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Portugal Is the World’s Most Vaccinated Country Because Its Population Trusts Its Free Health Care System

Portugal has the world's highest COVID-19 vaccination rate, with 85 percent of the population fully vaccinated. Its success drew on a strong public information campaign — but it couldn’t have done it without a free national health care system that has won massive popular trust.

A woman walks near a vaccination center in the Oriente district of Lisbon, 2021. (Jorge Mantilla / NurPhoto via Getty Images)

Last weekend Portugal placed first in the world for its COVID-19 vaccination rate, with 85 percent of its population fully vaccinated. Its campaign has been a sensational success — and even more incredible given how poorly the country was dealing with the spread of the virus at the start of 2021.

The Portuguese government, currently led by Socialist Party prime minister António Costa, has had a mercurial approach to the coronavirus. An early call for isolation and eventual lockdown in 2020 resulted in lower infection and mortality rates than many of its European neighbors. But following an easing of restrictions in the summer, Costa found it hard to reimpose strict measures for the winter holidays.

As the flux of people socializing and moving around the country increased, so, too, did the case numbers. The situation was significantly worsened by the arrival of the delta variant at a time when health systems were particularly strained. By February 2021, Portugal had the highest COVID-19 infection and death rates in the world.

As the crisis unfolded, the Portuguese vaccination task force threatened to collapse, after its leader — an executive at the Portuguese Red Cross — stepped down due to alleged “irregularities” with the system. In waltzed the program’s number two, Vice Admiral Henrique Gouveia e Melo, until then unknown to the wider public.

As any cursory investigation into Portugal’s vaccination success will tell you, Gouveia e Melo is the type of cool head needed in crisis situations. He swapped his vice admiral’s uniform for ordinary fatigues, set deadlines, got personally involved with distribution hiccups, and was loudly critical of Portugal’s small but nonetheless disruptive anti-vaxxer movement. “Negationism and obscurantism are the true killers,” Gouveia e Melo told journalists after a group of protesters accosted him outside a vaccination center in August. A few days later, at another vaccination center, he was received with a standing ovation by staff and patients. By the end of his “mission” in late September, Gouveia e Melo was nothing short of a national hero.

But for all his efforts, Gouveia e Melo’s leadership alone can’t explain the stunning success of Portugal’s vaccination drive. Across the world, similar efforts have been blighted by misinformation, skepticism, and infrastructural obstacles. England, cradle of the first universal health care system, the National Health Service, started its vaccination campaign twenty days ahead of Portugal, on December 7, 2020. By May, it had administered over 50 million doses among its 56 million inhabitants.

At that point Portugal lagged far behind, having provided 5 million jabs to a population of 10.3 million. But today, the full vaccination rate in England only stands at around 68 percent, while Portugal has raced ahead. And the discrepancy can’t just be blamed on Boris Johnson’s vacuous leadership.

Revolutionary Change

To many, the clearest explanation of the Portuguese success story is historical. Portugal has a publicly funded and universally accessible health care system, born following the 1974 revolution that not only brought down the fascist dictatorship but also hurried in the creation of a welfare state. The establishment of the Serviço Nacional de Saúde (SNS), and the ills it was able to eradicate, is still very present in Portugal’s collective and political memory.

According to nurse Mário Macedo, “a population that until the 1970s–1980s saw illnesses like cholera, diphtheria and polio, and subsequently trusts vaccinations,” contributed to the success of the coronavirus immunization campaign. This trust expands to the entire health care system, which has now operated for over forty years.

The geographical and financial accessibility of the SNS has allowed the Portuguese people to be particularly health-conscious and see health care as a social prerogative rather than a commodity. “The success of the vaccination campaign was the result of good public health policies, trust in vaccines, and, above all, in health professionals,” pharmacist Rita Miguel told me. “There is still a substantial part of the population that will not just Google out things, but go to the doctor or the pharmacy to clarify doubts.”

Fellow nurse André Beja echoed this sentiment, adding that Portugal’s “high vaccination coverage” prior to COVID-19 contributed to the high engagement of the Portuguese population this time around, too. The vaccination rate for once-devastating epidemics such as measles and rubella stands at 95 percent — one of the highest in Europe.

The nurse, who has been personally involved in the vaccination drive, said that “over the four decades of history of the SNS, primary care has implemented measures ensuring that, either by raising awareness among parents when they take their children to a routine appointment, or by regularly checking compliance with the vaccination schedule of adults on different occasions, Portugal now has a high vaccination coverage.”

As a result, “adults and the elderly are especially aware of the evolution of health indicators in this period, with a reduction in the incidence of certain diseases and of the morbidity and mortality episodes associated with them.” As a health professional, Beja said the experience had been personally “very remarkable on many levels.” He has tweeted about his many conversations with patients on the vaccination chair.

Bittersweet

Both mainstream and social media in Portugal have been inundated with the elated voices of those being vaccinated. For nationals there’s a sense of relief and pride, but for foreign residents often a tinge of bittersweetness over global vaccine inequality. This has rung particularly true for those with relatives across the Portuguese-speaking world.

Angola, Mozambique, and other African nations continue to be particularly vulnerable to the virus and dependent on international vaccine donation programs like COVAX. Meanwhile, Brazilians rue far-right president Jair Bolsonaro’s erratic and often skeptical approach toward coronavirus prevention, treatment, and immunization.

Importantly, Portugal now stands as an example not only to the world but also to itself. If the vaccination campaign proved to be a success in “beating this virus,” as Gouveia e Melo so proudly stated before stepping down at the end of his mission, it did so because of an organization that is constantly under fire and increasingly underfunded.

The trust the Portuguese population has in its public health care system has been weakened in recent years by lack of resources and the cannibalistic encroachment of private enterprises. In some rural areas the SNS is practically invisible, as smaller clinics and health centers closed down and their services incorporated into bigger structures in larger urban areas several miles away. The relationship between staff and patients is continually challenged by a high turnover resulting, almost always, from the crippling low salaries of public health care professionals.

As other nations look at what Portugal did right, Portugal too should consider the true secret to its success. Gouveia e Melo himself credited the Serviço Nacional de Saúde, its professionals, and its patients for the historic accomplishment. Any state attempting to mimic the feat must invest, expand, and nurture a similar publicly owned, universally accessible, health care organization — and to honor the success of its COVID-19 vaccination campaign, as must Portugal.