Portugal's Emergency Service Under Scrutiny: Will the 2027 Audit Fix Years of Neglect?

The Portugal Finance Inspectorate (IGF) has scheduled a comprehensive follow-up audit of the National Institute of Medical Emergency (INEM), set to conclude in 2027, to verify whether sweeping reforms are genuinely taking hold inside the country's beleaguered emergency medical service. The move comes after a scathing 2025 report exposed systematic mismanagement, budget waste, and operational failures during a period when the INEM struggled to respond to basic calls for help.

António Ferreira dos Santos, Inspector-General of Finance, confirmed the timeline during testimony before the parliamentary commission investigating the INEM crisis. His announcement underscores the scale of the challenge: more than 30 specific recommendations are now being implemented across the institute, from fixing broken IT systems to establishing legal frameworks for public subsidies within the Integrated Medical Emergency System (SIEM). Yet many of the deadlines for these reforms are still running, and it remains unclear how many have genuinely been completed.

Why the Original Audit Mattered

The IGF's Report 48/2025, approved in July 2025, dissected INEM operations from 2021 through 2024—a period marked by the leadership of former president Luís Meira, who resigned in July 2024 amid a controversial helicopter transport contract awarded through a direct award procedure rather than open tender. The audit's findings were damning:

• No automatic tracking of helicopter flight hours, raising the risk that the Portuguese State overpaid for aerial medical transport.

• Budget execution below 10%, signaling chronic underspending and failure to invest in critical infrastructure.

• No vehicle fleet renewal since 2015, leaving ambulances aging and unreliable.

• Inadequate digital solutions and a lack of interoperability with the broader health ministry's IT backbone, managed by Shared Services of the Ministry of Health (SPMS).

• Weak performance indicators, making it nearly impossible to measure clinical quality, patient safety, or the public health impact of pre-hospital care.

The report also criticized the systematic preference for direct awards over public tenders for helicopter services, a practice that circumvented competitive pricing and transparency. These findings came on top of an earlier inspection by the General Inspectorate of Health Activities (IGAS) in April 2025, which had already flagged serious gaps in the training of Pre-Hospital Emergency Technicians (TEPH).

What This Means for Residents

For anyone living in Portugal, the implications are practical and immediate. The INEM is the frontline responder when someone dials 112 for a medical emergency—whether that's a heart attack in Lisbon, a car crash in the Algarve, or a stroke in the interior. Over 50% of calls on November 4, 2024 were abandoned during a strike, meaning thousands of people could not reach help. The strike, which ran from October 30 to November 7, exposed the institute's lack of contingency planning: no procedure existed to manage strikes, according to the Inspector-General of Health, Carlos Carapeto, who testified that INEM leadership knew the strike was coming but failed to prepare.

The follow-up audit in 2027 will assess whether the institute has genuinely addressed these vulnerabilities. Key reforms under scrutiny include:

• Financial stability: Ensuring the INEM has a predictable, adequate funding model that doesn't leave it chronically underfunded.

• Operational efficiency: Streamlining the deployment of ambulances, helicopters, and medical teams based on objective demand factors and geographic coverage gaps.

• IT modernization: Building systems that talk to each other—linking the Medical Operations and Emergency Dispatch Centre (CODU) with hospital emergency departments and primary care centers in real time.

• Legal clarity on overtime and training: Defining special rules for supplementary work hours and establishing a dedicated regime for emergency medicine training, which has been improvised until now.

Political Accountability and the Parliamentary Inquiry

The parliamentary commission of inquiry (CPI), approved in July 2025 at the initiative of the Liberal Initiative party, is tasked with pinpointing political, technical, and financial accountability for the INEM's current state. Originally scheduled for 90 days, the inquiry has been extended for another 90 days, with hearings set to wrap up by late April 2026 to allow the rapporteur time to draft a final report by May 27.

The commission is examining not only the November 2024 strike but also the relationship between political overseers and the INEM since 2019, spanning the 22nd, 23rd, 24th, and 25th Constitutional Governments. Questions being asked include: Who signed off on repeated direct awards? Why wasn't the fleet renewed for a decade? And why did no one implement basic performance metrics?

Testimony from INEM workers during the inquiry acknowledged communication failures around minimum service levels during the strike. The National Association of Emergency Medical Technicians (ANTEM) publicly criticized both the Ministry of Health and INEM leadership for "inadequate decisions" in managing the labor action, while the IGAS inspection confirmed that on the worst day, more than half of emergency calls went unanswered.

Recommendations and Deadlines

The IGF directed a cluster of reforms at the INEM Directive Council, all accepted with implementation timelines that are still underway:

• Develop a strategic plan for facilities, including proper inventory control, tagging, and tracking of equipment and vehicles.

• Integrated planning of emergency resources, factoring in population density, road networks, and response time targets.

• Establish performance indicators with clinical quality metrics, supported by modern management information systems.

• Enhance organizational efficiency through clearer internal workflows and accountability structures.

Separately, the IGF made proposals to political decision-makers, including:

• Create a legal framework for SIEM subsidies, clarifying how public money flows to partner entities (fire departments, Red Cross, etc.) that operate ambulances under INEM coordination.

• Solve secondary transport bottlenecks, where non-urgent patient transfers between hospitals clog the system.

• Clarify overtime rules for INEM staff, who often work unpredictable and extended hours.

• Define a special training regime for emergency medicine, aligning Portugal with European best practices where emergency medicine is a recognized medical specialty (formalized in Portugal in 2024).

The INEM has submitted a preliminary progress report on these reforms, but Ferreira dos Santos cautioned Parliament that it is too early to assess actual implementation. "The monitoring will continue until we have final, sufficiently substantiated information," he said, adding that subsequent actions, if necessary, will be triggered once the full picture is clear.

International Context: How Europe Does It

Portugal's emergency medical service challenges are not unique, but international comparisons highlight gaps. In France, the SAMU system is hospital-based, with doctors on-board advanced life support ambulances and a strong medical dispatch center that triages calls and sends the appropriate resource. The system is fully funded by social security, and flight hours are automatically logged and audited.

Germany operates a mixed public-private model with ambulance services often run by fire departments or nonprofits like the Red Cross, with strict ISO 9001 quality management certification. The UK's NHS Ambulance Trusts publish national quality indicators and are inspected by the Care Quality Commission, ensuring transparency and accountability. In Sweden, regional councils fund emergency services through local taxes, and patients pay a capped annual co-payment, ensuring equity without breaking household budgets.

For the INEM, lessons include: investing in interoperable IT systems, certifying quality through external audits, ensuring stable multi-year funding, and empowering medical dispatch centers to route non-urgent cases to primary care or walk-in clinics, reducing hospital emergency room overload. Portugal's "Call First, Save Lives" project, which uses the SNS 24 health line to triage calls and direct patients appropriately, mirrors successful European models but remains underutilized.

What Happens Next

The 2027 follow-up audit will be the definitive test of whether the INEM has genuinely reformed or merely shuffled paperwork. The parliamentary inquiry's final report, expected by late May 2026, will likely name names and recommend sanctions or policy changes. Meanwhile, the Ministry of Health has framed the crisis as justification to "refound" the INEM, a term suggesting structural overhaul rather than incremental fixes.

For residents, the stakes are existential: in a medical emergency, seconds matter. Whether calling from a Lisbon apartment or a rural village in Trás-os-Montes, people need to trust that help will come—and that the system is managed with competence, accountability, and adequate resources. The 2027 audit will reveal whether that trust is finally being earned.