Abstract

The uncertainties about COVID-19 require evaluating national responses to identify successes and failures in the pandemic control. This article analyzes Portugal´s response, particularly the contribution of its health and surveillance systems in dealing with the pandemic. An integrative literature review was conducted, including consultations of observatories, documents, and institutional websites. Portugal´s response was agile and showed unified technical and political coordination, including surveillance structure using telemedicine. The reopening was supported by high testing and low positivity rates and strict rules. However, the relaxation of measures as of November/2020 resulted in an increase in cases, collapsing the health system. The response involved a consistent surveillance strategy with innovative monitoring tools, which, combined with high population adherence to vaccination, led to overcoming that moment and kept hospitalization and death rates at new disease waves at low levels. Thus, the Portuguese case discloses the risks of disease resurgence with the flexibility of measures and the population´s exhaustion in the face of restrictive measures and new variants, but also the importance of articulation between technical coordination, the political sphere, and the scientific committee.

Key words:
Health systems; Health surveillance; Portugal; COVID-19

Introduction

In December 2019, a new coronavirus was detected in Wuhan, China, named SARS-CoV-2¹1 Zhu N, Zhang D, Wang W, Li X, Yang B, Song J, Zhao X, Huang B, Shi W, Lu R, Niu P, Zhan F, Ma X, Wang D, Xu W, Wu G, Gao GF, Tan W. A novel coronavirus from patients with pneumonia in China, 2019. N Engl J Med 2020; 382(8):727-733., which quickly spread across the country²2 Liu W, Yue XG, Tchounwou PB. Response to the COVID-19 Epidemic: the Chinese experience and implications for other countries. Int J Environ Res Public Health 2020; 17(7):2304.. In view of the potential for the spread of COVID-19, the World Health Organization (WHO) declared a state of public health emergency of international concern on January 30 and a pandemic on March 11, 2020³3 World Health Organization (WHO). WHO Timeline - COVID-19 [Internet]. 2020. [cited 2020 maio 24]. Available from: https://www.who.int/news-room/detail/27-04-2020-who-timeline---covid-19
https://www.who.int/news-room/detail/27-... .

Strict and agile measures by the Chinese government to control the spread of COVID-19 allowed gaining time and adjusting strategies to face the health situation. These measures were shown to be successful and recommendable for adoption by other countries²2 Liu W, Yue XG, Tchounwou PB. Response to the COVID-19 Epidemic: the Chinese experience and implications for other countries. Int J Environ Res Public Health 2020; 17(7):2304..

In Europe, the first COVID-19 cases were reported in France on January 24, 2020⁴4 Ritchie H, Mathieu E, Rodés-Guirao L, Appel C, Giattino C, Ortiz-Ospina E, Hasell J, Macdonald B, Beltekian D, Roser M. Coronavirus Pandemic (COVID-19) [Internet]. Our World in Data. 2022. [cited 2022 jul 20]. Available from: https://ourworldindata.org/coronavirus
https://ourworldindata.org/coronavirus... . And, in March, the European continent was already the epicenter of the pandemic⁴4 Ritchie H, Mathieu E, Rodés-Guirao L, Appel C, Giattino C, Ortiz-Ospina E, Hasell J, Macdonald B, Beltekian D, Roser M. Coronavirus Pandemic (COVID-19) [Internet]. Our World in Data. 2022. [cited 2022 jul 20]. Available from: https://ourworldindata.org/coronavirus
https://ourworldindata.org/coronavirus... ^,55 World Health Organization (WHO). WHO Director-General's Opening Remarks at the Media Briefing on COVID-19 [Internet]. 2020. [cited 2020 ago 1]. Available form: https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-mission-briefing-on-covid-19---13-march-2020
https://www.who.int/dg/speeches/detail/w... , with the collapse of the health system in countries such as Italy and Spain⁶6 Palaniappan A, Dave U, Gosine B. Comparing South Korea and Italy's healthcare systems and initiatives to combat COVID-19. Rev Panam Salud Publica 2020; 44:e53.^,77 Tanne JH, Hayasaki E, Zastrow M, Pulla P, Smith P, Rada AG. Covid-19: how doctors and healthcare systems are tackling coronavirus worldwide. BMJ 2020; 368:m1090..

The controversies about the best strategies to be adopted⁸8 Werneck GL, Carvalho MS. A pandemia de COVID-19 no Brasil: crônica de uma crise sanitária anunciada. Cad Saude Publica 2020; 36(5):e00068820., along with the difficulties of some countries to contain and mitigate the pandemic, especially in the first year, resulted in a high scientific production in search for evidence that could guide health actions based on best practices. In addition to demands within the scope of therapies, vaccines and other immunobiologicals or the production of specific supplies, the way government actions were conducted has also been analyzed by specialists⁹9 Aquino EML, Silveira, IH, Pescarini JM, Aquino R, Souza-Filho JA, Rocha AS, Ferreira A, Victor A, Teixeira C, Machado DB, Paixão E, Alves FJO, Pilecco F, Menezes G, Gabrielli L, Leite L, Almeida MCC, Ortelan N, Fernandes QHRF, Ortiz RJF, Palmeira RN, Pinto Junior EP, Aragão E, Souza LEPF, Barral Netto M, Teixeira MG, Barreto ML, Ichihara MY, Lima RTRS. Medidas de distanciamento social no controle da pandemia de COVID-19: potenciais impactos e desafios no Brasil. Cien Saude Colet 2020; 25(Supl.1):2423-2446.^,1010 Greer SL, King EJ, Fonseca EM, Peralta-Santos A. The comparative politics of COVID-19: The need to understand government responses. Glob Public Health 2020; 15(9):1413-1416..

With the advent of mass immunization, there was a reduction in mortality rates and severity of cases¹¹11 Watson OJ, Barnsley G, Toor J, Hogan AB, Winskill P, Ghani AC. Global impact of the first year of COVID-19 vaccination: a mathematical modelling study. Lancet Infect Dis 2022; 22(9):1293-1302., with the return to normal activities in most countries. However, inequalities in vaccine distribution led to the emergence of new variants that resulted in a resurgence of the pandemic in several countries¹¹11 Watson OJ, Barnsley G, Toor J, Hogan AB, Winskill P, Ghani AC. Global impact of the first year of COVID-19 vaccination: a mathematical modelling study. Lancet Infect Dis 2022; 22(9):1293-1302..

The synthesis of the extensive literature on the diverse responses to the pandemic by different countries is necessary not only to systematize the actions to be prioritized during its course, but, above all, as a lesson for future viral pandemics. Although comparative analyses are relevant and necessary, exemplary case studies allow a deeper investigation of some dimensions of government responses.

Investigations on cases in South Korea, China and Singapore point to the importance of an effective surveillance system, including case isolation, adequate contact tracing and quarantine⁶6 Palaniappan A, Dave U, Gosine B. Comparing South Korea and Italy's healthcare systems and initiatives to combat COVID-19. Rev Panam Salud Publica 2020; 44:e53.^,1212 Chen Z, Cao C, Yang G. Coordinated multi-sectoral efforts needed to address the COVID-19 pandemic: lessons from China and the United States. Glob Health Res Policy 2020; 5:22.^,1313 Oh J, Lee J-K, Schwarz D, Ratcliffe HL, Markuns JF, Hirschhorn LR. National response to COVID-19 in the Republic of Korea and lessons learned for other countries. Health Syst Reform 2020; 6(1):e1753464.. The lessons learned from previous epidemics (SARS, MERS) in those countries also enabled the surveillance system improvement⁶6 Palaniappan A, Dave U, Gosine B. Comparing South Korea and Italy's healthcare systems and initiatives to combat COVID-19. Rev Panam Salud Publica 2020; 44:e53.^,1212 Chen Z, Cao C, Yang G. Coordinated multi-sectoral efforts needed to address the COVID-19 pandemic: lessons from China and the United States. Glob Health Res Policy 2020; 5:22.^,1414 Lee VJ, Chiew CJ, Khong WX. Interrupting transmission of COVID-19: lessons from containment efforts in Singapore. J Travel Med 2020; 27(3):taaa039 .. For timely case detection, the countries have expanded testing capacity and introduced emergency organizational forms such as drive-thru testing centers ⁶6 Palaniappan A, Dave U, Gosine B. Comparing South Korea and Italy's healthcare systems and initiatives to combat COVID-19. Rev Panam Salud Publica 2020; 44:e53.^,1414 Lee VJ, Chiew CJ, Khong WX. Interrupting transmission of COVID-19: lessons from containment efforts in Singapore. J Travel Med 2020; 27(3):taaa039 .. Social distancing is also indicated as an impact measure, especially before the introduction of vaccines, in countries that implemented successful responses to the pandemic¹⁵15 Koh WC, Naing L, Wong J. Estimating the impact of physical distancing measures in containing COVID-19: an empirical analysis. Int J Infect Dis 2020; 100:42-49..

