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The CNAIs provide a number of governmental and support services under one roof, with services provided directly by socio-cultural mediators. The Lisbon CNAI involves six government agencies across five different ministries; namely, the SEF, the Working Conditions Authority, the Ministry of Solidarity, Employment and Social Security, the Regional Health Administration, the Regional Directorate of Education and the Central Registry Office. At the time of writing, the CNAI in Lisbon had a daily average of 500 service users.

A network of 86 local immigrant integration support centres (CLAIIs) – providing local information services and a direct link to the CNAIs – reinforces the two CNAIs.

In Portugal, the Ministry of Internal Affairs is responsible for immigration matters. The SEF is a security service under the Ministry of Internal Affairs, with administrative autonomy, and forming part of the internal security policy of the country. The objectives of this service are to control the movement of people at borders, the permanence and the activities of foreigners in Portugal, as well as examining, promoting, coordinating and implementing measures and actions related to these activities and to migratory movements.

The SEF manages the only dedicated centre for temporary detention of migrants in Portugal, the Unidade Habitacional de Santo António (UHSA) in Porto (Fig. 3), along with several transit zone sites (CITs) located at airports, which are used for the short-term detention of undocumented migrants and asylum seekers entering the country. The section on service delivery towards the end of this report provides further details about these centres.

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The Portuguese Integrated Emergency Medical Service (SIEM) is managed by the National Institute of Medical Emergency (INEM), works closely with the Ministry of Health and is organized in a similar way to many other medical emergency services in other European countries.

The Portuguese civil protection structure is organized at the municipal, regional and national levels, with the aim of preventing and attenuating the effects of serious accidents or disasters, paying specific attention to fires and earthquake preparedness. The ANPC assumes a primary role in the planning, coordination and implementation of the civil protection policy. The ANPC is thus a central service, operational in nature and endowed with administrative and financial autonomy under the auspices of a responsible government member within the Ministry of Internal Affairs.

Emergency drills are regularly organized. However, sudden, massive influxes of migrants were never considered as a possible emergency scenario. During the mission, it was possible to visit the ANPC situation room in Lisbon. The room is fully equipped with the latest information and communication technologies to support operations and facilitate emergency preparedness and response coordination. In case of serious accidents or disasters, a nationwide incident


command system is in place. The ANPC organizes weekly interministerial coordination meetings to share information on ongoing activities. Ministry of Health representatives are invited to attend when health matters are on the agenda.

During the mission, we also visited the situation room of the Maritime Operations Centre. The centre is located within the North Atlantic Treaty Organization (NATO) compound in Oeiras, near Lisbon. Among other activities, the centre provides an operational coordination hub for sea operations, including search and rescue. A recent drill coordinated by the centre involved staff from the Ministry of Health because public health threats associated with undocumented migrants were included in the exercise scenario. However, the exercise did not provide for the presence of health staff during the rescue operations.

Portuguese civil society is particularly active in addressing the needs of undocumented migrants. NGOs and religious institutions play a crucial role in facilitating migrants’ access to the NHS.

Current Portuguese legislation regulating migrants’ access to health care services is based on three central documents (Law No. 48/90 of 24 August 1990; Health Ministry Decree 25360/2001 of 16 November 2001; and Decree-Law 67/2004 of 25 March 2004). Nevertheless, the current administrative procedures regarding access to health care for undocumented migrants are subject to different interpretations at local level. Thus, despite the active presence of innovative migrant information centres in Lisbon and in the main municipalities of the country, some grey areas persist in the country’s immigration law. For example, it was reported during the interviews carried out on the mission that the Ministry of Health’s administrative circulars and instructions on immigration matters can result in inconsistent administrative practices that in turn may limit access to health services for undocumented migrants, both under normal circumstances and in the case of sudden, massive influxes.

The national disaster management system includes a health component in general terms,7 but sudden, massive influxes of migrants are not identified as possible emergency scenarios.

Recommendations 1 The central administration of the health system should consider further simplifying, clarifying, standardizing and monitoring the implementation of administrative procedures for free access to basic NHS services for undocumented migrants, taking into consideration possible sudden, massive influxes.

2 The Directorate-General of Health should consider promoting the inclusion of sudden, massive influxes of migrants within the possible scenarios of the national health contingency planning.

