A decentralized healthcare system in the Azores—built around three hospitals spread across the archipelago—has proven more effective than a centralized model, helping reduce surgical backlogs and lowering mortality rates compared to Madeira during the COVID-19 pandemic.

That was the central message delivered by physician Mário Freitas during the conference “Health in the Azores – Indicators, Challenges and Regional Strategies,” part of the Reflecting on Autonomy lecture series organized by CDS-PP in Angra do Heroísmo. Freitas argued that consolidating services into a single central hospital on São Miguel Island could come at a steep cost: avoidable pre-hospital mortality in the more remote islands could rise between 15% and 25%, largely due to delays in transporting patients suffering from time-sensitive conditions such as strokes or cardiac events.

Long-term data appears to support the case for decentralization. Between 1970 and 2025, regional health indicators in the Azores have steadily improved, with infant mortality dropping to 3.5 per thousand births. The Hospital do Divino Espírito Santo (HDES), the region’s largest medical facility, stood out during the pandemic. In 2021, it posted positive financial results—certified by Portugal’s Court of Auditors—and cut its surgical waiting list by nearly 20% through the CIRURGE program.

Freitas pushed back against criticism leveled at the system during the pandemic, pointing instead to measurable outcomes. The Azores recorded 232 COVID-19 deaths, significantly fewer than Madeira’s 304, despite facing similar geographic challenges. He emphasized that the current network meets both World Health Organization and European Union standards, ensuring equitable access to care while maintaining resilience across a geographically dispersed region—conditions that also complicate the establishment of a full-fledged medical school.

“Not a Good Idea”

Rui Cernadas, a physician with extensive experience managing healthcare systems—particularly in northern Portugal—echoed the skepticism toward centralization during his presentation, “Rethinking Health and Citizenship: To Centralize or Decentralize.”

“Centralization is not a good idea—neither in Lisbon nor in Ponta Delgada,” Cernadas said, warning of the high costs associated with building and maintaining a university hospital. Such institutions, he noted, inherently require more diagnostic testing for training purposes and must sustain costly research programs. The teaching hospital model, he added, can often disrupt the efficiency of routine medical care.

Cernadas also challenged the notion of a fully state-run system. “The state doesn’t have to own everything,” he said, arguing that public systems are often inefficient managers. Instead, he advocated for a regional healthcare model in the Azores that integrates both public and private providers—while maintaining strong government oversight in regulation and evaluation.

Looking beyond healthcare delivery, Cernadas suggested that the Azores could leverage its medical infrastructure as part of a broader economic strategy. By investing in health tourism—an approach already embraced by countries like Turkey, Morocco, and Spain—the region could diversify its economy and position itself as a destination for specialized care.

In a region defined by distance and dispersion, both speakers made the same point clear: when it comes to healthcare, proximity isn’t just a matter of convenience—it can be a matter of life and death.

In Diário Insular-José Lourenço-director

Translated into English as a community outreach program by the Portuguese Beyond Borders Institute (PBBI) and the Modern and Classical Languages and Literatures Department (MCLL), in collaboration with Bruma Publication and ADMA (Azores-Diaspora Media Alliance) at California State University, Fresno. PBBI thanks Luso Financial for sponsoring NOVIDADES.