Although some studies analyze the response of Portugal to the pandemic as a successful one, the country has been rarely included in comparative analyses¹⁰10 Greer SL, King EJ, Fonseca EM, Peralta-Santos A. The comparative politics of COVID-19: The need to understand government responses. Glob Public Health 2020; 15(9):1413-1416.^,1616 Haldane V, De Foo C, Abdalla SM, Jung AS, Tan M, Wu S, Chua A, Verma M, Shrestha P, Singh S, Perez T, Tan SM, Bartos M, Mabuchi S, Bonk M, McNab C, Werner GK, Panjabi R, Nordström A, Legido-Quigley H. Health systems resilience in managing the COVID-19 pandemic: lessons from 28 countries. Nat Med 2021; 27(6):964-980.^,1717 Ikinci Keles A, Keles G. A comparative analysis of world health systems and COVID-19. J Exp Clin Med 2021; 38(2):115-120.. After the recording of the first cases of COVID-19 on March 2, 2020 and the first death 15 days later, the containment of the 1^st wave occurred in approximately 45 days⁴4 Ritchie H, Mathieu E, Rodés-Guirao L, Appel C, Giattino C, Ortiz-Ospina E, Hasell J, Macdonald B, Beltekian D, Roser M. Coronavirus Pandemic (COVID-19) [Internet]. Our World in Data. 2022. [cited 2022 jul 20]. Available from: https://ourworldindata.org/coronavirus
https://ourworldindata.org/coronavirus... . Even with the resumption of activities in May 2020, the country reached zero deaths on August 3, 2020¹⁸18 Dantas M, Lopes MJ, Baptista SC, Carvalho H. Zero mortes por COVID-19 nas últimas 24 horas em Portugal. "De um momento para o outro, situação pode inverter-se", avisa Governo [Internet]. Público. 2020. [acessado 2020 ago 4]. Disponível em: https://www.publico.pt/2020/08/03/sociedade/noticia/covid19-mundo-ultrapassa-18-milhoes-infeccoes-1926822
https://www.publico.pt/2020/08/03/socied... . This initial rapid control developed into a system collapse at a second moment, which led to learning, the development of innovative information technologies and the regaining of control over the pandemic. The importance of systematizing the produced knowledge about the response attained in Portugal is highlighted, emphasizing that this country had faced a period of fiscal austerity with an impact on its health system¹⁹19 Europa. Parlamento Europeu. Operações da troika em Portugal: Parlamento Europeu aprova conclusões e recomendações. Comunicado de Imprensa [Internet]. 2014. [acessado 2022 jun 21]. Disponível em: https://www.europarl.europa.eu/news/pt/press- room/20140307IPR38407/operacoes-da-troika-em-portugal-pe-aprova-conclusoes-e-recomendacoes
https://www.europarl.europa.eu/news/pt/p... .

This article analyzes the measures adopted by the Portuguese government to face the COVID-19 pandemic and the characteristics of its health and surveillance systems, aiming at identifying the main reasons for the observed performance, the errors and successes that may constitute recommendations for other countries.

Methods

An integrative review adapted from the proposal by Whittemore and Knafl (2005)²⁰20 Whittemore R, Knafl K. The integrative review: updated methodology. J Adv Nurs 2005; 52(5):546-53. about the response of Portugal to the COVID-19 pandemic was performed. Using the Journal Portal of the Coordination for the Improvement of Higher Education Personnel (CAPES, Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - https://www.periodicos.capes.gov.br/), a search was carried out for articles published between January/2020 and December/2021 in the following databases: Web of Science, Science Direct, Scopus and PubMed Central. In all databases, the combination (Boolean operator “and”) of the descriptors “Portugal” and “COVID-19” with “health system”, “national response”, “surveillance” was used, applying the search restriction to the title, abstract and keywords. The 197 articles (in English and Portuguese) were sent to the Rayyan web application for selection using a “double-blind” format involving two researchers. Divergence situations were discussed by the two researchers until a consensus was reached. After identifying duplicates and reading the titles and abstracts, 167 articles were excluded, and 30 were read in full. Reports, opinion articles and articles that did not address the Portuguese response to the COVID-19 pandemic were excluded (Figure 1). Ten articles that met the study objectives were selected (Chart 1).

To characterize the country, its health and surveillance systems, Health Systems observatories and government documents were consulted. Data regarding the evolution of the pandemic were extracted from Our World in Data⁴4 Ritchie H, Mathieu E, Rodés-Guirao L, Appel C, Giattino C, Ortiz-Ospina E, Hasell J, Macdonald B, Beltekian D, Roser M. Coronavirus Pandemic (COVID-19) [Internet]. Our World in Data. 2022. [cited 2022 jul 20]. Available from: https://ourworldindata.org/coronavirus
https://ourworldindata.org/coronavirus... , from the European Centre for Disease Prevention and Control (ECDC) (https://www.ecdc.europa.eu/) and used information from the Portuguese Observatory of Health Systems (https://opss.pt/), bulletins and documents from the General Directorate of Health (DGS, Direção Geral da Saúde - https://covid19.min-saude.pt/), from the National Institute of Statistics (https://www.ine.pt/) and the PORDATA website (https://www.pordata.pt/).

The information was synthesized in three dimensions: characteristics of the country; characteristics of the health system (Chart 2); evolution of the pandemic and adopted measures (Figure 2 and Chart 3) seeking to gather elements that would allow understanding the conditions related to the health system and the surveillance model for the country’s performance when facing the COVID-19 pandemic.

Results

Characterization of the country and its population

Portugal is a unitary state with two autonomous regions (Azores and Madeira)²¹21 Simões J, Magalhães JPM, Biscaia A, da Luz Pereira A, Augusto GF, Fronteira I. Organisation of the State, model of health system and COVID-19 health outcomes in six European countries, during the first months of the COVID-19 epidemic in 2020. Int J Health Plann Mgmt. 2021; 36(5):1874-1886.; it occupies an area of 92,212Km² and has 10.3 million inhabitants, being the fourth country with the largest elderly population in the European Union (EU). It has had a semi-presidential government system since 1974, and it has been consolidating its democracy based on a strong social protection system²²22 Portugal. Constituição da República Portuguesa, abril de 1976. VII Revisão Constitucional; 2005. [acessado 2022 jun 21]. Disponível em: https://www.parlamento.pt/Legislacao/Paginas/ConstituicaoRepublicaPortuguesa.aspx
https://www.parlamento.pt/Legislacao/Pag... , albeit threatened by the economic crisis and the fiscal austerity policy in the first two decades of the 2000s¹⁹19 Europa. Parlamento Europeu. Operações da troika em Portugal: Parlamento Europeu aprova conclusões e recomendações. Comunicado de Imprensa [Internet]. 2014. [acessado 2022 jun 21]. Disponível em: https://www.europarl.europa.eu/news/pt/press- room/20140307IPR38407/operacoes-da-troika-em-portugal-pe-aprova-conclusoes-e-recomendacoes
https://www.europarl.europa.eu/news/pt/p... .

After the economic crisis that took place between 2010 and 2014, and the resumption of economic growth from 2015 onwards, the GDP per capita ranged from €17,350.1 (2015) to €20,840.9 (2019)²³23 PORDATA. Estatísticas sobre Portugal e Europa. PIB per capita [Internet]. [acessado 2022 jun 21]. Disponível em: https://www.pordata.pt/Portugal/PIB+per+capita+(base+2016)-2297
https://www.pordata.pt/Portugal/PIB+per+... . Between 2015 and 2019, there was a reduction in the unemployment rate, ranging from 12.9% to 6.6%, respectively²³23 PORDATA. Estatísticas sobre Portugal e Europa. PIB per capita [Internet]. [acessado 2022 jun 21]. Disponível em: https://www.pordata.pt/Portugal/PIB+per+capita+(base+2016)-2297
https://www.pordata.pt/Portugal/PIB+per+... . However, the country experienced more inequality in 2020, reflected in the increase in the Gini coefficient and in the risk of poverty rate, which corresponds to the proportion of the population with an income below the established poverty threshold²⁴24 Instituto Nacional de Estatística (INE). O risco de pobreza aumentou para 18,4% em 2020-2021 [Internet]. 2021. [acessado 2022 jun 21]. Disponível em: https://www.ine.pt/xportal/xmain?xpid=INE&xpgid=ine_destaques&DESTAQUESdest_boui=473574196&DESTAQUESmodo=2
https://www.ine.pt/xportal/xmain?xpid=IN... . The risk of poverty rate, which had reached 17.2% in 2018, the lowest percentage since 2003, reached 18.4% in 2020 after social transfers²⁴24 Instituto Nacional de Estatística (INE). O risco de pobreza aumentou para 18,4% em 2020-2021 [Internet]. 2021. [acessado 2022 jun 21]. Disponível em: https://www.ine.pt/xportal/xmain?xpid=INE&xpgid=ine_destaques&DESTAQUESdest_boui=473574196&DESTAQUESmodo=2
https://www.ine.pt/xportal/xmain?xpid=IN... . The Gini coefficient was 0.33 in 2020, revealing growth in inequalities in all regions of the country, except in the Autonomous Region of Azores²⁴24 Instituto Nacional de Estatística (INE). O risco de pobreza aumentou para 18,4% em 2020-2021 [Internet]. 2021. [acessado 2022 jun 21]. Disponível em: https://www.ine.pt/xportal/xmain?xpid=INE&xpgid=ine_destaques&DESTAQUESdest_boui=473574196&DESTAQUESmodo=2
https://www.ine.pt/xportal/xmain?xpid=IN... .

