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New practical strategies improve health care accessibility in Portugal
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The ophthalmology community in Portugal has demonstrated a highly dynamic approach to social changes and designed new practical strategies to improve accessibility to health care and promote synergistic public-private collaboration.
A growing private sector has helped cover the increasing needs for eye care in the country and created successful partnerships with public institutions, Rufino Martins Silva, MD, PhD, said.
A government initiative — SIGIC, an integrated management system for patients enrolled for surgery, which involves 57 public hospitals and 96 private clinics — managed to achieve remarkable goals in terms of waiting lists for surgery, Silva said. Networking with private clinics, which were enabled by a specific convention to deliver services under National Health Service coverage, allowed patients to be scheduled for surgery in the first available location within the network. A 36% increase in the volume of surgeries performed and a 60% reduction in wait time days were obtained.
Rufino Martins Silva
The private sector has also created opportunities for ophthalmologists to compensate for their relatively low salaries earned through public employment, Silva said. However, with the growing number of ophthalmologists, a new situation is emerging.
“More and more new specialists are faced with greater difficulties in obtaining a position in public or even private hospitals,” he said.
There are areas of the ophthalmology practice in which eye physicians are challenged by the competition of optometrists and opticians.
“The lack of a legal definition of ‘medical act’ enables routine performance of medical acts of ophthalmology by other professions, with potential risks for the health of patients,” Silva said.
It also entitles optometrists and opticians to both prescribe and sell spectacles.
“The definition of what is a medical act is fundamental to determine what falls within the exclusive competences of the ophthalmologists,” he said.
Uneven distribution of services
In 2013, there were 793 ophthalmologists in Portugal, with 146 residents. Although the number of ophthalmologists is more than sufficient to cover the needs of the country, great asymmetry in their distribution is responsible for less efficient access to eye care in the south and in the interior territory of Portugal.
“The vast majority of ophthalmologists works in public hospitals, concentrated in major cities along the coast, namely in Lisbon, Porto and Coimbra. Very few are located in the south and in the hinterland,” Silva said.
Access to eye care is especially critical for diabetic patients, and nationwide programs are needed.
“The prevalence of diabetes has grown to 11% and has increased the need for screening programs, monitoring and treatment of diabetic retinopathy. Currently, screening programs are not covering all the country,” Silva said.
A partnership among the Regional Health Administration of the Centre Region of Portugal, the ophthalmology department of the Centro Hospitalar e Universitário de Coimbra and the Association for Innovation and Biomedical Research on Light and Image, a private nonprofit research institute based in Coimbra, has allowed the operation of a screening program for diabetic retinopathy in the region over the past 10 years, with significant benefits for patients.
Lisbon, Porto and Coimbra offer the most complete training programs for ophthalmology residents. Training programs must meet the criteria set by the College of Ophthalmology, with well-defined objectives and graded responsibility. Considerable variability still exists between medical schools regarding faculty, patients, technical resources and supporting facilities, but residents are allowed to complete the training program in central hospitals.
Silva explained that specialty requirements in ophthalmology include 4 years of approved residency training, which comes after a national exam at the end of 6 years of medical school and 1 year of tutored general medical practice. The residency program is well-defined and includes ambulatory care, surgery, consultation and emergency services. All residents are trained in public hospitals. On completion of residency, a final exam is performed, organized by the Ministry of Health and the Order of Physicians of Portugal.
“Only after passing this exam, doctors finish their residency and can formally enroll in the College of Ophthalmology,” Silva said.
The distribution of ophthalmologists in 2013 in terms of age and sex shows that more than 50% are older than 50 years and 63% are men. However, the distribution of residents is quite different, with 59% being women. – by Michela Cimberle
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- Rufino Martins Silva, MD, PhD, is Head of the Medical Retina and Neuroph-thalmology Department at the University of Coimbra. He can be reached at rufino.silva@oftalmologia.co.pt.
Disclosure: Silva is a consultant to Novartis, Bayer, Théa, Allergan, Alcon and Alimera.