3 The ANPC should consider including sudden, massive influxes of migrants in scenario exercises.

Health workforce: medical products, vaccines and technology Findings T he number of physicians per 1000 population in Portugal is currently above the EU27 average. However, general practitioners (GPs) and nurses are relatively few compared to other European countries (7). Notably, to comply with the Memorandum of Understanding between the Portuguese Government and the troika,8 expenditure cuts amounting to a total of €670 million were demanded from the Portuguese health care system. Specific targets for expenditure cuts included drugs, prescriptions and the workforce. Incomes of public sector employees (including health professionals) were cut in 2011 and 2012. In addition, citizens’ co-payments for primary care and user charges were increased, although the latter were capped at €50 per hospital visit (8). In primary care the co-payment is €5 for a medical consultation with a GP and €4 for a nurse consultation. In hospitals, a basic urgent care episode costs €15.50.

Data from the Portuguese Medical Association (Ordem dos Médicos - OM) show that the number of registered foreign doctors in Portugal represented 9.3% of the country’s practising physicians in 2011. The majority of them are Spanish, with doctors from Latin America and former Portuguese colonies in Africa making up the rest.

The implementation of the influenza pandemic preparedness plan, developed in line with the WHO recommendations, has promoted the adoption of human resources surge mechanisms that, according to Ministry of Health officials, could be quickly adapted to respond to sudden, massive influxes of migrants.

A comprehensive assessment of the health system capacity for crisis management has not yet been conducted in Portugal. However, this was not the aim of the mission.

The troika is the entity consisting of the European Commission, the European Central Bank and the International Monetary Fund.

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Data on the number of cultural mediators are not available, although mediators were present in almost all migrant services visited during the mission.9 In 2009 the ACIDI launched the project Intercultural Mediation in Public Services, which has permitted the integration of cultural diversity management into the public administrative services of various sectors, including health, education and social services. The project comprised training, supervision and monitoring components. One of the project outcomes was the elaboration of a training manual in intercultural mediation, and the ACIDI Intercultural Trainers’ Network was subsequently established. The network comprises a decentralized team of almost 40 trainers providing sessions to raise awareness on immigration and intercultural mediation.

Medical products, vaccines and modern medical technology are widely available in Portugal. Rapid stock mobilization mechanisms are also in place.

Several NGOs and religious institutions have systems in place for collecting medicines donated by pharmaceutical companies, pharmacists and private donors. Those medicines are distributed after a medical consultation with the migrants at the organizations’ own medical centres.

Immunization is free for migrant children and follows the Portuguese immunization calendar.

Recommendation 1 The Directorate-General of Health should consider incorporating health management for sudden, massive influxes of migrants into health staff training topics.

Possible area of technical collaboration WHO could provide support to the Directorate-General of Health to develop training modules on the health management of sudden, massive influxes of migrants.

This would contribute to providing leadership for improving health and eliminating health disparities in the context of international migration through the provision of multidisciplinary courses that bring together research findings, policy and practice implications.

Health information Findings P ortugal has experience in setting up syndromic surveillance systems, for instance in cases of mass gatherings (9), disease outbreaks and other situations of international public health concern under the International Health Regulations (IHR) (10).

The ACIDI Immigration Observatory gathers, processes and makes available information on the issue of immigration in Portugal in the form of regular research study publications, newsletters, theses and working papers (11). The Portuguese health system performance assessment carried out by the WHO Regional Office for Europe in 2008 and 2009 highlighted critical gaps in health information in Portugal that may limit the potential to develop health system policies and strategy on the basis of sound evidence (12).

Various multilingual health information and promotion materials published by governmental bodies and NGOs were available in almost all migrant services centres and organizations visited during the mission.

Recommendation 1 The Directorate-General of Health should consider promoting syndromic surveillance refreshment training for health staff working in key public health institutions, including health staff belonging to other ministries involved in the management of national emergency operations.

The CNAI in Lisbon has more than 80 cultural mediators of 11 nationalities.


Health financing Findings It was not possible to collect detailed information about the availability of funds to cover preparedness and response activities in cases of influxes of migrants.

According to several health workers in various migrant service centres and organizations, the current economic crisis sometimes results in restrictive interpretations of undocumented migrants’ rights to access NHS services.

Service delivery Findings P ortugal has one dedicated immigration detention centre, the UHSA in Porto, which is managed by the SEF and falls under the authority of the Ministry of Internal Affairs. The centre has capacity for 30 adults and six children.

At the time of the visit, 12 adults were detained, waiting to be repatriated. Overall, hygienic conditions appeared to be in line with minimum standards. The NGO Doctors of the World and the JRS provide primary health care (Fig. 4) and psychosocial support consultations on a weekly basis. When necessary, migrants are escorted to the referral health centre or hospital. The most frequent health needs relate to dental health and mental health. The centre covers the health costs, including medicines, laboratory tests and hospital care.

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