Health system

The health system, of the Beveridge type, is funded primarily by citizens’ taxes and guarantees access to health care to all residents in the country. The National Health Service (SNS, in Portuguese Serviço Nacional de Saúde), created by Law number 56, of September 15, 1979, guarantees universal, comprehensive, and free access to health care; although it admits the charging of some fees to users for the utilization of some services²⁵25 Portugal. Serviço Nacional de Saúde (SNS). História do SNS [Internet]. [acessado 2022 jun 16]. Disponível em: https://stg.sns.gov.pt/sns/servico-nacional-de-saude/
https://stg.sns.gov.pt/sns/servico-nacio... .

The SNS was created under the principles of centralized control and decentralized management²¹21 Simões J, Magalhães JPM, Biscaia A, da Luz Pereira A, Augusto GF, Fronteira I. Organisation of the State, model of health system and COVID-19 health outcomes in six European countries, during the first months of the COVID-19 epidemic in 2020. Int J Health Plann Mgmt. 2021; 36(5):1874-1886. and it is organized based on the structure, operation and management of the Ministry of Health (MoH) which defines, conducts and funds the national health policy, regulates and inspects the activities of the NHS, as well as of the private sector. Direct administration within the MoH consists of four institutions: General Secretariat; Inspectorate-General of Health Activities; General Directorate of Health (DGS); and the Intervention Service for Addictive Behaviors and Addictions. It also includes the National Health Council (NHC), an advisory body related to the national health policy²⁶26 Portugal. Decreto-Lei nº124/2011. Lei Orgânica do Ministério da Saúde. Diário da República 2011; 29 dez. [acessado 2020 nov 30]. Disponível em: https://dre.pt/web/guest/legislacao-consolidada/-/lc/115165188/201701090000/exportPdf/normal/1/cacheLevelPage?_LegislacaoConsolidada_WAR_drefrontofficeportlet_rp=indice
https://dre.pt/web/guest/legislacao-cons... .

The DGS, the MoH’s central service, is endowed with administrative autonomy, monitors the national epidemiological situation and, among other attributions, is responsible for declaring the alert systems and coordinating the response in public health emergency situations²⁷27 Portugal. Decreto Regulamentar nº 14/2012. Dispõe sobre missão e atribuições da DGS. Diário da República 2012; 26 jan. [acessado 2022 jun 16]. Disponível em: https://files.dre.pt/1s/2012/01/01900/0048000482.pdf
https://files.dre.pt/1s/2012/01/01900/00... . The country has a Public Health device for emergency situations, a management mechanism coordinated by the DGS that establishes a Center for Emergencies in Public Health, with representations of other government institutions, including those linked to the MoH, other ministries and federal entities, to generate the preparedness and response strategy²⁸28 Portugal. Ministério da Saúde (MS). Direção-Geral da Saúde (DGS). Plano Nacional de Preparação e Resposta à Doença por novo coronavírus (COVID-19). Lisboa: DGS; 2020.. This device was activated to face the COVID-19 pandemic and a task force was created under three work axes: evaluation (epidemiology and statistics), risk management and communication²⁹29 Portugal. Ministério da Saúde (MS). Direção-Geral da Saúde (DGS). Dispositivo de Saúde Pública - DGS ativa Dispositivo de Saúde Pública. Lisboa: DGS; 2020..

The SNS has invested in Primary Health Care (PHC) as a priority point of access to the health system³⁰30 Portugal. República Portuguesa. Serviço Nacional de Saúde (SNS). Relatório Anual - Acesso a cuidados de saúde nos estabelecimentos do SNS e entidades convencionadas em 2019. Lisboa: SNS; 2019.. In 2019, the 264 Community Care Units (CCUs) covered 95.9% of the population living on the continent and the 564 Family Health Units (FHUs) guaranteed coverage of 63.2% of those enrolled in PHC³⁰30 Portugal. República Portuguesa. Serviço Nacional de Saúde (SNS). Relatório Anual - Acesso a cuidados de saúde nos estabelecimentos do SNS e entidades convencionadas em 2019. Lisboa: SNS; 2019.. There were 238 hospitals, 111 of which were part of the NHS. The country had 36,064 hospital beds, of which 67.9% were located in public hospitals or in public-private partnerships. There were 1,235 beds for in Intensive Care Unit (ICU) admissions, including neonatal and pediatric care and adult hospitalization³¹31 Instituto Nacional de Estatística (INE). Dos 19,6 anos de esperança de vida aos 65 anos em 2019, 7,3 são de vida saudável [Internet]. 2021. [acessado 2022 jun 25]. Disponível em: https://www.ine.pt/xportal/xmain?xpid=INE&xpgid=ine_destaques&DESTAQUESdest_boui=471121097&DESTAQUESmodo=2
https://www.ine.pt/xportal/xmain?xpid=IN... . Before the pandemic, the number of ICU beds was 3.5/1,000 inhabitants, which is low compared to the EU average of 5.3/1,000³²32 Organisation for Economic Co-operation and Development (OCDE), European Observatory on Health Systems and Policies (EOHSP). Estado da saúde na EU: Portugal - perfil de saúde do país 2021. Paris, Bruxelas: OCDE/ EOHSP; 2021.. The number of physicians had been increasing, while the number of nurses was below the EU average³²32 Organisation for Economic Co-operation and Development (OCDE), European Observatory on Health Systems and Policies (EOHSP). Estado da saúde na EU: Portugal - perfil de saúde do país 2021. Paris, Bruxelas: OCDE/ EOHSP; 2021.. The network of laboratories comprised 18 units³³33 Portugal. Ministério da Saúde (MS). Instituto Nacional de Saúde Doutor Ricardo Jorge (INSA). Programa Nacional de Vigilância da Gripe: relatório da época 2018/2019. Lisboa: INSA; 2019.. The surveillance system has a network of sentinel physicians, emergency health services, laboratories and instruments for disseminating information³⁴34 Rodrigues AP, Batista I, Silva S. Médicos-Sentinela: o que se fez em 2017. Relatórios científicos e técnicos 2019. Lisboa: INSA); 2019.^,3535 Andrade HR. Vigilância epidemiológica da gripe em Portugal. Rev Port Clin Geral. 2005; 21:379-88. (Chart 2).

Evolution of the epidemic and responses by the Portuguese government

Although the first two cases of COVID-19 were confirmed on March 2, 2020⁴4 Ritchie H, Mathieu E, Rodés-Guirao L, Appel C, Giattino C, Ortiz-Ospina E, Hasell J, Macdonald B, Beltekian D, Roser M. Coronavirus Pandemic (COVID-19) [Internet]. Our World in Data. 2022. [cited 2022 jul 20]. Available from: https://ourworldindata.org/coronavirus
https://ourworldindata.org/coronavirus... , the government had adopted measures preparing to face the health crisis since January/2020²⁸28 Portugal. Ministério da Saúde (MS). Direção-Geral da Saúde (DGS). Plano Nacional de Preparação e Resposta à Doença por novo coronavírus (COVID-19). Lisboa: DGS; 2020.^,3636 Portugal. República Portuguesa. Direção-Geral da Saúde (DGS). Comunicado C160_05_v1; 24 de janeiro de 2020. Atualização-Surto de pneumonia por novo Coronavírus (2019-nCoV) na China [Internet]. [acessado 2022 jun 19]. Disponível em: https://www.dgs.pt/a-direccao-geral-da-saude/comunicados-e-despachos-do-director-geral/atualizacao-de-2401 2020-surto-de-pneumonia-por-novo-coronavirus-2019-ncov-na-china-pdf.aspx
https://www.dgs.pt/a-direccao-geral-da-s... and, at the end of February, it started publishing daily newsletters with the monitoring of suspected cases.

