{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,1,2]],"date-time":"2026-01-02T07:49:45Z","timestamp":1767340185008,"version":"build-2065373602"},"reference-count":56,"publisher":"MDPI AG","issue":"2","license":[{"start":{"date-parts":[[2021,2,13]],"date-time":"2021-02-13T00:00:00Z","timestamp":1613174400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Healthcare"],"abstract":"<jats:p>This article investigates the political legitimacy of the health care system and the effects of austerity on the population\u2019s welfare, paying particular attention to Portugal, a country severely harmed by the economic crisis. Based on analysis of data collected from the European Social Survey on 14,988 individuals living in private households during the years between 2002 and 2018, the findings of this study aim to analyze the social and political perception of citizens on the state of health services in two distinctive periods\u2014before and after the economic crisis, according to self-interest, ideological preferences, and institutional setup as predictors of the satisfaction with the health system. The results demonstrate a negative attitude towards the health system over the years, a consistent drop during the financial crisis period, and a rapid recovery afterward. The research also shows that healthcare evaluations depend on the perceived institutional effectiveness in the citizenry\u2019s eyes. The more the citizens perceive the government as effective and trust-worthy, the more they are satisfied with the health system. Also, differences in healthcare evaluations among social groups were felt unequally: while vulnerable citizens were more affected by the Government\u2019s plan of austerity measures for health reform, healthcare evaluations of better-off social groups\u2014younger individuals, those with higher incomes, higher education, and better health status\u2014did not decline. This study contributes to the academic debate on the effects of austerity on the population\u2019s welfare attitudes and highlights the need to examine the different impacts of reforms introduced by the crisis on social groups.<\/jats:p>","DOI":"10.3390\/healthcare9020202","type":"journal-article","created":{"date-parts":[[2021,2,14]],"date-time":"2021-02-14T02:08:12Z","timestamp":1613268492000},"page":"202","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":4,"title":["The Political Legitimacy of the Healthcare System in Portugal: Insights from the European Social Survey"],"prefix":"10.3390","volume":"9","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-3559-1237","authenticated-orcid":false,"given":"Maria","family":"Asensio","sequence":"first","affiliation":[{"name":"CIES-IUL, ISCTE\u2014University Institute of Lisbon, 1649-026 Lisboa, Portugal"}]}],"member":"1968","published-online":{"date-parts":[[2021,2,13]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"53","DOI":"10.1177\/000169939503800105","article-title":"The End of Class Politics? Structural Cleavages and Attitudes to Swedish Welfare Policies","volume":"38","author":"Svallfors","year":"1995","journal-title":"Acta Sociol."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"177","DOI":"10.1093\/esr\/jcp014","article-title":"How Do Europeans Perceive Their Healthcare System? Patterns of Satisfaction and Preference for State Involvement in the Field of Healthcare","volume":"26","author":"Wendt","year":"2010","journal-title":"Eur. Sociol. Rev."},{"key":"ref_3","unstructured":"Taylor-Gooby, P. (1985). Public Opinion, Ideology, and State Welfare, Routledge."},{"key":"ref_4","doi-asserted-by":"crossref","unstructured":"Taylor-Gooby, P., Leruth, B., and Chung, H. (2017). After Austerity: Welfare State Transformation in Europe after the Great Recession, Oxford University Press.","DOI":"10.1093\/oso\/9780198790266.001.0001"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"431","DOI":"10.1080\/713767005","article-title":"Public Attitudes to Social Protection and Political Economy Traditions in Western Europe","volume":"2","author":"Bonoli","year":"2000","journal-title":"Eur. Soc."},{"key":"ref_6","unstructured":"Ellen, M.I., Anderson, K.M., Devitt, C., and Popic, T. (2021). Portugal. Health Politics in Europe: A Handbook, Oxford University Press."