Life expectancy at birth has practically doubled during the twethieth century in Portugal both in women (40,0 years in 1920; 77,3 years in 1990) and in men (35,8 years in 1920; 70,2 years in 1999). Although this trend  has continued to develop favourably in the past twenty years (see Table 2) life expectancy of the portuguese population still remains below EU average. According to 1999 data, average life expectancy at birth was 78.37 years in the EU and 75.52 years in Portugal). Life expectancy for women is higher in Portugal than in some EU countries. In 1999 life expectancy at birth for women was 79,08 years in Portugal and 81,43 years in the EU. On the contrary, Portuguese men still have the lowest life expectancy compared to EU countries. In 1999 life expectancy at birth for men was 71,93 years in Portugal and 75,19 years in the EU (WHO, Health For All Database, 2003).

Indicators of child health, although improving since the early sixties, suffered dramatic reductions since the 1974 revolution, and are now near the average European rate. The infant mortality rate decreased fivefold between 1970 and 1990, and halved from 10.8/1000 in 1991 to 5.0/1000 in 2001. However, regional differences still persist, the highest in the Atlantic Islands of Açores (6,5/1000) and the lowest in the Region of Centro (3,8/1000) (National Institute for Statistics, Demographic statistics, 2001).

The components of the infant mortality rate have also shown favourable evolutions. For example, the perinatal mortality rate dropped from 12.1/1000 in 1991 to 5.6/1000 in 2001. From 1990 to 2002 the neonatal mortality rate decreased 50,7% from 6,9/1000 to 3,4/1000 and the post-neonatal mortality rate decreased 60,4% from 4,0/1000 to 1,6/1000 (National Institute for Statistics, Health Statistics 2002).

The distinctive successful evolution of infant  mortality, where Portugal is, nowadays, better than the EU average and better than some more developed countries may in a greater part be related to the persistence, through more than 30 years, of well defined policies, strategies, programmes and selective and coherent investments in the field of perinatal, maternal and child care, in spite of political changes and discontinuities. Recent data shows that neonatal mortality still accounts for 68% of infant deaths.

Improvements in health status of the Portuguese population seem to be associated with increases in human, material and financial resources devoted to health care as well as to a general improvement in economic and social conditions (e.g. housing, education, sanitation, communication and transport infrastructures).

Despite the overall improvement in living standards, there are inequalities between the regions, and probably between social classes. These disparities are evident in the variation of some health indicators, e.g. mortality rates and infant mortality rates, as well as in inequalities of access, e.g. the ratio of inhabitants to hospitals and the ratio of inhabitants to health professionals.

Table 2. Main Health and Demographic indicators

	1980	1985	1990	1995	1998	1999	2000
Male life expectancy at birth	65.7	69.4	70.5	71.3	71.7	71.9	72.6
Female life expectancy at birth	74.6	76.5	77.5	78.7	79.0	79.1	79.7
Death rate (crude rate per 1000)	9.6	9.7	10.4	10.5	10.7	10.8	10.4
% of population 65 years or older	10.5	11.9	13.8	14.6	15.2	15.3	15.5
Birth rate (1000 population)	16.0	13.0	11.8	10.8	11.4	11.6	11.8
Fertility rate (children per women 15-49)	2.2	1.7	1.5	1.4	1.5	1.5	1.5
Infant mortality (deaths per 1000 live births)	24.3	17.8	11.0	7.5	6.0	5.6	5.5
Perinatal mortality, deaths per 1000 total births	22.4	17.4	10.5	7.2	5.8	5.5	5.2
Literacy rate (% population 15 years of age or more)	81.8	84.4	87.2	89.9	91.4	91.9	92.2

Source: WHO, Health for All DATA BASE 2003

The leading causes of death are shown in Table 3. In 2000, diseases of the circulatory system accounted for 39% of all deaths and cancers 20% of all deaths. Together, these two groups now represent 59% of all deaths. From 1960 up to 1990 the increase has been remarkable (35% in 1960, 42% in 1970, 58% in 1980, and 62% in 1990). External causes represented 4.5% of all deaths in 2000, predominantly in men (73%). In the year 2000, 29% of deaths caused by external causes were due to motor vehicle related accidents (Instituto Nacional de Estatística, Estatísticas da Saúde 2000).

Portugal has one of the lowest mortality rates from cardiac ischaemic disease among the 15 EU countries. In 1999 this group of diseases accounted for one fifth of all deaths from diseases of the circulatory system and there were substantial differences between the Districts. In 1999 the highest standardized mortality rate was observed in the Açores (166,3/10000) and the lowest in Leiria 41,2/100000 (General Directorate of Health, Risco de Morrer, 1999).

Despite this favourable indicator diseases of the circulatory system are the leading cause of death in Portugal and rank high among EU countries. In 1999 the SDR from diseases of the circulatory system was 329,03/100000 in Portugal while the EU average was 257,83/100000 (WHO, Health For All 1999).

Cerebrovascular diseases account for almost half of the deaths associated with diseases of the circulatory system. Despite a remarkable 44% decrease between 1986 and 1999 mortality from this cause (SMR both genders: 204.4/100000 in 1986; 154,0/100000 in 1999) Portugal still has the highest mortality rate among the 15 European Community countries. In 1999 the two countries with the highest SMR for this cause of death were Portugal (186,5/100000) and Greece (113,0/100000) (WHO, Health For All 1999).