Preparedness plans used to deal with previous pandemics were adapted to guide the initial response and the adoption of contingency measures³⁷37 Waitzberg R, Hernández-Quevedo C, Bernal-Delgado E, Estupiñán-Romero F, Angulo-Pueyo E, Theodorou M, Kantaris M, Charalambous C, Gabriel E, Economou C, Kaitelidou D, Konstantakopoulou O, Vildiridi LV, Meshulam A, Belvis AG, Morsella A, Bezzina A, Vicentini K, Augusto GF, Fronteira I, Simões J, Karanikolos M, Williams G, Maresso A. Early health system responses to the COVID-19 pandemic in Mediterranean countries: a tale of successes and challenges. Health Policy 2022; 126(5):465-475.. The National Contingency Plan followed the WHO and ECDC guidelines and defined the alert and response levels determined by the epidemiological evolution of the infection, risk assessment and impact for the country²⁸28 Portugal. Ministério da Saúde (MS). Direção-Geral da Saúde (DGS). Plano Nacional de Preparação e Resposta à Doença por novo coronavírus (COVID-19). Lisboa: DGS; 2020..

Portugal had a firm and fast response. Soon after the first cases, the country suspended events, closed schools, imposed travel restrictions, closed borders and limited non-essential activities³⁸38 Correia PMAR, Mendes IO, Pereira SPM, Subtil I. The combat against COVID-19 in Portugal: how State measures and data availability reinforce some organizational values and contribute to the sustainability of the National Health System. Sustainability 2020; 12:7513.. There was a political coordination in this action, with decisions being taken by the President of the Republic, together with the Prime Minister, supported by the Council of Ministers, the Parliament and technical staff of the DGS.

There was a ban on air traffic between Portugal and non-EU countries³⁹39 Portugal. Despacho nº 11231/2020, 13 de novembro de 2020. Prorrogação das medidas aplicáveis ao tráfego aéreo com destino e a partir de Portugal. Diário da República 2020; 13 nov. and the disembarkation of passengers and crews from cruise ships in ports⁴⁰40 Portugal. Despacho nº 11231/2020, 13 de novembro de 2020. Prorrogação da proibição do desembarque e licenças para terra de passageiros e tripulações dos navios de cruzeiro nos portos nacionais. Diário da República 2020; 13 nov.. Passengers from non-EU countries were authorized exclusively for essential trips, with a negative laboratory test³⁹39 Portugal. Despacho nº 11231/2020, 13 de novembro de 2020. Prorrogação das medidas aplicáveis ao tráfego aéreo com destino e a partir de Portugal. Diário da República 2020; 13 nov.. Transit in the country was limited, including, for example, a sanitary cordon for two months in the municipality of Ovar, due to the outbreak in the first weeks of March/2020⁴¹41 Queiroz G, Sá R, Matos J, Carmo S, Ferreira JD, Pinho-Bandeira T, Leitão R, Pereira T, Duarte I, Costa C, Oliveira A. Cordon sanitaire, a necessary evil? Evaluation of non-pharmacological interventions against COVID-19 in Ovar, Portugal. Acta Biomed 2021; 92(Suppl. 6):e2021459..

The state of emergency, declared on March 18, 2020⁴²42 Portugal. Decreto do Presidente da República nº 14-A/2020, de 18 de março de 2020. Diário da República 2020; 18 mar., ensured control of social isolation and transgression of the new rules was considered a crime of civil disobedience.

The Security Forces contributed to ensure that the rules were complied with during the blockade and the media disseminated information to the community, which also played an important role in this adherence³⁸38 Correia PMAR, Mendes IO, Pereira SPM, Subtil I. The combat against COVID-19 in Portugal: how State measures and data availability reinforce some organizational values and contribute to the sustainability of the National Health System. Sustainability 2020; 12:7513.. Military forces acted in the creation of field hospitals and in the collaboration of the military laboratory³⁸38 Correia PMAR, Mendes IO, Pereira SPM, Subtil I. The combat against COVID-19 in Portugal: how State measures and data availability reinforce some organizational values and contribute to the sustainability of the National Health System. Sustainability 2020; 12:7513..

During the blockade, the country kept children’s daycare and schools open to accommodate the children of essential service professionals, including the health sector²¹21 Simões J, Magalhães JPM, Biscaia A, da Luz Pereira A, Augusto GF, Fronteira I. Organisation of the State, model of health system and COVID-19 health outcomes in six European countries, during the first months of the COVID-19 epidemic in 2020. Int J Health Plann Mgmt. 2021; 36(5):1874-1886.^,4343 Kuhlmann E, Brînzac MG, Burau V, Correia T, Ungureanu MI. Health workforce protection and preparedness during the COVID-19 pandemic: a tool for the rapid assessment of EU health systems. Eur J Public Health 2021; 31(Suppl. 4):iv14-iv20., a measure of preparation and protection of the health workforce⁴³43 Kuhlmann E, Brînzac MG, Burau V, Correia T, Ungureanu MI. Health workforce protection and preparedness during the COVID-19 pandemic: a tool for the rapid assessment of EU health systems. Eur J Public Health 2021; 31(Suppl. 4):iv14-iv20..

This set of measures related to social distancing resulted in a high Stringency Index (SI), an indicator proposed by the University of Oxford to measure the rigor of restriction/lockdown policies adopted by governments⁴⁴44 Hale T, Angrist N, Goldszmidt R, Kira B, Petherick A, Phillips T, Webster S, Cameron-Blake E, Hallas L, Majumdar S, Tatlow H. A global panel database of pandemic policies (Oxford COVID-19 Government Response Tracker). Nat Hum Behav 2021; 5(4):529-538., which varied between 82.41 and 87.96, in the period from March 19 to May 3, 2020, one of the highest among European countries⁴4 Ritchie H, Mathieu E, Rodés-Guirao L, Appel C, Giattino C, Ortiz-Ospina E, Hasell J, Macdonald B, Beltekian D, Roser M. Coronavirus Pandemic (COVID-19) [Internet]. Our World in Data. 2022. [cited 2022 jul 20]. Available from: https://ourworldindata.org/coronavirus
https://ourworldindata.org/coronavirus... .

Seeking to overcome the initial difficulties in obtaining Personal Protective Equipment (PPE) and necessary medical supplies, Portugal resorted to centralized procurement of tests and PPE and then organized itself to produce PPE internally³⁷37 Waitzberg R, Hernández-Quevedo C, Bernal-Delgado E, Estupiñán-Romero F, Angulo-Pueyo E, Theodorou M, Kantaris M, Charalambous C, Gabriel E, Economou C, Kaitelidou D, Konstantakopoulou O, Vildiridi LV, Meshulam A, Belvis AG, Morsella A, Bezzina A, Vicentini K, Augusto GF, Fronteira I, Simões J, Karanikolos M, Williams G, Maresso A. Early health system responses to the COVID-19 pandemic in Mediterranean countries: a tale of successes and challenges. Health Policy 2022; 126(5):465-475.. It also received donations and ventilator loans to expand its ICU bed capacity³⁷37 Waitzberg R, Hernández-Quevedo C, Bernal-Delgado E, Estupiñán-Romero F, Angulo-Pueyo E, Theodorou M, Kantaris M, Charalambous C, Gabriel E, Economou C, Kaitelidou D, Konstantakopoulou O, Vildiridi LV, Meshulam A, Belvis AG, Morsella A, Bezzina A, Vicentini K, Augusto GF, Fronteira I, Simões J, Karanikolos M, Williams G, Maresso A. Early health system responses to the COVID-19 pandemic in Mediterranean countries: a tale of successes and challenges. Health Policy 2022; 126(5):465-475..

In the 1^st wave of the pandemic (first months of 2020) there was an increase in cases, but without “a more prominent peak”³⁸38 Correia PMAR, Mendes IO, Pereira SPM, Subtil I. The combat against COVID-19 in Portugal: how State measures and data availability reinforce some organizational values and contribute to the sustainability of the National Health System. Sustainability 2020; 12:7513. and the containment and attenuation measures implemented early and in an articulated manner contributed to the reduction of severe morbidity and mortality in this initial phase³⁸38 Correia PMAR, Mendes IO, Pereira SPM, Subtil I. The combat against COVID-19 in Portugal: how State measures and data availability reinforce some organizational values and contribute to the sustainability of the National Health System. Sustainability 2020; 12:7513.^,4545 Ricoca Peixoto V, Vieira A, Aguiar P, Carvalho C, Rhys Thomas D, Abrantes A. Initial assessment of the impact of the emergency state lockdown measures on the 1st wave of the COVID-19 epidemic in Portugal. Acta Med Port 2020; 33(11):733-741. (Figure 2).

