Although participants did not perceive the quality of perinatal care as having deteriorated, the analysis of their responses on work experience revealed that it was indeed adversely modified in all eight WHO Quality Standards. Results disclosed an identifiable interrelation between macro-socioeconomic determinants and perinatal healthcare quality within all Quality Standards. High-quality care calls for appropriate usage of the healthcare infrastructure, skilled and motivated healthcare providers, adequate availability of materials, evidence-based clinical practices and non-clinical interventions to guarantee effective surveillance and organization . Our results reveal that the major obstacle to deliver adequate care were the budget cuts in physical and human resources by the EAP which influenced the working environment of professionals and alternated perinatal healthcare quality.
Previous structural problems of the NHS were exacerbated by the austerity measures of the EAP. Overall, the unequal distribution of general practitioners and lack of GPs, nurses, obstetricians, and perinatologists created obstacles in perinatal healthcare. In primary care, the lack of GPs as key players of the gatekeeping-system caused obstacles in the functional referral as a result of a compromised gatekeeping-system with: higher waiting times, hampered timely access, and inconsistency in surveillance due to cuts in consultations, ineffective healthcare facility articulation and coordination, and incoherent follow-up. It ultimately led to inefficiencies and high budget spending on health as emergency care continued to be overused. In secondary care, lack of physical and human resources led to unnecessary paediatric inter-hospital transport of VPT/VLBW infants between HAP to HAPD. VPT/VLBW infants in need of special care and intensive surveillance due to prematurity complications experienced differential capacity issues in the referral system.
Healthcare professionals tried with extraordinary efforts to maintain quality of care under time constraints, high stress levels, and pressure to work with less essential physical resources. It caused less productivity, work absence, and ultimately burnout amongst healthcare professionals in primary and differentiated care facilities. We argue that this effort cannot be maintained over the long-term and will undermine sustainability of the NHS. Other studies confirmed diminished productivity, work absence, and burnout among Portuguese healthcare professionals, which was also associated with perceived poor working conditions and reduced professional experience [23,24,25,26,27,28] or crisis related reasons . National statistics reveal that 21.6% of healthcare professionals indicated moderate burnout and 47.8% severe burnout between 2011 and 2013 .
Non-availability of human resources was further worsened through brain drain of healthcare professionals due the introduction of a 40-week-hour work schedule and salary freeze by the EAP [Act 68/2013 of August 29]. The decree-law [(updated) DL 71/2019 of May 27] particularly affected nurses which were hired by individual contracts, which faced increased hours of work with no extra hourly pay and no right to a day off between shifts. Many healthcare professionals left their position in public care and either changed to private care or emigrated to another country seeking better working conditions or chose an early retirement with severe salary cuts. An emigration wave of 12,500 nurses was estimated between 2009 and 2015 due to: worsened working conditions through salary cuts, the search for better working conditions, financial problems caused by the crisis, and a demoralized workforce [31, 32]. In 2016, a study reported that 15% of medical doctors considered migration due to alternated working conditions by the crisis and EAP (e.g., 30.5% decrease in public compensation), and disclosed a higher demand of health care provision, a decrease in public care and an increase in private care . The 35-week-hour schedule was re-established in 2016 [Act 18/2016 of June 20] but only applied for individual contracts at public services in July 2018. In 2019, 8 years after the onset of the crisis, the lack of nurses due to that re-instalment was experienced to a greater extent than during crisis period (2009–2016).
The shortage of human resources was tried to be restored and reorganized by: i) providing an extension of GP patient lists from 1500 to 1900 patients per GP in 2013; ii) hiring 2000 healthcare professionals between 2013 and 2014 to reduce 50% of the shortage from 1 million to 5000 GPs and; iii) implementing a family nurse in 2014 [Decree-Law 118/2014 of August 5] . Still, the shortage of human resources remains a major challenge for all cross-sectional services of the NHS until today . In 2015, the NHS employed 4.6 GPs and 6.3 nurses per 1000 patients, compared to the EU average of 3.5 GPs and 8.4 nurses . Even though the GP provision is slightly above and nurse provision below EU average, it is arguable which ratio would be best to achieve a high-quality care provision in a country-based context. Given the unequal geographic distribution of GPs, national statistics on emigration and burnout, and the responses of participants, the availability of doctors and nurses who could provide care persists as inadequate.
The EAP sought to increase the number of primary care units operating under regional government contracts with a mix of salary and performance-related payments in order to be more autonomous and to establish a mechanism to ensure a more even distribution of GPs across the country . However, it was found that unequal geographical distributions of health facilities have continued until today . As of the end of 2017, there were still 390 non-reformed family health units compared to 505 reformed ones, of which around 235 received a performance-based allowance . Enhancing accessibility to primary care has not been fully achieved by the EAP and the population without a GP across the country remains high [23, 26]. Other studies also revealed that longer travel distance due to the lack of nearby facilities was a major factor in the increase in emergency visits . Geographic access continues to be one of the major challenges in accessing health care between low and high income groups and health care facilities remain unevenly distributed [41, 42]. In 2017, Portugal had 225 hospitals, of which 107 were public, 114 private, and four public-private partnership hospitals. The majority [n = 208] was located across mainland Portugal . Primary care centres, which are obliged under the Basic law [Act 95/2019 on September 4] to be allocated in the immediate vicinity at regional level, have been so far mainly concentrated in the main metropolitan area of Coimbra (26%), Lisbon (25%), and Porto (24%) . EAP reforms have also potentiated the rapid growth of the private health care sector which surpassed the public in number of facilities in a few years. Their services are, however, only accessible as long as paying users can afford it.