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"741","DOI":"10.1017\/S0047279418000818","article-title":"Public Opinion on Healthcare in the Context of Economic Crisis: Evidence from Portugal","volume":"48","author":"Popic","year":"2018","journal-title":"J. Soc. Policy"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"68","DOI":"10.1111\/ajps.12251","article-title":"The deservingness heuristic and the politics of health care","volume":"61","author":"Jensen","year":"2017","journal-title":"Am. J. Political Sci."},{"key":"ref_9","doi-asserted-by":"crossref","unstructured":"Svallfors, S. (2012). Does Popular Support for Welfare States Depend on their Outcomes?. Contested Welfare States: Welfare Attitudes in Europe and Beyond, Stanford University Press.","DOI":"10.11126\/stanford\/9780804782524.001.0001"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"660","DOI":"10.1111\/1475-6765.12190","article-title":"\u2018Going beyond the Troika\u2019: Power and discourse in Portuguese austerity politics","volume":"56","author":"Moury","year":"2017","journal-title":"Eur. J. Political Res."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"89","DOI":"10.1023\/A:1020520321533","article-title":"Changing Principles in European Social Security","volume":"4","year":"2002","journal-title":"Eur. J. Soc. Secur."},{"key":"ref_12","doi-asserted-by":"crossref","unstructured":"Gelissen, J. (2002). Worlds of Welfare, Worlds of Consent? Public Opinion on the Welfare State, Leiden.","DOI":"10.1163\/9789047401339"},{"key":"ref_13","doi-asserted-by":"crossref","unstructured":"Rothstein, B., and Steinmo, S. (2002). Restructuring the Welfare State: Political Institutions and Policy Change, Palgrave.","DOI":"10.1007\/978-0-230-10924-7"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"321","DOI":"10.1177\/0001699306067718","article-title":"What Makes People Support Public Responsibility for Welfare Provision: Self-interest or Political Ideology?","volume":"49","author":"Jaeger","year":"2006","journal-title":"Acta Sociol."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"393","DOI":"10.1093\/esr\/jcm012","article-title":"Economic conditions and public attitudes to welfare policies","volume":"23","author":"Blekesaune","year":"2007","journal-title":"Eur. Sociol. Rev."},{"key":"ref_16","first-page":"15","article-title":"Why pay for welfare: A sociological analysis of reasons for welfare solidarity, Netherlands","volume":"36","year":"2000","journal-title":"J. Soc. Sci."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"415","DOI":"10.1093\/esr\/19.5.415","article-title":"Public Attitudes toward Welfare State Policies","volume":"19","author":"Blekesaune","year":"2003","journal-title":"Eur. Sociol. Rev."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"109","DOI":"10.1002\/(SICI)1099-1050(199703)6:2<109::AID-HEC251>3.0.CO;2-L","article-title":"Citizens\u2019 Views on Health Care Systems in the 15 Member States of the European Union","volume":"6","author":"Mossialos","year":"1997","journal-title":"Health Econ."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"231","DOI":"10.1177\/0958928713480065","article-title":"The popular legitimacy of European healthcare systems: A multilevel analysis of 24 countries","volume":"23","author":"Missinne","year":"2013","journal-title":"J. Eur. Soc. Policy"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"363","DOI":"10.1017\/S175577391200015X","article-title":"Government Quality, Egalitarianism, and Attitudes to Taxes and Social Spending: A European Comparison","volume":"5","author":"Svallfors","year":"2013","journal-title":"Eur. Political Sci. Rev."},{"key":"ref_21","first-page":"233","article-title":"Worlds of Welfare and Attitudes to Redistribution: A Comparison of Eight Western Nations","volume":"1","author":"Svallfors","year":"1997","journal-title":"Eur. Sociol. Rev."},{"key":"ref_22","doi-asserted-by":"crossref","unstructured":"Rose, R., and Peters, B. (1978). Can Government Go Bankrupt?, Basic Books.","DOI":"10.1007\/978-1-349-81418-3"},{"key":"ref_23","unstructured":"Wilensky, H. (1975). The Welfare State and Equality: Structural and Ideological Roots of Public Expenditure, University of California Press."