The accord between the head of the government, the Parliament and the heads of the DGS is highlighted regarding the conduct of centralized governance to coordinate the national response, in constant dialogue with a scientific advisory committee³⁷37 Waitzberg R, Hernández-Quevedo C, Bernal-Delgado E, Estupiñán-Romero F, Angulo-Pueyo E, Theodorou M, Kantaris M, Charalambous C, Gabriel E, Economou C, Kaitelidou D, Konstantakopoulou O, Vildiridi LV, Meshulam A, Belvis AG, Morsella A, Bezzina A, Vicentini K, Augusto GF, Fronteira I, Simões J, Karanikolos M, Williams G, Maresso A. Early health system responses to the COVID-19 pandemic in Mediterranean countries: a tale of successes and challenges. Health Policy 2022; 126(5):465-475. and the nomination of five State Secretariats to implement the state of emergency²¹21 Simões J, Magalhães JPM, Biscaia A, da Luz Pereira A, Augusto GF, Fronteira I. Organisation of the State, model of health system and COVID-19 health outcomes in six European countries, during the first months of the COVID-19 epidemic in 2020. Int J Health Plann Mgmt. 2021; 36(5):1874-1886.^,3838 Correia PMAR, Mendes IO, Pereira SPM, Subtil I. The combat against COVID-19 in Portugal: how State measures and data availability reinforce some organizational values and contribute to the sustainability of the National Health System. Sustainability 2020; 12:7513..

The pandemic required adaptations from health professionals and changes in the work process⁴³43 Kuhlmann E, Brînzac MG, Burau V, Correia T, Ungureanu MI. Health workforce protection and preparedness during the COVID-19 pandemic: a tool for the rapid assessment of EU health systems. Eur J Public Health 2021; 31(Suppl. 4):iv14-iv20.. In the initial phase, the PHC decreased face-to-face consultations for non-COVID-19 cases and prioritized childhood vaccination⁴⁶46 Ares-Blanco S, Astier-Peña M, Gómez-Bravo R, Fernández-García F, Bueno-Ortiz M. El papel de la atención primaria en la pandemia COVID-19: una mirada hacia Europa. Aten Primaria 2021; 53(8):102134.. Although the PHC did not undertake the task of diagnosis at that time, family physicians followed up the cases using an application or through telephone contact⁴⁶46 Ares-Blanco S, Astier-Peña M, Gómez-Bravo R, Fernández-García F, Bueno-Ortiz M. El papel de la atención primaria en la pandemia COVID-19: una mirada hacia Europa. Aten Primaria 2021; 53(8):102134..

Regarding the workforce, the relocation of SNS workers was prohibited, a subsidy was established for the remuneration of physicians trained abroad and on leave, and international support was received related to the availability of health workers during the most critical phase⁴³43 Kuhlmann E, Brînzac MG, Burau V, Correia T, Ungureanu MI. Health workforce protection and preparedness during the COVID-19 pandemic: a tool for the rapid assessment of EU health systems. Eur J Public Health 2021; 31(Suppl. 4):iv14-iv20.. The hiring of professionals was also simplified, a ‘student bank’ was created²¹21 Simões J, Magalhães JPM, Biscaia A, da Luz Pereira A, Augusto GF, Fronteira I. Organisation of the State, model of health system and COVID-19 health outcomes in six European countries, during the first months of the COVID-19 epidemic in 2020. Int J Health Plann Mgmt. 2021; 36(5):1874-1886. and the hiring of retired and inactive professionals, payment of overtime and cancellation of leaves³⁷37 Waitzberg R, Hernández-Quevedo C, Bernal-Delgado E, Estupiñán-Romero F, Angulo-Pueyo E, Theodorou M, Kantaris M, Charalambous C, Gabriel E, Economou C, Kaitelidou D, Konstantakopoulou O, Vildiridi LV, Meshulam A, Belvis AG, Morsella A, Bezzina A, Vicentini K, Augusto GF, Fronteira I, Simões J, Karanikolos M, Williams G, Maresso A. Early health system responses to the COVID-19 pandemic in Mediterranean countries: a tale of successes and challenges. Health Policy 2022; 126(5):465-475. was enabled.

An exceptional expenditure authorization system was created, allowing necessary expenditures on equipment, goods and services²¹21 Simões J, Magalhães JPM, Biscaia A, da Luz Pereira A, Augusto GF, Fronteira I. Organisation of the State, model of health system and COVID-19 health outcomes in six European countries, during the first months of the COVID-19 epidemic in 2020. Int J Health Plann Mgmt. 2021; 36(5):1874-1886.^,4747 Portugal. Decreto-Lei nº 10-E/2020. Diário da República 2020; 24 mar..

Undocumented immigrants were temporarily qualified for assistance by the SNS. The government granted temporary residency rights to all immigrants and asylum seekers who had applied by March 18, 2020³⁷37 Waitzberg R, Hernández-Quevedo C, Bernal-Delgado E, Estupiñán-Romero F, Angulo-Pueyo E, Theodorou M, Kantaris M, Charalambous C, Gabriel E, Economou C, Kaitelidou D, Konstantakopoulou O, Vildiridi LV, Meshulam A, Belvis AG, Morsella A, Bezzina A, Vicentini K, Augusto GF, Fronteira I, Simões J, Karanikolos M, Williams G, Maresso A. Early health system responses to the COVID-19 pandemic in Mediterranean countries: a tale of successes and challenges. Health Policy 2022; 126(5):465-475.^,4848 Raposo VL, Violante T. Access to health care by migrants with precarious status during a health crisis: some insights from Portugal. Human Rights Review 2021; 22:459-482.. The regularization process allowed equal treatment to foreigners and exemption from the costs of services related to COVID-19³⁷37 Waitzberg R, Hernández-Quevedo C, Bernal-Delgado E, Estupiñán-Romero F, Angulo-Pueyo E, Theodorou M, Kantaris M, Charalambous C, Gabriel E, Economou C, Kaitelidou D, Konstantakopoulou O, Vildiridi LV, Meshulam A, Belvis AG, Morsella A, Bezzina A, Vicentini K, Augusto GF, Fronteira I, Simões J, Karanikolos M, Williams G, Maresso A. Early health system responses to the COVID-19 pandemic in Mediterranean countries: a tale of successes and challenges. Health Policy 2022; 126(5):465-475.^,4848 Raposo VL, Violante T. Access to health care by migrants with precarious status during a health crisis: some insights from Portugal. Human Rights Review 2021; 22:459-482. was established.

The first deconfinement measures began on May 4, 2020, through a sustained reduction in hospitalizations and occupation of ICU beds and expansion of testing capacity⁴⁹49 Portugal. Resolução do Conselho de Ministros nº 33-C/2020. Diário da República 2020; 30 abr.. The reduction of confinement measures, with the maintenance of monitoring and follow-up of epidemiological data, followed a calendar with a 15-day interval between each phase⁴⁹49 Portugal. Resolução do Conselho de Ministros nº 33-C/2020. Diário da República 2020; 30 abr.. Thus, gradually, restrictive measures related to public transportation, work, commerce, public services and sports and cultural activities were relaxed⁴⁹49 Portugal. Resolução do Conselho de Ministros nº 33-C/2020. Diário da República 2020; 30 abr..

Testing was restricted at the start of the pandemic⁴4 Ritchie H, Mathieu E, Rodés-Guirao L, Appel C, Giattino C, Ortiz-Ospina E, Hasell J, Macdonald B, Beltekian D, Roser M. Coronavirus Pandemic (COVID-19) [Internet]. Our World in Data. 2022. [cited 2022 jul 20]. Available from: https://ourworldindata.org/coronavirus
https://ourworldindata.org/coronavirus... , but contact tracing was already foreseen²⁸28 Portugal. Ministério da Saúde (MS). Direção-Geral da Saúde (DGS). Plano Nacional de Preparação e Resposta à Doença por novo coronavírus (COVID-19). Lisboa: DGS; 2020.. The effort with the involvement of academia and also private laboratories made it possible to expand the testing capacity; one of the country’s priorities⁵⁰50 Portugal. Ministério da Saúde (MS). Direção-Geral da Saúde (DGS). Aumento da capacidade de testagem é prioritário [Internet]. 2020. [acessado 2022 jun 19]. Available from: https://www.dgs.pt/em-destaque/aumento-da-capacidade-de-testagem-e-prioritario.aspx
https://www.dgs.pt/em-destaque/aumento-d... . With an initial capacity to perform 10,000 tests/day, the expectation was to reach 21,000 tests a day⁵⁰50 Portugal. Ministério da Saúde (MS). Direção-Geral da Saúde (DGS). Aumento da capacidade de testagem é prioritário [Internet]. 2020. [acessado 2022 jun 19]. Available from: https://www.dgs.pt/em-destaque/aumento-da-capacidade-de-testagem-e-prioritario.aspx
https://www.dgs.pt/em-destaque/aumento-d... . On November 23, 2020, Portugal reached 4.3 million PCR tests, with a positivity ratio of 15.9%⁵¹51 Portugal. Ministério da Saúde (MS). Direção-Geral da Saúde (DGS). Portugal já realizou cerca de 4,3 milhões de testes à COVID-19 [Internet]. 2020. [acessado 2020 nov 23]. Disponível em: https://covid19.min-saude.pt/portugal-ja-realizou-cerca-de-43-milhoes-de-testes-a-covid-19/
https://covid19.min-saude.pt/portugal-ja... . In that same month, the overall fatality rate was 1.6% and the fatality rate in individuals aged over 70 years was 9.7%⁵¹51 Portugal. Ministério da Saúde (MS). Direção-Geral da Saúde (DGS). Portugal já realizou cerca de 4,3 milhões de testes à COVID-19 [Internet]. 2020. [acessado 2020 nov 23]. Disponível em: https://covid19.min-saude.pt/portugal-ja-realizou-cerca-de-43-milhoes-de-testes-a-covid-19/
https://covid19.min-saude.pt/portugal-ja... .