The fragility of a crisis-affected population was among other reflected in the medication intake behaviour of users, which was verified by other studies [26, 43,44,45]. In 2011, the EAP introduced several measures on drug purchasing: i) setting the maximum price of the first generic presented in the market to 60% of the branded product; ii) user charges for over-the-counter drugs; iii) reinforcements in generic prescriptions which reached 40% in 2013; iv) and compulsory electronic prescription for medicines and diagnostics covered by public reimbursement for medical doctors in public and private sectors . The EAP introduced changes in user fees which reflect the not absolute gratuity of the NHS: i) reviewing existing exemption categories (e.g. pregnant women and children under 12 years); ii) extending co-payments for most services; iii) and increasing user charges . Even though the EAP substantially reduced the prices of medications and pregnant women are exempt from user charges, participants reported that mothers of VPT/VLBW chose among the cheaper medications on the prescriptions in 2018/2019.
The crisis and EAP especially influenced pregnant women with lower SES in a threefold manner which resulted in lower or non-attendance of antenatal consultations at primary care centres. Firstly, patients faced inferior monetary situation and unemployment due to the crisis . Secondly, the EAP reduced one-third of patient transportation by limiting non-urgent patient transport and implementing detailed rules for health service provider on transportation authorizations which diminished free transportation [32, 37, 45, 46]. Thirdly, economic and financial crisis effects influenced behaviour of women who postponed their maternity as another study confirmed . Non-attendance of consultations caused issues in patient referral, information provision, communication, support during the antenatal and postnatal period and overlap in postpartum appointments. Despite exemption from out-of-pocket payments, intensified monetary hardship through decreased household income consequently adversely affected healthcare access for pregnant women.
Decreases in infant mortality rates, commonly used as a measure of population health and quality of health care when considering healthcare outcomes, represent an enhancement in socio-economic conditions and quality of obtainable health services [47, 48]. In 2017, 1.8 per 1000 live births in Portugal compared to EU-19 average of 3.3 were reported . The crisis was associated with a significant increase of low birth weight rates in Portugal between 2008 and 2011, resultant of health expenditure decline, slowdown of general gross product (GDP), and increased unemployment . The study indicates that it was mainly caused by reductions in government expenditure on health as a proportion of GDP and reduced percentage expenditure of social protection and healthcare . When looking at perinatal deaths, a slight increase in perinatal deaths with 2.9 to 3.6 per 100 live births was recorded after the crisis hit Portugal between 2010 and 2012 . Similar observations were made in other crisis-affected European countries which reported effects on health within the same time period. In Greece an increase in infant mortality rates of 43% and a significant rise in the proportion of low birth weight and stillbirths, and in Italy a significant drop in fertility rates was observed . Recent statistics of November 2019 revealed that due to the consequence of pregnancy complications, maternal mortality was at 17 women per 100,000 births in 2018, compared to 9 women per 100,000 births in 2017 . This retrospectively corresponded to the same values described in 1980 with 19.5 maternal deaths per 100,000 births .
The adverse impact of the recent economic crisis on healthcare system provision and health service utilization has been widely discussed [24, 32]. European wide, vulnerable populations such as children or pregnant women were one of the first groups to be affected from economic hardship and to have suffered from health inequalities . Common impacts were the increase of differences in access due to higher financial burden to household, the reduction of adequate response to health needs, and the decrease of satisfaction with health services [33, 45]. Since the late twentieth century, privatization in healthcare and the reinforcement of the free market system has been at the forefront of political agenda and applied as a shared principle in countries facing rapidly rising health care costs and decreasing public resources . Rising healthcare costs and high economic burden have been commonly addressed with the application of austerity policy and privatization aiming to save non-essential healthcare costs . However, consequences of privatization have been linked to the intensification of health inequalities in accessing healthcare due to reduced availability of public financial resources for health service coverage and investment [23, 45, 54]. Despite its greatly political debated controversy, public health response on the impact of austerity measures on provision and accessibility of health services has been scarce .
Limitations and added value
A limitation depicts a relative low generalizability of study findings due to the nature of a qualitative study. Yet, as our study focused on the two main metropolitan areas of Portugal where the majority of health care units are concentrated, the findings are still of high importance and partially generalizable. A minor limitation is that the participants might have been more susceptible towards the study as they communicated their interest and availability.
The added value is the disclosure of an in-depth understanding on the interrelation of macro-socioeconomic determinants and healthcare permitting a distinct representation from quantitative methods. The non-linearity between policy response and expected outcomes chiefly complements its comprehension and demonstrates its relevance for further research on assessing effects of austerity measures.