like Matos to provide care and employs residents, doctors from other countries waiting to get their certification, and retired physicians. The doctors literally take a back seat to nurses, working mostly from a back room, consulting on complex cases, providing prescriptions, and when needed, coming out with their stethoscopes. (In Portugal, it’s only doctors that are allowed to listen to the heart.) The clinic runs on donated computers, and Fernandes used money she was awarded for a professional prize to purchase tables and microwaves for the staff room.
But she is working in a brand new building — that was built for a family health unit that never opened because of the doctor shortage. “We were happy because we put the poorest patients in the most beautiful of health centers,” she said. “It’s very dignifying for people.”
Fernandes knows what she’s doing is not enough. And she hopes the health system can find a way to educate and entice more doctors to work for the public system so more residents can get the appointments they need. “This is kind of a wartime model,” she said. “The happiest day will be our extinction day.”
Some say it’s not fair to compare health metrics in the U.S. to Portugal, because it’s a much smaller country: It’s about the size of Maine with the population of Michigan. But that hasn’t stopped other countries, and even some states in the U.S., from emulating its policies, such as its approach to cutting drug overdoses, which is considered a model for the world.
In the 1990s, Portugal had one of the highest rates of heroin use and fatal overdoses anywhere. In 2001, the country not only decriminalized the use and possession of drugs, but also, in partnership with several non-governmental organizations such as Crescer, created a network of mostly free inpatient and outpatient treatment centers and mobile street teams that seek out drug users to provide medical care, clean needles, and support to enter addiction programs.
Two decades later, drug overdose deaths have fallen sharply, from one per day (that’s a lot of deaths for such a small country) to about 70 to 80 per year. New Jersey, with a smaller population than Portugal, sees 3,000 a year. HIV infection rates have dropped dramatically, too.
On a recent day, a two-person street team from Crescer, recent college graduates Mariana Gomes and Antonio Cabrita — clad in boots with three-inch-thick soles to prevent a stick from stepping on a discarded needle — set out across downtown Lisbon in a Fiat station wagon packed with fresh water, cleaning wipes, and a nurse’s bag filled with first aid supplies. At Martim Moniz Square — which could be a street in New Delhi with shops selling samosas and fragrant spices — people emerged from doorways and walked up to the team as soon as they arrived, looking for new smoking pipes.
Those approaching were a mix of recent immigrants and longtime residents. The team wished they had pipes to distribute — smoking heroin is less dangerous than injecting it — but there was a shortage. Instead, they handed out antiseptic wipes to keep injection sites clean, water, and condoms as part of a harm reduction strategy. “You can’t just have the law, you need the services,” Gomes said as she handed out clean squares of aluminum foil to use for smoking. “We try to start the process to get people to go to rehab. It can take up to a year.”
In a sign fewer people were injecting, no one asked for syringe kits. The duo looked for a pregnant woman they knew needed medical attention, but couldn’t find her. They moved on to their next stop, in a wooded area up a muddy path where a man needed care for chronic eczema and abscess wounds. He’d emailed them a horrifying photo of his skin — yellow, cracked, and bloodied — so they were bringing medicine.
“It’s so bad,” said Gomes, clad in a blue vest covered with zippered pockets holding the tools of her trade such as hand sanitizer. “But he’s so disorganized, he can’t go to an appointment. Sometimes people don’t even know what day it is.”
The clients are clearly comfortable with Gomes and Cabrita, probably because they see them nearly every day. Coming regularly at the same time is key. Sometimes clients get a little too comfortable, flirting incessantly with the young social workers. “Taking a hit is like an orgasm to my brain,” said one, laughing, as he threw an arm around Cabrita, 26. “I tell them, ‘You’re older than my father, just stop it,’” she said, as she shrugged off his arm.
“I was nervous about working with this population,” said Gomes, who took the position as her first job out of college. “But you do it because it makes a difference.”
And it does. “Our results were so impressive, the drug phenomenon dropped from the number one political priority to 13th or 14th,” said João Goulão, who spent more than a decade fighting to put “the Portugal model” in place after seeing the toll addiction took on the patients in his general practice, and now serves as the country’s drug czar.
Portugal’s success inspired the state of Oregon, where voters embraced a measure to decriminalize drugs in 2020, then unceremoniously dumped it earlier this year when they deemed it wasn’t working.
That approach was wrong, said Goulão. Oregon wasn’t patient enough to see the program through, he said, and didn’t learn the most important lesson that his country offers: that a legal change in drug policy means little without a strong, compassionate, and affordable public health response. Portugal’s success, he said, is inextricably linked to its national health system.
While the longevity here is a reward for having a good health system, it’s brought new challenges: nearly one in four Portuguese are over 65, and many of them live with serious chronic conditions.
“Since 1979, people here live 10 years longer, but these 10 years are frequently lived with difficulty,” said Manuel Lopes, who directs the nursing school at the University of Evora and sits on the board of the Comprehensive Health Research Center, a consortium of researchers developing new strategies to better deliver health care in Portugal.
Lopes has been advising Portuguese health leaders to shift from thinking of health care as a largely medical concern to making it easier (and cheaper) for patients to get care from physiotherapists, speech therapists, psychologists, and other allied health professionals for disabilities and mental health issues that arise with age. “What they need are not more appointments,” he said. “They need a continuity of care.”
The nation’s health service has recruited a wave of younger leaders, including 37-year-old Director General of Health Rita Sá Machado, to replace an old guard and modernize the system. Among the newcomers is André Peralta-Santos, the country’s deputy director of public health and a Lisbon-trained physician, who earned a Ph.D. in global health from the University of Washington, where he focused on data science. Peralta-Santos helped optimize contact tracing in Seattle when the Covid-19 pandemic hit. The pandemic then brought him home to help his country manage.
He’s now trying to apply much of what he learned in the U.S. — especially the willingness to try unorthodox approaches and to use high-level data science — to Portugal’s health system. “The openness of American culture really amazes me, how open you are to new ideas,” he said. “It’s a culture of not being afraid to try things.”
Chief among the challenges facing Peralta-Santos and his boss Sá Machado are trying to increase the efficiency of their health system, grappling with the consequences of an aging population, and taking on newer issues like childhood obesity. “We have a lot of reasons to be happy with our progress over the last 50 years, but we also have a lot of challenges,” he said. “We tend to live long, but not in a great condition.”
This project was funded in part by an International Health Study Fellowship from the Association of Health Care Journalists supported by the Commonwealth Fund. Our financial supporters are not involved in any decisions about our journalism.