With approximately 23.4% of elderly individuals in the population, according to provisional census results of 2021, a group identified as high risk right from the start, visits to homes for the elderly were suspended and resumed on May 18, 2020⁵²52 Portugal. Ministério da Saúde (MS). Direção-Geral da Saúde (DGS). Informação nº 011/2020, de 11/05/2020, atualizada a 18/05/2020 [Internet]. [acessado 2020 ago 3]. Disponível em: https://www.dgs.pt/normas-orientacoes-e-informacoes/informacoes/informacao-n-0112020-de-11052020-pdf.aspx
https://www.dgs.pt/normas-orientacoes-e-... .

In addition to a proportionally high elderly population, the low testing capacity at the start and the availability of doctors, nurses and beds lower than in other EU countries were factors that compromised Portugal’s capacity to prepare for the pandemic⁵³53 Aristodemou K, Buchass L, Claringbould D. The COVID-19 crisis in the EU: the resilience of healthcare systems, government responses and their socio-economic efects. Eurasian Econ Rev 2021; 11:251-281.. Thus, the country ended up adopting stricter restrictive measures, a combination also observed in other countries with health systems considered to be less prepared⁵³53 Aristodemou K, Buchass L, Claringbould D. The COVID-19 crisis in the EU: the resilience of healthcare systems, government responses and their socio-economic efects. Eurasian Econ Rev 2021; 11:251-281..

With the reopening⁴⁹49 Portugal. Resolução do Conselho de Ministros nº 33-C/2020. Diário da República 2020; 30 abr., the number of cases increased again in June/2020, but resumed the downward trend, reaching the lowest number of infections since March⁵⁴54 Portugal. Ministério da Saúde (MS). Direção-Geral da Saúde (DGS). Primeira semana de Agosto com os melhores números desde março [Internet]. 2020. [acessado 2022 jun 20]. Disponível em: https://www.dgs.pt/em-destaque/primeira-semana-de-agosto-com-os-melhores-numeros-desde-marco.aspx
https://www.dgs.pt/em-destaque/primeira-... in the first week of August/2020.

The StayAway Covid application, for the monitoring of contacts, was made available in September/2020, with voluntary adherence³²32 Organisation for Economic Co-operation and Development (OCDE), European Observatory on Health Systems and Policies (EOHSP). Estado da saúde na EU: Portugal - perfil de saúde do país 2021. Paris, Bruxelas: OCDE/ EOHSP; 2021.. In that same month, considering the possible increase in cases of COVID-19, the seasonality of the flu and the population’s health needs, the MoH published the 2020-2021 autumn-winter action plan⁵⁵55 Portugal. Ministério da Saúde (MS). Direção-Geral da Saúde (DGS). Plano da Saúde para o Outono-Inverno 2020-21 [Internet]. 2020. [acessado 2020 nov 23]. Disponível em: https://www.dgs.pt/documentos-e-publicacoes/plano-da-saude-para-o-outono-inverno-2020-2021-pdf.aspx
https://www.dgs.pt/documentos-e-publicac... .

Towards the development of e-Health, strategies such as the Web Portal, smartphone applications, videos to promote immunization campaigns, e-mail reminder systems (about vaccination deadlines and consultations) and electronic immunization record system were adopted⁵⁶56 Odone A, Gianfredi V, Sorbello S, Capraro M, Frascella B, Vigezzi GP, Signorelli C. The use of digital technologies to support vaccination programmes in Europe: state of the art and best practices from experts' interviews. Vaccines 2021; 9(10):1126..

Telemedicine was expanded and widely utilized during the pandemic³²32 Organisation for Economic Co-operation and Development (OCDE), European Observatory on Health Systems and Policies (EOHSP). Estado da saúde na EU: Portugal - perfil de saúde do país 2021. Paris, Bruxelas: OCDE/ EOHSP; 2021.. The SNS 24-hour free telephone line was expanded to incorporate screening, follow-up, actions related to testing and the creation of a psychological support line³²32 Organisation for Economic Co-operation and Development (OCDE), European Observatory on Health Systems and Policies (EOHSP). Estado da saúde na EU: Portugal - perfil de saúde do país 2021. Paris, Bruxelas: OCDE/ EOHSP; 2021..

For the return of classes, guidelines were published for the management of cases and outbreaks of COVID-19 and it was established that the local health authority would be responsible for carrying out epidemiological inquiries in outbreak situations and determining the closing of the involved classes or the school in high-risk situations⁵⁷57 Portugal. Ministério da Saúde (MS). Direção-Geral da Saúde (DGS). Referencial Escolas: controlo da transmissão de COVID-19 em contexto escolar [Internet]. 2020. [acessado 2020 nov 23]. Disponível em: https://www.dgs.pt/documentos-e-publicacoes/referencial-escolas-controlo-da-transmissao-de-covid-19-em-contexto-escolar-pdf.aspx
https://www.dgs.pt/documentos-e-publicac... .

The rapid increase in cases and deaths as of October 2020 led the country to declare a new state of emergency in November, when the highest number of cases in that year was recorded (7-day moving average of 632.21 cases/million inhabitants)⁴4 Ritchie H, Mathieu E, Rodés-Guirao L, Appel C, Giattino C, Ortiz-Ospina E, Hasell J, Macdonald B, Beltekian D, Roser M. Coronavirus Pandemic (COVID-19) [Internet]. Our World in Data. 2022. [cited 2022 jul 20]. Available from: https://ourworldindata.org/coronavirus
https://ourworldindata.org/coronavirus... , as shown in Figure 2. The entry of the Alpha variant, a more transmissible one, which on February 22, 2021 corresponded to 55% of the tests, together with the exhaustion due to restrictive measures and relaxation of these measures, may be related to the lack of control verified from January 28/2021, when the 7-day moving average doubled, reaching 1,267.77 cases/million inhabitants (Figure 2). Without effective control, the 2^nd wave of the pandemic resulted in the collapse of the Portuguese health system³²32 Organisation for Economic Co-operation and Development (OCDE), European Observatory on Health Systems and Policies (EOHSP). Estado da saúde na EU: Portugal - perfil de saúde do país 2021. Paris, Bruxelas: OCDE/ EOHSP; 2021.. The occupancy rate of ICU beds exceeded 90% in hospitals in the North region⁵⁶56 Odone A, Gianfredi V, Sorbello S, Capraro M, Frascella B, Vigezzi GP, Signorelli C. The use of digital technologies to support vaccination programmes in Europe: state of the art and best practices from experts' interviews. Vaccines 2021; 9(10):1126.. It should be noted that in the beginning of the pandemic, Portugal had limited hospital capacity, being the European country with the lowest number of ICU beds per 100,000 inhabitants⁵⁸58 Taxa de ocupação em UCI ultrapassa os 90% em alguns hospitais [internet]. SIC Notícias 2020. [acessado 2020 nov 23]. Disponível em: https://sicnoticias.pt/especiais/coronavirus/2020-11-17-Covid-19-no-Norte.-Taxa-de-ocupacao-em-UCI-ultrapassa-os-90-em-alguns-hospitais
https://sicnoticias.pt/especiais/coronav... and, even doubling the number of ICU beds between March/2020 and March/2021, hospitals in some regions were overwhelmed³²32 Organisation for Economic Co-operation and Development (OCDE), European Observatory on Health Systems and Policies (EOHSP). Estado da saúde na EU: Portugal - perfil de saúde do país 2021. Paris, Bruxelas: OCDE/ EOHSP; 2021..

The significant decrease in the number of cases (7-day moving average of around 50 cases/million inhabitants) during several months of 2021 was associated with the increase in mobility restrictions and social distancing measures between January-June/2021 (average SI of 70.68, reaching 87.93 in March), the population’s adherence to these guidelines, the adoption of epidemiological criteria for reopening, and the “Red Lines” strategy.