},{"key":"ref_24","unstructured":"Galbraith, J. (1992). The Culture of Contentment, Penguin."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"276","DOI":"10.1111\/ijsw.12067","article-title":"Increasing conflict in times of retrenchment? Attitudes towards healthcare provision in Europe between 1996 and 2002","volume":"23","author":"Naumann","year":"2014","journal-title":"Int. J. Soc. Welf."},{"key":"ref_26","doi-asserted-by":"crossref","unstructured":"Hechter, M. (1987). Principles of Group Solidarity, University of California Press.","DOI":"10.1080\/01419870.1987.9993580"},{"key":"ref_27","doi-asserted-by":"crossref","unstructured":"Inglehart, R. (1990). Culture Shift in Advanced Society, Princeton University Press.","DOI":"10.1515\/9780691186740"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"97","DOI":"10.1017\/S0047279499005450","article-title":"Markets and Motives: Trust and Egoism in Welfare Markets","volume":"28","year":"1999","journal-title":"J. Soc. Policy"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"341","DOI":"10.1111\/1475-6765.00452","article-title":"Trust in government and welfare regimes: Attitudes to redistribution and financial cheating in the USA and Norway","volume":"35","author":"Edlund","year":"1999","journal-title":"Eur. J. Political Res."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"211","DOI":"10.1093\/ijpor\/10.3.211","article-title":"A Comparison of Attitudes Towards the Welfare States in Different Institutional Regimes, 1985\u20131990","volume":"10","author":"Bean","year":"1998","journal-title":"Int. J. Public Opin. Res."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"1027","DOI":"10.2307\/2579713","article-title":"The Determinants of Public Attitudes Toward the Welfare State","volume":"67","author":"Hasenfeld","year":"1989","journal-title":"Soc. Forces"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"301","DOI":"10.1111\/1468-2397.00141","article-title":"Public Health Care in the Balance: Exploring Popular Support for Health Care Systems in the European Union","volume":"9","author":"Gevers","year":"2000","journal-title":"Int. J. Soc. Welf."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"360","DOI":"10.2307\/3090184","article-title":"Social distance and patients\u2019 rating of healthcare providers","volume":"42","author":"Malat","year":"2001","journal-title":"J. Health Soc. Behav."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"62","DOI":"10.1016\/j.healthpol.2013.03.004","article-title":"Public satisfaction as a measure of health system performance: A study of nine countries in the former Soviet Union","volume":"112","author":"Footman","year":"2013","journal-title":"Health Policy"},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"829","DOI":"10.1016\/S0277-9536(97)00128-7","article-title":"Patient Satisfaction: A Review of Issues and Concepts","volume":"45","author":"Sitzia","year":"1997","journal-title":"Soc. Sci. Med."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"131","DOI":"10.1002\/hpm.917","article-title":"Determinants of public satisfaction with the National Health Insurance in South Korea","volume":"24","author":"Lee","year":"2009","journal-title":"Int. J. Health Plan. Manag."},{"key":"ref_37","doi-asserted-by":"crossref","unstructured":"Pavollini, E., and Guill\u00e9n, A. (2013). Health Care Systems in Europe under Austerity: Institutional Reforms and Performance, Springer.","DOI":"10.1057\/9780230369627"},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"145","DOI":"10.1093\/phe\/phz009","article-title":"Being Healthy, Being Sick, Being Responsible: Attitudes towards Responsibility for Health in a Public Healthcare System","volume":"12","author":"Traina","year":"2019","journal-title":"Public Health Ethics"},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"45","DOI":"10.1016\/j.electstud.2007.11.002","article-title":"Identifying Sources of Democratic Legitimacy: A Multi-level Analysis","volume":"27","author":"Huang","year":"2008","journal-title":"Elect. Stud."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"784","DOI":"10.1111\/1467-9248.12080","article-title":"Social Protection and Satisfaction with Democracy: A Multi-Level Analysis","volume":"62","year":"2014","journal-title":"Political Stud."