The contribution of Portuguese nursing to universal health access and coverage

Objective: to analyze the contribution of Portuguese nursing to improving universal health access and coverage by means of the identification of nurses in the health system; evolution of health indicators; and access-promoting systems, in which nurses play a relevant role. Method: this was documentary research of publications fromnational and international organizations on planning and health outcomes. Statistical databases and legislation on health reforms were consulted. Results: nurses represent 30.18% of human resources in the national health service; the systems of access promotion performed by nurses have good levels of efficacy (95.5%) and user satisfaction (99% completely satisfied); in the local care the creation of Community Care Units (185) occurred, and 85.80% of home consultations were performed by nurses. Conclusion: political strategies, the National Health Service and strengthening of human resourcesin healthcareare the main determinants. Nursing is the most numerous professional group in the National Health Service, however numbers remaindeficient in primary health care. The improvement of academic qualification and self-regulation of this professional group has allowed for better answers inimproving health for the Portuguese.


care system, s
pported by social insurance, which funded access to care forthose to whomthe state considered itself a debtor.Only the indigent, attested by parish councils, were entitled to free care.Most of the population paid for poor quality of care in public hospitals, concentrated in three major cities (Lisbon, Porto and Coimbra), or the few private clinics that existed across the country, but which had higher incidence in these three cities.On the other hand, the need to offer epidemic-free harbors, thereby strengthening the economic weight that they had to trade and supply goods to an industrializing Europe, made the State assume the health authority as a control pla for the major epidemics.Also, with the creation -a pioneer in Europe -of a network of public health facilities which beganin 1971

but was
ot fully implemented in 1974, the shortage of health care provision was marked by a reductionist view of the determinants of health and disease, very focused on a biological or biomedical dimension, which was followed by an increase in medical specialties.The number of health professionals was likewise reduced.The provision of care was "a fragme ted set of varied nature of health services -large state h

pitals, an extensive network of Mercy hospitals,
medical centers of the Social Welfare Medical Services; Public Health Services (health centers from 1971); municipal physicians; specialized services for ma ernal and child health, tuberculosis and psychiatric disorders; private sector particularly developed in the ambulatory area" (1).The State contribution to health was not enough to account for 3% of the wealth produced in 1970 (1) .

With democracy, the right of access to a universal, general and free health system (it leans toward being free of charge since the second constitutional revision


The Population

Portugal, in the mid-1970s, was a poor country with poorroad access to large centers, with an employed population, mainly in the primary (34.94%) and secondary (33.73%) sectors, and of low literacy(25.7%illiteracy).The infant mortality rate reached 37,900; deliveries were mainly performed at home, with poor care, by cu

(62.51% non-hospital care).
ife expectancy was low (68.2 years) (2) .Overall, all socioeconomic and health indicators were very unfavorable.Presently, with a population of 10457.There is a reduction of young people under 15 years, 25.3% in 1981 to 14.7% in 2013.In the same period, there has been an increase in the elderly (over 65 years) from 11 5% to 19.6% (2) .These demographic changes pose new challenges to the health system and its professionals to better respond to the emerging needs.


Nursing

With regard to nursing, there were about 3,000 nurses and 15,000 nu se aids in Portugal in 1974.The following year, educational institutions no lo ger offered courses for nurse aids; the course to promote nurse aids to nurses was encouraged; there was movementto a single level of training for access to the profession, the nursing program (3) .

In 1988, nursing education was integrated into the national education system (polytechnic subsystem), granting a bachelor's degree in three years.A decade later (1998), with Portugal's adherence to the Bologna Health changes resultfrommultiple determ nants.Of these determinants, the macro-contextual and strategic ones are quite relevant, especially when a context switch occurs, such as that which differentiates the country before and after 1974.However, despite the signi i cant increase in living standards and improved health in Portugal, regional and social class asymmetries remain evident.These inequalities have been recently deepened due to the economic crisis in the country and are refl ected particularly in the access to health

are and utilization of health resources (5) .Th
oughout this period, the overall improvement of living conditions strongly interacted with the performance of the national health system and human


Results


Nurs s in the Health System

The provisi
n of nursing care in Portugalgrew as the global supply of care increased.By comparing the numbers of nurses in the he lth system, it is found that it almost doubled between the 1970s and the 1980s, following the growth in the number of hospital beds.In 2012, there were 39,797 nurses workingin the system.

However, this number decreased by about 2% in 2013,to 38,937 (6) .

Despite the increasing orientation of health policies for primary health care, of the 66,452 nurses enrolled in the Order of Nurses in 2015, only 11.51% worked in this area, while 51.46% worked in hospitals.The lowest percentage (0.61%) of those who worked in liberal