This monitoring and control strategy was created in March/2021, considering the success when facing the 1^st wave and the collapse experienced in the 2^nd wave⁵⁹59 Peralta-Santos A, Nunes B, Gomes BM, Nunes C, Antunes C, Goveia J, Gomes MC, Felgueiras O. Linhas Vermelhas: epidemia de infecção por SARS-CoV-2/COVID-19 [Internet]. 2021. [acessado 4 abr 2021]. Disponível em: https://www.dgs.pt/documentos-e-publicacoes/estudo-define-as-linhas-vermelhas-para-intervencao-na-epidemia-por-covid-19.aspx
https://www.dgs.pt/documentos-e-publicac... . Critical limits were established for a set of indicators that, when adequately monitored, could guide measures to be adopted for each moment of the epidemic⁵⁹59 Peralta-Santos A, Nunes B, Gomes BM, Nunes C, Antunes C, Goveia J, Gomes MC, Felgueiras O. Linhas Vermelhas: epidemia de infecção por SARS-CoV-2/COVID-19 [Internet]. 2021. [acessado 4 abr 2021]. Disponível em: https://www.dgs.pt/documentos-e-publicacoes/estudo-define-as-linhas-vermelhas-para-intervencao-na-epidemia-por-covid-19.aspx
https://www.dgs.pt/documentos-e-publicac... . Three main indicators were defined: cumulative incidence at 14 days per 100,000 inhabitants; real-time (Rt) infection effective reproduction number; number of ICU beds occupied by COVID-19 patients. In addition to four secondary indicators: percentage of positive tests among the tested samples (test positivity rate); percentage of cases and contacts isolated and traced in the first 24 hours after notification; percentage of confirmed cases reported late; emergence and spread of Variants of Concern (VOC)⁵⁹59 Peralta-Santos A, Nunes B, Gomes BM, Nunes C, Antunes C, Goveia J, Gomes MC, Felgueiras O. Linhas Vermelhas: epidemia de infecção por SARS-CoV-2/COVID-19 [Internet]. 2021. [acessado 4 abr 2021]. Disponível em: https://www.dgs.pt/documentos-e-publicacoes/estudo-define-as-linhas-vermelhas-para-intervencao-na-epidemia-por-covid-19.aspx
https://www.dgs.pt/documentos-e-publicac... .

It is noteworthy that the DGS and Dr. Ricardo Jorge National Institute of Health (INSA) systematically disseminated on their websites monitoring reports on the epidemiological situation, with details of the observed values for the “Red Lines” indicators. Genomic surveillance, developed by INSA with the support of public and private laboratories and academic institutions, also represented an important tool in the fight against the pandemic⁶⁰60 Portugal. Ministério da Saúde (MS). Direção-Geral da Saúde (DGS). INSA e Unilabs criam ferramenta para identificar nova variante [Internet]. 2021. [acessado 2022 jun 19]. Disponível em: https://www.dgs.pt/em-destaque/insa-e-unilabs-criam-ferramenta-para-identificar-nova-variante.aspx
https://www.dgs.pt/em-destaque/insa-e-un... .

Amidst the 2^nd wave, Portugal started vaccinating the population on January 5, 2021⁶¹61 Portugal. INEM inicia vacinação dos profissionais prioritários [Internet]. 2021. [acessado 2022 jun 20]. Disponível em: https://www.dgs.pt/em-destaque/inem-inicia-vacinacao-dos-profissionais-prioritarios.aspx
https://www.dgs.pt/em-destaque/inem-inic... . The Immunization Plan established priorities according to groups of diseases, risk of exposure, age and workers in essential services⁶²62 Portugal. Ministério da Saúde (MS). Estamos on - a resposta de Portugal à COVID-19. Plano Vacinação COVID-19 [internet]. 2020. [acessado 2022 mar 21]. Disponível em: https://covid19estamoson.gov.pt/plano-vacinacao-covid-19/
https://covid19estamoson.gov.pt/plano-va... .

The global difficulties regarding the availability of vaccines initially determined a slower process, leading the country to activate the task force to accelerate the immunization process³²32 Organisation for Economic Co-operation and Development (OCDE), European Observatory on Health Systems and Policies (EOHSP). Estado da saúde na EU: Portugal - perfil de saúde do país 2021. Paris, Bruxelas: OCDE/ EOHSP; 2021.. The acceptance of the vaccine by the Portuguese population, associated with management efforts aimed at increasing immunization rates, contributed to the fact that more than 70% of the population was vaccinated with two doses by the end of August/2021, a percentage well above the 48% rate in Europe⁴4 Ritchie H, Mathieu E, Rodés-Guirao L, Appel C, Giattino C, Ortiz-Ospina E, Hasell J, Macdonald B, Beltekian D, Roser M. Coronavirus Pandemic (COVID-19) [Internet]. Our World in Data. 2022. [cited 2022 jul 20]. Available from: https://ourworldindata.org/coronavirus
https://ourworldindata.org/coronavirus... ^,3232 Organisation for Economic Co-operation and Development (OCDE), European Observatory on Health Systems and Policies (EOHSP). Estado da saúde na EU: Portugal - perfil de saúde do país 2021. Paris, Bruxelas: OCDE/ EOHSP; 2021., reaching 85% in early October/2021 (Chart 3).

The reduction of restrictive measures and the circulation of the Delta variant led to an increase in cases between May-June/2021, which can be considered as a 3^rd wave (Figure 2). In this case, the significant percentage rates of vaccination may explain the lower proportion of deaths in relation to the number of cases than that observed in the previous waves (Figure 2).

By the end of 2021, the pandemic worsened, leading the country to declare a state of calamity on December 1, 2021⁶³63 Portugal. Ministério da Saúde (MS). Estamos on - a resposta de Portugal à COVID-19. Medidas de Controlo da Pandemia a partir de 1 de dezembro de 2021 [internet]. 2021. [acessado 2022 jun 20]. Disponível em: https://covid19estamoson.gov.pt/levantamento-de-restricoes-covid-19/
https://covid19estamoson.gov.pt/levantam... . The 4^th pandemic wave, with the introduction of the Omicron variant in November/2021, resulted in a very high occurrence of cases (7-day moving average of 6,105.81 cases/million inhabitants on January 31, 2022), which, as it occurred in the 3^rd wave, also did not correspond to an increase of the same magnitude in hospitalizations and number of deaths (Figure 2).

Discussion

It can be said that Portugal had four noteworthy moments in controlling the pandemic: a) rapid control during the 1^st wave, flattening the curve and sparing the national health system; b) the moment of lack of control, with high mortality and collapse of the health system; c) the establishment of a robust surveillance strategy for the monitoring and control of COVID-19 in the national territory; and d) adequate and timely expansion of vaccination coverage.