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"351","DOI":"10.1007\/BF02334712","article-title":"Social Position, Ideology, and Distributive Justice","volume":"8","author":"Steijn","year":"1995","journal-title":"Soc. Justice Res."},{"key":"ref_42","unstructured":"Misztal, B. (1996). Trust in Modern Societies: The Search for the Bases of Social Order, Wiley."},{"key":"ref_43","unstructured":"Van Oorschot, W. (1999). The Legitimacy of Welfare: A Sociological Analysis of the Motives for Contributing to Welfare Schemes, Paper 99, WORC\/TISSER."},{"key":"ref_44","unstructured":"Bentes, M., Dias, C.M., Sakellarides, C., and Bankauskaite, V. (2004). Portugal: Health Care Systems in Transition, European Observatory on Healthcare Systems and Policies."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"1003","DOI":"10.1111\/spol.12480","article-title":"Portuguese healthcare reforms in the context of crisis: External pressure or domestic choice?","volume":"53","author":"Asensio","year":"2019","journal-title":"Soc. Policy Adm."},{"key":"ref_46","unstructured":"Barros, P.P., Machado, S., and Sim\u00f5es, J. (2007). Portugal: Health Care System Review, European Observatory on Healthcare Systems and Policies."},{"key":"ref_47","first-page":"1","article-title":"Portugal. Health Systems Review","volume":"19","author":"Augusto","year":"2017","journal-title":"Health Syst. Transit."},{"key":"ref_48","unstructured":"European Commission (2014). Portugal: Memorandum of Understanding on Specific Economic and Policy Conditionality, European Commission."},{"key":"ref_49","unstructured":"INE (2014). Health Satellite Accounts\u2013Base 2011, INE."},{"key":"ref_50","unstructured":"European Commission (2011). Portugal: Memorandum of Understanding on Specific Economic and Policy Conditionality, European Commission."},{"key":"ref_51","unstructured":"Thomson, S., Figueras, J., Evetovits, T., Jowett, M., Mladovsky, P., Maresso, A., Cylus, J., Karanikolos, M., and Kluge, H. (2014). Health, Health Systems and Economic Crisis in Europe Impact and Policy Implications, WHO."},{"key":"ref_52","unstructured":"Avram, S., Figari, F., Leventi, C., Levy, H., Navicke, J., Matsaganis, M., Militaru, E., Paulus, A., Rastringina, O., and Sutherland, H. (2013). The Distributional Effects of Fiscal Consolidation. EUROMOD Work. Pap. n.\u00ba EM 2\/13, Institute of Social and Economic Re-search, Essex University."},{"key":"ref_53","first-page":"e00170116","article-title":"Economic Crisis and Inequalities in Health Systems in the Countries of Southern Europe","volume":"33","author":"Serapioni","year":"2017","journal-title":"Cadernos de Sa\u00fade P\u00fablica"},{"key":"ref_54","unstructured":"OPSS\u2013Observat\u00f3rio Portugu\u00eas dos Sistemas de Sa\u00fade (2015). Acesso aos Cuidados de sa\u00fade. Um Direito em Risco?, Observat\u00f3rio Portugu\u00eas dos Sistemas de Sa\u00fade. Relat\u00f3rio de Primavera."},{"key":"ref_55","doi-asserted-by":"crossref","unstructured":"Glatzer, W., Below, S.V., and Stoffregen, M. (2004). Satisfaction with Health Care Systems: A Comparison of EU Countries\u2019. Challenges for Quality of Life in the Contemporary World, Kluwer Academic Publishers.","DOI":"10.1007\/978-1-4020-2903-5"},{"key":"ref_56","doi-asserted-by":"crossref","first-page":"951","DOI":"10.2307\/1959140","article-title":"Political issues and trust in government: 1964\u20131970","volume":"68","author":"Miller","year":"1974","journal-title":"Am. Political Sci. Rev."}],"container-title":["Healthcare"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2227-9032\/9\/2\/202\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T05:23:55Z","timestamp":1760160235000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2227-9032\/9\/2\/202"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2021,2,13]]},"references-count":56,"journal-issue":{"issue":"2","published-online":{"date-parts":[[2021,2]]}},"alternative-id":["healthcare9020202"],"URL":"https:\/\/doi.org\/10.3390\/healthcare9020202","relation":{},"ISSN":["2227-9032"],"issn-type":[{"type":"electronic","value":"2227-9032"}],"subject":[],"published":{"date-parts":[[2021,2,13]]}}}