Malignancies are the second cause of death, and gastro-intestinal tumours are the most frequent type of cancer in both men and women. Gastric and large intestine cancers account for the majority of this type of cancers but while the former has shown a decrease in mortality death rates from the later have increased one third from 1986 to 1999 (General Directorate of Health, Risco de Morrer, 1999). Using mortality data tumours of the respiratory system rank second as the most frequent location of cancer in men and the third in women.

Approximately a quarter of premature mortality (potential years of life lost) in men is caused by external causes, namely traffic accidents (WHO 1994). The mortality rate associated with motor vehicle accidents was 20 per 100000 in year 2000, the highest in EU countries (European Commission. Eurostat. Key Figures on Health – Pocketbook. Luxembourg: Office for Official Publications of The European Communities. 2002.). Excessive speed, dangerous manoeuvres and high blood alcohol levels are considered to be the main causes of this problem and have been targeted with specific legislation and law enforcement measures.

The other important causes for premature mortality among Portuguese men are cancer, mainly lung and gastric cancer (17,2%), diseases of the circulatory system (14,2%) and cerebrovascular diseases (5,2%) (WHO 1994).

Among women the highest proportion of potential years of life lost is caused by cancer (25,9%), followed by external causes (14,7%), diseases of the circulatory system (12,9%) and cerebrovascular diseases (5,8%).

Table 3.  Leading causes of death, (Portugal 1997 – 2001) as percentage of all deaths in men and women

	1997	2001	1997	2001
Cerebrovascular diseases	17.3	16.0	24.8	23.0
Ischemic hearth diseases	9.0	9.0	8.4	8.2
Gastric cancer	2.9	2.9	2.1	2.0
Colon cancer	1.8	2.2	1.8	2.0
Lung cancer	4.0	0.9	4.3	1.0
Female Breast cancer	-	-	3.1	3.3
Prostate cancer	3.0	3.0	-	-
Pneumonia	3.9	3.7	3.6	3.6
Liver Cirrosis	2.8	2.6	1.2	1.0
Motor vehicle accidents	2.8	2.6	0.9	0.9
Diabetes	2.4	3.0	3.8	4.6

Source: Division of Epidemiology, General Directorate of Health, Ministry of Health, Portugal 2003.

Portugal still has the highest rate of notification of new cases of tuberculosis among EU countries (In 2000 Portugal had 41.4 new cases/100000 population compared to 10.6 new cases/100000 population among EU countries) (HFA 2003). Epidemiologic patterns are distinctive among the regions depending on the relative weight of social and demographic factors (social exclusion and immigration)  HIV infection and antibiotic resistance Men between 25 and 34 years of age are the group at highest risk (Portugal 2001).

The National program for the control of tuberculosis is managed by the General Directorate of Health and is strongly rooted on primary care services supported by Specialist Hospital and Laboratory services. The WHO DOTS strategy is the cornerstone of the programme. The percentage of cure of positive baciliferous patients has increased from 74.2% in 1996 to 85.0% in 2000 demonstrating the effectiveness of the programme (Portugal 2001).

Portugal has one of the highest prevalences of HIV infection in Europe. Up until the end of 2001 there was a total accumulated number of 18995 cases of HIV infection.

The total accumulated number of AIDS cases was 8710 at the end of 2001 (342 with infection HIV2 and 126 with infection by HIV1 and HIV2). Mortality rates from HIV/AIDS have been growing  from 3.96 deaths per 100000 population in 1985/1990 up to 28.74 deaths per 100000 population in 1997/1999.

HIV/AIDS is predominantly associated with drug addiction, social exclusion and imprisonment and affects in a large proportion sexually active young men and women.

Of the cases diagnosed in 2001, 572 cases (48%) occured among users of injected drug, 494 cases (41%) occured among the heterossexual population.

The national commission for fight against AIDS has identified the following priority areas for intervention: development of epidemiological information,  health education, set up of a national network of counseling and early detection centers, set up of a national network of centers for administration of combined therapy and extra-hospital support activities..

The situation concerning major health determinants reflects the late adoption of a western way of life more widespread among the general population since the 1974 revolution. Age and gender differences on the adoption of lifestyle already result in higher mortality caused by external causes and tobacco consumption among men, for example, but will probably impact on morbidity and mortality in decades ahead (tobacco use among women has been increasing steadily since the eighties) (Portugal, Health Interview Survey 1987, 1996, 1999).

The Portuguese population in general has high levels of alcohol consumption, low levels of physical exercise and rapidly changing dietary habits (although vegetables and fruit consumption are still higher than in most European countries and fat consumption is lower) (WHO, The European Health Report 2003). Per capita pure alcohol consumption was 15.6 litres in 1999, higher than the EU average of 11.7 litres. Half this value comes from wine consumption (WHO, Health For All Database, 2002).

Although Portugal still has one of the lowest smoking prevalence in the EU (percent daily smokers aged 15 or more in 1999: Portugal 20.5%; EU average 30.8%), the prevalence daily smokers among young women seems to be increasing according to Health Interview Survey data (WHO, HFA Database 2002; Ministry of Health, Inquérito Nacional de Saúde, 1999).