Parliamentary Inquiry Reveals INEM's Operational Failures During 2024 Strike

The Portugal National Institute of Medical Emergency (INEM) was facing significant operational challenges by April 2024, according to testimony delivered today before a parliamentary commission investigating the agency's handling of a deadly strike. Former State Secretary for Health Management Cristina Vaz Tomé told lawmakers that the emergency service was "not functioning normally" when she assumed her role, revealing over 60% of the annual budget remained uncommitted despite urgent shortfalls in ambulances, staff, and basic equipment.

Why This Matters

• €70M sat unused while ambulances operated with 500,000 km on the odometer—more than double European norms—and critical hiring contracts went unsigned.

• 12 deaths occurred during a 6-day technician strike in late October 2024, with 3 directly linked to delayed response, per the Health Activities Inspectorate (IGAS).

• Vaz Tomé claims she never received formal strike notice, despite IGAS records showing the warning reached ministerial offices on October 9, 2024.

• Parliamentary inquiry seeks accountability for systemic failures dating back to 2019, with the final report expected to reshape emergency medical governance across Portugal.

The "Obsolete" Emergency Service

Vaz Tomé, a Social Democratic appointee who served from April 2024 through June 2025, described inheriting an agency mired in bureaucratic processes. While revenue streams remained healthy—INEM is funded partly through insurance levies—substantial delays in budget execution persisted. More than 60% of allocated funds had not been earmarked for specific expenditures, leaving frontline services starved of resources even as cash accumulated in state coffers.

"There were financial resources, but they were not being invested in equipment or field response," she told the 24-member Parliamentary Inquiry Commission (CPI) convened by the Liberal Initiative party in July 2025. The commission is tasked with determining political, technical, and financial responsibility for INEM's current state, with particular focus on the October 30–November 4, 2024 strike by pre-hospital emergency technicians (TEPH).

Among the structural deficits Vaz Tomé catalogued: a chronic shortage of TEPH technicians and nurses, a fleet of ambulances averaging well over 300,000 km beyond recommended replacement thresholds, and procurement contracts for 312 new vehicles that had been authorized but never launched. Subsidies promised to volunteer firefighter brigades—who provide the backbone of Portugal's rural emergency response—remained unpaid despite a memorandum signed in late March 2024 between INEM, the Portuguese Firefighters League (LBP), and the National Health Service executive board.

The ex-official outlined corrective measures taken during her tenure, including unblocking budget execution, authorizing the hiring of 200 TEPH technicians and 18 nurses, deploying psychologists and additional nurses to the Urgent Patient Orientation Centers (CODU), regularizing firefighter payments, and greenlighting the 312-vehicle procurement. She also initiated a new tender for helicopter emergency transport and explored structural alternatives, including potential involvement of the Portugal Air Force in medical airlift operations.

The Strike No One Claims to Have Known About

The focal point of the inquiry, however, centers on the chaotic October 2024 labor action and the apparent communication breakdown that preceded it. Vaz Tomé testified repeatedly that she never saw the strike pre-notification, which union rules and public service law require be submitted at least 10 days before a walkout. She insists the Union of Pre-Hospital Emergency Technicians (STEPH) never contacted her directly to negotiate or discuss minimum service guarantees—a legal requirement for strikes affecting essential services.

Yet the IGAS audit trail tells a different story: the union filed its formal notice on October 9, 2024, and the document was routed to all relevant ministerial offices, including Vaz Tomé's. She only learned of the strike upon returning from an official trip to Brazil on November 2, by which time the walkout was already underway and emergency call centers were overwhelmed.

"I didn't receive information about the pre-notification. I was not contacted by the union president," she stated. When pressed on why her staff failed to escalate the alert, Vaz Tomé blamed what she described as an "extremely archaic, obsolete, and entirely paper-based" workflow within the Portugal Health Ministry. Official correspondence, she explained, required ten procedural steps before reaching a secretary of state, and the strike notice—sent via postal mail—arrived only after the crisis had begun.

She also claimed that INEM President Sérgio Janeiro, with whom she held regular meetings, never flagged persistent worker dissatisfaction or warned of an impending stoppage. "If I had known strikes were coming, we could have done something more," she said. Under a directive issued by former Health Minister Paulo Macedo, strikes targeting overtime work in essential services require formal minimum service agreements—a safeguard Vaz Tomé says she would have triggered had she been informed.

The Human Cost

Between October 30 and November 4, more than half of the 7,326 emergency calls placed on the worst day went unanswered. Average wait times ballooned to 8.5–9.4 minutes, compared to a 4% abandonment rate on the same date in 2023. IGAS investigators documented 12 fatalities during the strike period, determining that three deaths had a direct causal link to delayed ambulance dispatch.

In one case, an 86-year-old man suffering a heart attack in Bragança waited so long for care that inspectors concluded the delay likely contributed to his death, though they stopped short of blaming individual workers given the call volume backlog. In another incident involving a 74-year-old woman in Almada, IGAS found no causation between response lag and the fatal brain injury, citing the irreversibility of her condition.

Current INEM President Luís Mendes Cabral, appointed in late 2025, called the agency's performance during the strike a "serious ethical failure," telling the commission that the institute "simply stopped answering calls" at the height of the crisis. Former Health Minister Manuel Pizarro, who oversaw INEM under the previous government, testified that had he remained in office, "the consequences would never have happened," citing his continuous dialogue with labor unions.

What This Means for Residents

For Portugal residents, the inquiry revelations underscore a troubling reality: the emergency service tasked with coordinating life-or-death response operates with structural weaknesses dating back years, if not decades. The 21,000 at-risk patients who did not receive the specialized level of care mandated by law in 2024 serve as a stark benchmark for the agency's dysfunction. These at-risk patients—typically those with chronic conditions requiring urgent transport—faced longer wait times and reduced access to specialized ambulances equipped with advanced life support.

Vaz Tomé emphasized that the problems she encountered were "not new—they were structural, everyone knew about them, and they remained unresolved." The parliamentary commission is examining INEM's governance and political oversight since 2019, a timeline that spans multiple administrations and raises questions about systemic accountability.

Since the crisis, the Portugal Government has pledged a comprehensive overhaul. In January 2026, the cabinet approved the acquisition of 275 new emergency vehicles worth €16.8M—the largest fleet investment in a decade—and authorized hiring drives to double the number of TEPH technicians. A new organizational law for INEM, based on findings from an independent technical commission, is expected to establish clearer command structures and financial controls.

The agency's 2026 budget of approximately €220M will be exempt from spending freezes (cativações)—a Portuguese budgetary mechanism that temporarily withholds allocated funds—and technological upgrades are underway to modernize the CODU call centers, including real-time geolocation tracking for ambulances—a capability that, as of today, still does not exist across much of the network.

The Path Forward

For now, INEM operates under a cloud of scrutiny as the inquiry continues. Whether the ongoing reforms—new vehicles, expanded staffing, digital modernization—will fundamentally alter the trajectory of Portugal's emergency medical system depends on more than appropriations and org charts.

It requires, as Vaz Tomé noted in her closing remarks, addressing "the starting point" honestly. "We can debate options, of course," she said. "But what we cannot do is ignore where we began." The final CPI report, expected later this year, will determine whether political leaders, INEM executives, or the labyrinthine machinery of the Portugal Health Ministry ultimately bears responsibility for the system's near-collapse—and the lives lost in its wake.