The Portugal Ministry of Health has pledged to revise a controversial pay decree that inadvertently excludes stroke unit physicians from additional production bonuses tied to life-saving thrombectomy procedures, a move that triggered immediate backlash from medical unions and the Portuguese Medical Association.
Why This Matters
• Health service disruption risk: Stroke units across Portugal's National Health Service (SNS) face potential staffing shortages if physicians who coordinate emergency stroke care remain excluded from performance pay
• Discrimination within multidisciplinary teams: Neuroradiologists, anaesthetists, and nurses treating the same stroke patient receive additional compensation—but the doctors who triage, activate, and manage the entire "Via Verde AVC" fast-track protocol do not
• Legal questions raised: The exclusion may violate constitutional principles of equality and fair remuneration, according to the Northern Doctors' Union (SMN)
A Decree with "Good Intentions" Goes Awry
Health Minister Ana Paula Martins acknowledged the misstep in remarks to journalists at a health centre inauguration in Miranda do Corvo, in the Coimbra district. "When something doesn't come out properly, we have to look, talk to people, and naturally, correct it. That's what we are doing," she stated.
The Dispatch nº 8134-A/2026, published on June 29, was designed to regulate extra pay for emergency procedures in three critical specialties: interventional neuroradiology, interventional cardiology, and interventional radiology—including the fast-track protocols for stroke (AVC) and heart attacks across the SNS. According to Martins, the decree marked the first time such a framework existed and aimed to clarify remuneration and team composition for these high-stakes procedures.
Yet shortly after publication, Martins' office was flooded with complaints from medical societies, the Portuguese Medical Association, and several physicians' unions, all warning that the decree failed to reflect operational reality.
The Missing Link in the Stroke Chain
The Sindicato dos Médicos do Norte (SMN), affiliated with the National Federation of Doctors (Fnam), sent a formal letter to Martins and the SNS Executive Board demanding urgent correction. Their argument: without stroke unit physicians, thrombectomy simply does not happen.
These doctors evaluate incoming stroke patients, activate the Via Verde AVC emergency pathway, decide whether to refer for thrombectomy, and shoulder clinical responsibility before and after the procedure. Yet the decree compensates neuroradiologists, anaesthetists, nurses, and diagnostic technicians—but not the stroke unit physicians who orchestrate the entire clinical episode.
"The minister has created an incomprehensible discrimination among members of the same multidisciplinary team, devaluing doctors whose intervention is indispensable to saving lives," the SMN wrote. The union noted the exclusion raises "well-founded doubts" about legality and constitutional compliance, particularly Article 59 of the Portuguese Constitution, which enshrines the right to fair pay for work performed.
The omission affects every SNS centre with a Via Verde AVC pathway, creating pay inequality among professionals participating in the same clinical process with complementary responsibilities. "This is not an isolated problem," the SMN warned.
What This Means for Stroke Patients in Portugal
Thrombectomy is a time-critical procedure in which a catheter is threaded through blood vessels to physically remove clots blocking arteries in the brain. International research, including a large-scale Australian study, shows that pay-for-performance incentives in stroke care can reduce six-month mortality by 12.5% and increase access to specialised stroke units by 35%, especially in rural and regional areas.
If stroke unit physicians feel undervalued or financially penalised relative to their colleagues, Portugal risks losing experienced staff or seeing reduced engagement in the demanding 24/7 Via Verde protocol. Stroke outcomes are highly time-sensitive; every delay in triage or referral decision measurably worsens patient prognosis.
The Ministry's promise to revise the decree aims to prevent a cascade of consequences: physician attrition, operational bottlenecks in emergency stroke pathways, and ultimately, poorer outcomes for the roughly 25,000 stroke patients treated annually in Portuguese hospitals.
Close Dialogue to Rebuild the Framework
Martins confirmed she is in "very close dialogue" with the Portuguese Medical Association (Ordem dos Médicos), the Portuguese Nursing Association (Ordem dos Enfermeiros), and relevant scientific societies to construct a replacement decree. The new framework will, wherever legally feasible, retroactively correct the original dispatch to ensure no professional is disadvantaged.
"It's the first time we've had a specific decree of this kind," Martins explained, suggesting the initial drafting may have lacked input from frontline clinical teams who understand the interdependencies within stroke care.
The SMN framed the dispute not merely as a defence of its members, but as a matter of institutional fairness: "Those who save lives should be treated with equality." The union underscored that it is advocating "for all doctors affected by this injustice and for an SNS that is only strengthened when it values all professionals indispensable to the care provided."
Broader Context: Stroke Care Disparities Across Europe
Portugal's controversy unfolds against a backdrop of significant European variation in stroke care access and quality. The European Stroke Action Plan emphasises well-organised stroke units with multidisciplinary teams as the most effective intervention to improve outcomes. Yet access to units and onset-to-treatment times vary widely across the continent.
In the United Kingdom, for instance, only four of 23 active thrombectomy centres offered round-the-clock service as of 2021, and a far smaller percentage of eligible patients received treatment compared to Northern and Central Europe. Germany integrates thrombectomy routinely, while countries like Italy and Sweden have documented the procedure's cost-effectiveness despite high upfront device and infrastructure costs.
Portugal's Via Verde AVC is considered a relatively mature fast-track system, but maintaining its efficacy depends on retaining experienced staff across the entire care chain—from initial assessment to post-procedure monitoring. Any regulatory omission that inadvertently marginalises key players in that chain risks undermining the system's effectiveness.
What Comes Next
The Ministry has not announced a specific timeline for the revised decree, but the intensity of the pushback—from both organised medical bodies and clinical societies—suggests the correction will be expedited. Legal experts note that retroactive application of pay adjustments in the public sector is possible under certain conditions, particularly when the original decree is acknowledged to contain drafting errors rather than intentional policy choices.
For now, stroke unit physicians across Portugal await formal recognition that their role in the Via Verde protocol is not ancillary but central—and that their compensation should reflect that reality. The episode serves as a reminder that in high-stakes emergency care, every link in the clinical chain must be valued equally, not only for reasons of fairness but for the tangible impact on patient survival and recovery.