The performance observed during the 1^st wave has been assessed as positive²¹21 Simões J, Magalhães JPM, Biscaia A, da Luz Pereira A, Augusto GF, Fronteira I. Organisation of the State, model of health system and COVID-19 health outcomes in six European countries, during the first months of the COVID-19 epidemic in 2020. Int J Health Plann Mgmt. 2021; 36(5):1874-1886.^,3737 Waitzberg R, Hernández-Quevedo C, Bernal-Delgado E, Estupiñán-Romero F, Angulo-Pueyo E, Theodorou M, Kantaris M, Charalambous C, Gabriel E, Economou C, Kaitelidou D, Konstantakopoulou O, Vildiridi LV, Meshulam A, Belvis AG, Morsella A, Bezzina A, Vicentini K, Augusto GF, Fronteira I, Simões J, Karanikolos M, Williams G, Maresso A. Early health system responses to the COVID-19 pandemic in Mediterranean countries: a tale of successes and challenges. Health Policy 2022; 126(5):465-475.^,3838 Correia PMAR, Mendes IO, Pereira SPM, Subtil I. The combat against COVID-19 in Portugal: how State measures and data availability reinforce some organizational values and contribute to the sustainability of the National Health System. Sustainability 2020; 12:7513.^,4545 Ricoca Peixoto V, Vieira A, Aguiar P, Carvalho C, Rhys Thomas D, Abrantes A. Initial assessment of the impact of the emergency state lockdown measures on the 1st wave of the COVID-19 epidemic in Portugal. Acta Med Port 2020; 33(11):733-741. and resulted in a lower number of deaths³⁸38 Correia PMAR, Mendes IO, Pereira SPM, Subtil I. The combat against COVID-19 in Portugal: how State measures and data availability reinforce some organizational values and contribute to the sustainability of the National Health System. Sustainability 2020; 12:7513.^,4545 Ricoca Peixoto V, Vieira A, Aguiar P, Carvalho C, Rhys Thomas D, Abrantes A. Initial assessment of the impact of the emergency state lockdown measures on the 1st wave of the COVID-19 epidemic in Portugal. Acta Med Port 2020; 33(11):733-741., new cases, ICU admissions and occupation of hospital beds than the projections based on the initial data⁴⁵45 Ricoca Peixoto V, Vieira A, Aguiar P, Carvalho C, Rhys Thomas D, Abrantes A. Initial assessment of the impact of the emergency state lockdown measures on the 1st wave of the COVID-19 epidemic in Portugal. Acta Med Port 2020; 33(11):733-741.. The analysis of excess mortality by waves confirms this assessment, when compared to neighboring European countries. In the 1^st wave, Portugal had the lowest percentage of excess mortality (18%) compared to Spain (156%), Italy (68%) and France (61%). However, in the 2^nd wave, the situation was reversed and Portugal led among the four neighboring countries with 72%, followed by Spain with 22%, Italy and France with 11% each⁴4 Ritchie H, Mathieu E, Rodés-Guirao L, Appel C, Giattino C, Ortiz-Ospina E, Hasell J, Macdonald B, Beltekian D, Roser M. Coronavirus Pandemic (COVID-19) [Internet]. Our World in Data. 2022. [cited 2022 jul 20]. Available from: https://ourworldindata.org/coronavirus
https://ourworldindata.org/coronavirus... . The following aspects have been pointed out as explanations for the success in controlling the 1^st wave and, after the period of collapse, its recovery: the management coordination that was enabled through the articulation between the executive government and the parliament, with the collaboration of the different entities involved in the crisis management (local governments, hospitals, military forces, media and researchers)³⁸38 Correia PMAR, Mendes IO, Pereira SPM, Subtil I. The combat against COVID-19 in Portugal: how State measures and data availability reinforce some organizational values and contribute to the sustainability of the National Health System. Sustainability 2020; 12:7513.; the existence of a centralized health system³⁷37 Waitzberg R, Hernández-Quevedo C, Bernal-Delgado E, Estupiñán-Romero F, Angulo-Pueyo E, Theodorou M, Kantaris M, Charalambous C, Gabriel E, Economou C, Kaitelidou D, Konstantakopoulou O, Vildiridi LV, Meshulam A, Belvis AG, Morsella A, Bezzina A, Vicentini K, Augusto GF, Fronteira I, Simões J, Karanikolos M, Williams G, Maresso A. Early health system responses to the COVID-19 pandemic in Mediterranean countries: a tale of successes and challenges. Health Policy 2022; 126(5):465-475. and the population’s adherence to the compliance with social isolation guidelines³⁸38 Correia PMAR, Mendes IO, Pereira SPM, Subtil I. The combat against COVID-19 in Portugal: how State measures and data availability reinforce some organizational values and contribute to the sustainability of the National Health System. Sustainability 2020; 12:7513.^,4545 Ricoca Peixoto V, Vieira A, Aguiar P, Carvalho C, Rhys Thomas D, Abrantes A. Initial assessment of the impact of the emergency state lockdown measures on the 1st wave of the COVID-19 epidemic in Portugal. Acta Med Port 2020; 33(11):733-741.^,6464 Valente de Almeida SV, Costa E, Lopes FV, Santos JV, Barros PP. Concerns and adjustments: How the Portuguese population met COVID-19. PLoS ONE 2020; 15(10):e0240500.. The crisis management was also described as firm³⁸38 Correia PMAR, Mendes IO, Pereira SPM, Subtil I. The combat against COVID-19 in Portugal: how State measures and data availability reinforce some organizational values and contribute to the sustainability of the National Health System. Sustainability 2020; 12:7513.^,5353 Aristodemou K, Buchass L, Claringbould D. The COVID-19 crisis in the EU: the resilience of healthcare systems, government responses and their socio-economic efects. Eurasian Econ Rev 2021; 11:251-281. and fast³⁸38 Correia PMAR, Mendes IO, Pereira SPM, Subtil I. The combat against COVID-19 in Portugal: how State measures and data availability reinforce some organizational values and contribute to the sustainability of the National Health System. Sustainability 2020; 12:7513.^,4545 Ricoca Peixoto V, Vieira A, Aguiar P, Carvalho C, Rhys Thomas D, Abrantes A. Initial assessment of the impact of the emergency state lockdown measures on the 1st wave of the COVID-19 epidemic in Portugal. Acta Med Port 2020; 33(11):733-741..

The fact that the pandemic onset in Portugal occurred more than one month after the 1^st European case may have influenced the population’s perception of risk, contributing to the adoption of preventive behaviors³⁷37 Waitzberg R, Hernández-Quevedo C, Bernal-Delgado E, Estupiñán-Romero F, Angulo-Pueyo E, Theodorou M, Kantaris M, Charalambous C, Gabriel E, Economou C, Kaitelidou D, Konstantakopoulou O, Vildiridi LV, Meshulam A, Belvis AG, Morsella A, Bezzina A, Vicentini K, Augusto GF, Fronteira I, Simões J, Karanikolos M, Williams G, Maresso A. Early health system responses to the COVID-19 pandemic in Mediterranean countries: a tale of successes and challenges. Health Policy 2022; 126(5):465-475.^,6464 Valente de Almeida SV, Costa E, Lopes FV, Santos JV, Barros PP. Concerns and adjustments: How the Portuguese population met COVID-19. PLoS ONE 2020; 15(10):e0240500.. However, this may have implied complications in routine care and in the financial situation⁶⁴64 Valente de Almeida SV, Costa E, Lopes FV, Santos JV, Barros PP. Concerns and adjustments: How the Portuguese population met COVID-19. PLoS ONE 2020; 15(10):e0240500..

The participation of PHC in the response to the pandemic differed between countries⁴⁶46 Ares-Blanco S, Astier-Peña M, Gómez-Bravo R, Fernández-García F, Bueno-Ortiz M. El papel de la atención primaria en la pandemia COVID-19: una mirada hacia Europa. Aten Primaria 2021; 53(8):102134. and, in the case of Portugal, considering the good PHC coverage, it was possible to give this level of care a more central role. On the other hand, the epidemiological surveillance, especially after the 2^nd wave, awareness and prevention campaigns and transparent communication were some of the prioritized aspects³⁸38 Correia PMAR, Mendes IO, Pereira SPM, Subtil I. The combat against COVID-19 in Portugal: how State measures and data availability reinforce some organizational values and contribute to the sustainability of the National Health System. Sustainability 2020; 12:7513.^,4646 Ares-Blanco S, Astier-Peña M, Gómez-Bravo R, Fernández-García F, Bueno-Ortiz M. El papel de la atención primaria en la pandemia COVID-19: una mirada hacia Europa. Aten Primaria 2021; 53(8):102134., illustrating the relevance and convenience of integration between PHC, surveillance and social communication in health. Portugal is an example of good practices in the management of pandemic crises, with emphasis on organizational values such as legality, government transparency, citizenship appreciation, efficiency, effectiveness and sustainability³⁸38 Correia PMAR, Mendes IO, Pereira SPM, Subtil I. The combat against COVID-19 in Portugal: how State measures and data availability reinforce some organizational values and contribute to the sustainability of the National Health System. Sustainability 2020; 12:7513..

Among the worldwide consequences of COVID-19, the high increase in unemployment is highlighted by the International Labor Organization. It is estimated a decline in the GDP of around 6.9% in Portugal for 2020, an economic impact among the highest ones. In April/2020, the number of unemployed individuals in 74 municipalities was more than twice the number registered in April/2019⁶⁵65 Shaaban AN, Peleteiro B, Martins MRO. COVID-19: what is next for Portugal? Front Public Health 2020; 8:392..

Measures such as quarantine and social distancing, the closing of borders and/or limiting the entry of foreigners, although effective in mitigating the pandemic, generate economic implications, particularly due to the contribution of tourism to the Portuguese economy⁶⁵65 Shaaban AN, Peleteiro B, Martins MRO. COVID-19: what is next for Portugal? Front Public Health 2020; 8:392. and, therefore, they must be monitored.

The present study contributes to the understanding of the Portuguese response to the pandemic and points out successes and failures to be considered by other nations in future health crises. However, as it is based on a review, it has limitations. Therefore, it is advisable to carry out further investigations that can establish comparative methodological strategies capable of explaining the how and why of the differences in responses to the pandemic between countries, including Portugal.

The Portuguese response to COVID-19 showed that political stability contributed to the creation of a consensus in the implementation of control measures approved by the population. On the other hand, the existence of a national health system (the SNS) of a public nature corresponded not only to a pre-existing infrastructure, but to a capacity to plan and perform the required epidemiological surveillance, as well as provide hospital care for severe cases. Another aspect is related to the agility in adopting measures to fight the pandemic. The preparation started two months before the first case, always with transparency regarding surveillance and monitoring of cases and suspected ones. Adherence to the “Test-Track-Trace” strategy led the SNS to carry out many tests, aimed at identifying contacts.

On the other hand, the resurgence of the pandemic that constituted the 2^nd wave shows that the health situation requires constant vigilance. Despite preparations for a possible 2^nd wave, there was a delay in adopting measures related to social distancing, possibly due to the resulting economic impact. The adequate measures during the 1^st wave did not prevent the country from experiencing the collapse of its health system in the 2^nd wave but resulted in learning from the adoption of the “Red Lines” and efforts to implement vaccination. Although the epidemiological situation must be closely monitored, in view of the uncertainties regarding the consequences of this health crisis, Portugal has demonstrated the importance of adopting articulated and technically well-established political-administrative measures.

References

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