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Portugal: assessing health-system

capacity to manage sudden

large influxes of migrants

Ministério da Saúde




Portugal: assessing health-system capacity

to manage sudden large influxes of migrants

Joint report on a mission of the Ministry of Health of Portugal, the International Centre for Migration, Health and Development and the WHO Regional Office for Europe Ministério da Saúde i


Abstract The area of migration and health is one of the topics to which the new WHO European health policy framework – Health 2020 – has drawn particular attention, along with other issues related to population vulnerability and human rights. Health 2020 provides a comprehensive framework for, as well as values and approaches to action that are much needed in public health work in the field of migration and health.

A sudden influx of migrants has occurred on several occasions in the countries of the WHO European Region over recent years, posing significant challenges to the health systems of the recipient countries and requiring basic services to be scaled up to facilitate the appropriate response to the essential needs of the migrants and to fulfil their fundamental human rights.

The unpredictable nature of the migration phenomenon calls Member States to strengthen the preparedness of their health systems to manage a potential large influx of displaced populations and to invest in emergency management capabilities and effective multisectoral coordination mechanisms. With this in mind, an assessment of Portugal’s health system capacity to manage large influxes of migrants was jointly conducted by the country’s Ministry of Health and WHO.

Influxes in the southern European countries in particular underlined the need to identify best practices, share experiences and enter into an efficient policy dialogue between stakeholders. Portugal is implementing measures consistent with World Health Assembly resolution WHA 61.17 of 2008 and the Global Consultation on Migrant Health of 2010 in Madrid, Spain. In several aspects, Portugal could be seen as model for migrant integration practices, although in terms of preparedness there is scope to strengthen planning and surge capacity.

Activities were conducted within the framework of WHO’s Public Health Aspects of Migration in Europe project, which, sustained by a direct contribution from the ItalianMinistry of Health, supports the ongoing work of the WHO European Region to strengthen national and local capacities of Member States in order to address migrants’ health needs, with a focus on public health aspects.

Keywords DELIVERY OF HEALTH CARE – organization and administration






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ISBN 978 92 890 5072 2 © World Health Organization 2014 All rights reserved. The Regional Office for Europe of the World Health Organization welcomes requests for permission to reproduce or translate its publications, in part or in full.

The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.

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Edited by Nicole Satterley Publication and cover illustration designed by GIOVANNIRUSSOGRAFICO Printed by AREAGRAPHICA SNC DI TREVISAN GIANCARLO & FIGLI Cover ©WHO/Matteo Dembech

–  –  –

Contents Acknowledgments



Executive summary


Scope of the mission


Site selection


Overall findings and recommendations

Leadership and governance



Health workforce: medical products, vaccines and technology



Possible area of technical collaboration

Health information



Health financing


Service delivery



Testing the assessment tool




–  –  –

Acknowledgments T he WHO Public Health Aspects of Migration in Europe project team would like to express sincere appreciation to the Portuguese Ministry of Health for its commitment and funding to improve the national health system in the area of migration health.

Special thanks go to Dr Francisco George, Director-General of Health; Ms Eva Falcão, Director of the Directorate of International Relations; Dr Rui Portugal, Coordinator of the National Health Plan; Ms Filipa Pereira, Senior Officer at the Directorate of International Relations; and all staff of the Directorate-General of Health for their collaboration and technical support, as well as their active participation in the work of the team members during the mission.

Appreciation for special support also goes to the High Commission for Immigration and Intercultural Dialogue, the Immigration and Borders Service, the International Organization for Migration, the Portuguese Refugee Council, the Jesuit Refugee Service, Doctors of the World, the Maritime Operational Centre and the National Civil Protection Authority.

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Peer reviewers and contributors Executive summary In recent decades Portugal has not been affected by sudden, massive influxes of migrants, mostly owing to its geographical location. Indeed, the country is bounded to the west and south by the Atlantic Ocean and to the north and east by Spain. However, conflict and dramatic economic crises can result in new migration routes to Europe, and Portugal must be ready to respond to unprecedented migrant influxes.

Portugal strongly promoted the endorsement of World Health Assembly resolution WHA61.17 on the health of migrants in May 2008. The country was praised in 2006 for having the best migrant education policies and anti-discrimination laws of all the countries recently experiencing migrant influxes that had not historically attracted migrants. In 2009 Portugal was recognized as the country with the best legal framework for the protection of migrants’ rights and was ranked second among 31 developed countries for its policies on migrant integration in 2011. This far-sighted approach may set an example for other countries in the WHO European Region.

The WHO Regional Office for Europe, in agreement with the Portuguese Ministry of Health decided to use the WHO toolkit for assessing local health system capacity to manage sudden, massive influxes of migrants in Portugal because of its prominent role in health and migration policies in Europe. It was also an opportunity to test the usefulness of the tool in a country never previously affected by such migrant events.

The mission took place on 11–15 November 2013 and the assessment team consisted of two WHO experts, two International Centre for Migration, Health and Development experts and two officials from the Portuguese DirectorateGeneral of Health.

Portuguese legislation regarding access to health care for undocumented migrants is based on three key documents (from 1990, 2001 and 2004). However, despite the active presence of innovative migrant information centres working in Lisbon and in the main municipalities of the country, some grey areas persist in immigration law. For example, different interpretations at local level of current legislation result in inconsistent administrative practices that may limit access to health services for undocumented migrants, both in normal circumstances and in cases of sudden, massive influxes of migrants.

The national disaster management system includes a health component in general terms, but sudden, massive influxes of migrants are not identified as possible emergency scenarios.

Although Portugal does not have a national plan to respond to sudden, massive influxes of migrants, the willingness to further improve the migrant integration process, coupled with already existing interministerial collaboration and coordination mechanisms represent fertile ground for enhancing the capacity for preparing and responding to such (albeit so far unlikely) events.

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Introduction P ortugal, a European migrant source country, has seen steady growth in its immigrant population from the second half of the 1970s, particularly from the Portuguese-speaking countries in Africa, such as Angola, Cabo Verde, Guinea-Bissau, Mozambique, São Tomé and Príncipe, and, from the 1990s onwards, Brazil and the eastern European countries, namely the Republic of Moldova, Romania, the Russian Federation and Ukraine. Between 1990 and 2010 the proportion of international migrants (as a percentage of the Portuguese population) increased from 4.4% to 8.6% (1).

More recently, the influx of migrants to Portugal seems to be decreasing. In fact, 417 042 immigrants (almost 4% of the total population) were registered as legally residing in the country as of 31 December 2012. This figure represents a reduction of almost 20 000 (or 4.5% of the population) compared to the same date a year earlier (2).

Portugal has been instrumental in promoting health and migration on the international agenda. For instance, the European Union (EU) began formally committing to address the topic of migration and health in 2007, with the Portuguese Presidency Conference on health and migration in the European Union, entitled “Better health for all in an inclusive society”. The conclusions of this initiative contributed to the Eighth Conference of European Health Ministers, promoted by the Council of Europe in Bratislava, and were noted by the EU’s Employment, Social Policy, Health and Consumer Affairs Council. Moreover, Portugal strongly promoted the endorsement of World Health Assembly resolution WHA61.17 on the health of migrants in May 2008. It should be also highlighted that Portugal received an award from the Migrant Integration Policy Index (MIPEX) (3) for best migrant education policies and antidiscrimination laws of all the new immigration countries. In 2011, Portugal was ranked second among 31 developed countries for its policies in the area of migrant integration by MIPEX for the second consecutive time. It should also be mentioned that Portugal was recognized as the country with the best legal framework in the protection of migrants’ rights in the United Nations 2009 human development report.

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