فقر، محرومیت اجتماعی و سلامت در پرتغال

People in Portugal have never been so healthy. Nevertheless, there are great differences in health status between social groups and regions. In 1994, Portugal was the country with the second worst level of inequality in terms of income distribution and with the highest level of poverty in the European Union (EU). Poverty in Portugal affects mainly the elderly and women (especially in single parent families). Beyond these groups, there are the children, the ethnic minorities and the homeless. Substance abusers, the unemployed, and ex-prisoners are also strongly affected by situations of social exclusion and poverty. Although poverty has been an important issue on the political agenda in Portugal, it shows a worrying tendency to resist traditional Social Security interventions. In the late 1990s, however, welfare coverage rates appear to have risen. To what extent can poverty cause a worsening of health status? Is there any sustainable positive association between welfare and improved health status? How, to whom and when should actions to improve the health status of the disadvantaged be addressed, without subverting the health status of the rest of the population. It is also necessary to reveal the consequences of poor health to individuals, families and communities in terms of income, social empowerment and the ability to fulfil other needs. Finally, reflection on the role and effectiveness of traditional social security models is necessary, in order to improve the impact and adequacy of its interventions. The goal of this paper is to contribute to the knowledge about disadvantage, the current health situation of the most vulnerable groups in Portuguese society—those affected by poverty, deprivation and social exclusion—and to detect the constraints on access to health and health care.

In Portugal, poverty has become an important issue on the political agenda. However, research about poverty and its impact on health and vice versa is still rare. Considering the national dimension of poverty phenomena and their evolution during recent years, the Portuguese situation should be described and monitored in the context of the European Union (EU), because important lessons can be adduced regarding the future processes of EU integration of East Europe countries. The persistency of poverty, even in the presence of a general improvement of national income and life conditions, proceeds from previous social and political conditions that, at different levels, are also present in other European countries, especially in those that are waiting for their integration into the EU. So, particular attention should be addressed to the consequences of poverty on individual and collective health and how European countries face the problem of accessibility to health care by the poor and socially excluded. During the last two decades, Portugal has experienced considerable economic and social development. Gross national product has grown, the educational level of the population has increased significantly, accessibility to health services has improved, social security covers almost all the national population, and housing and working conditions have undergone dramatic improvement. Despite remarkable increases in health (for example, the decrease in infant and maternal mortality rates and the increase in life expectancy), health and health services accessibility inequities still persist (McCalley et al., 1 (2000a) and Santana (2000b)). The goal of this paper is to contribute to knowledge about disadvantaged people, the current health situation of the most vulnerable groups in Portuguese society—those affected by poverty and social exclusion—and to detect constraints regarding access to health and health care. This paper will address several aspects of the problem, and is organised into five main sections: (1) concepts of poverty, exclusion and deprivation; (2) the evolution of poverty in Portugal and the European context; (3) characterisation of disadvantaged groups in Portugal; (4) comparison between the portuguese population and the disadvantaged groups, regarding health and health care accessibility conditions; and (5) discussion of social and political answers to the needs of disadvantaged groups, regarding health and health care consumption, poverty and social exclusion.

Health inequalities have been increasing in almost all developed countries as well as in Portugal. Manual workers have higher premature mortality rates than non-manual workers, and such inequality will continue to increase (Mackenbach, 2000; Kunst, 2000). Despite the fact that the Portuguese general population now has a longer life expectancy than ever before, this trend is less significant among disadvantaged people. The health status of the disadvantaged differs from that of the general Portuguese population. This suggests the need for an improvement in health and in health services utilisation. The poorest sectors are simultaneously those who feel the greatest need as recognised by health professionals, and who experience the greatest difficulties in accessing health care (Graham, 2000). This fact is particularly relevant not only in Portugal but in other Southern European countries (McCalley et al., 1 (2000a) and Santana (2000b); Regidor, 2000; Costa & Cardano, 2000). However, Portugal appears in this context, despite having a universal, general and increasingly more cost free health system (Graham, 2000). There are also groups in Portugal who deserve more attention, with more adequate health care for their specific needs (Graham, 2000). The findings of our 1999 survey of the disadvantaged are congruent with the current literature. Disadvantaged people have a high level of complex health needs (musculoskeletal diseases, mental disorders, respiratory disorders, skin disorders, infectious diseases, digestive system, injuries, etc.) or greater risk of adverse health outcomes. In most cases, forgoing health care at the earliest stages of a problem leads to the aggravation of symptoms and subsequent visits to facilities are more expensive and have a lower success rate. Examples can be found among homeless children and families (Vostanis et al., 1998) and single mothers (Benzeval, 1998), with high costs of hospitalisation, high rates of treatment failure and consequent premature mortality (Weinreb et al., 1998). McCally et al. (1998) suggest that improving the health of poor populations depends, among other solutions, on the reduction of barriers to the adoption of healthier modes of living as well as to adequate health services and other social services to their real needs (Hwang et al., 1998). Actions should be taken to correct such inequalities through health promotion and equity of access to adequate and timely health services. Strategies to reduce inequalities in specific determinants (such as health-related behaviours or occupational exposures to health risks) and to increase the supply of health care in lower socio-economic groups are just some examples. Other policy actions mentioned above, involving the Ministries of Health and of Labour and Social Security, are needed to raise the real income of weaker social groups and provide occupational training. The reduction of inequalities in socio-economic determinants (such as income) can have a significant impact on health status. However, it is necessary to invest more in areas such as education and health information, to reduce unhealthy behaviours that are intimately related to a lack of adequate information or with low literacy and to facilitate access and utilisation of health services. These issues should also be inscribed in the national political agenda. However, the main Portuguese policies regarding disadvantaged people are based upon subsidies, not giving adequate attention to the health problems of this population and to the importance of the improvement of their health status as a way of overcoming poverty and social exclusion. “On the other hand, social protection contributes to reduce poverty. Poverty affects economy, mainly when it passes through several generations, provoking social exclusion. Poverty consumes human capital and threatens stability and social cohesion. All social security benefits have a value higher than those that affects individuals, directly, affecting all of society, because they generate externalities and improve economic efficiency.” ( Campos, 2000, p. 22). As Touraine, according to Campos (2000, p. 66,67) argues