Table 9 Additional verbatim following the structure of the results section

Affordability

▪ “The troika agreement had a huge impact in Portugal at different levels […] clearly one of the biggest impact was on all elderly people. […] I would say it was obviously the population group that most suffered from this economic crisis at different levels […].”

▪ Public Health expert (ID6)

▪ “I have the perception that many people have restricted access to health care or medication for economic difficulties, because there are often elderly whose pension serves to feed children and grandchildren who are unemployed, from the standpoint of care that has some impact.”

▪ [Translated quote] Primary care expert (ID10)

▪ “Access to the National Health Service is easier for people who have very little money. […]These people have social support on health and other. Others, who do not have much more money, around 600 €, no longer get aid. This group, which in my opinion lives more in misery because they seem to have enough, but do not have money ‘cause they have to pay all the expenses themselves.”

▪ [Translated quote] Nurse, Healthcare staff (ID11)

▪ “On the one hand with the poly-medication for elderly, there were benefits for the consumption of generics. On the other hand elderly do not take medication properly or take medication double or the medication has interactions and after the family doctor or the nurse does not have enough time to support the elderly to use the medication properly.“

▪ Primary Care expert (ID10)

▪ […] “people avoid to buy bills, because they don’t have money […] And you know people that are not so well informed well which is not such a good thing, but 10 pills a day, they say ‘Oh I cannot pay 10 pills I buy 5′.But then they decide by themselves …where they cut.[…] by the colours or the size or whatever “[…]

▪ Public health (ID6)

▪ […]“many people don’t have access, to their medicines. They cannot pay. […] chronic disease who have to spend a lot on drugs, and so there is a problem of access “[…]

▪ Health Economy (ID2)

▪ “[…] what we noticed is that during and after the troika people go to emergency departments of the hospitals, normally they are in a worse condition, than they were before. […] people wait more time, before going for the emergency department.”

▪ Public Health expert (ID5)

▪ “More elderly tried to contact the doctors so that they do not need to pay the moderating fee when accessing the hospital, because they are being chronically ill patients and have an inability certificate.“

▪ Primary care expert (ID 10)

Approachability

▪ “In primary care, we were in the course of reform and intended to be a higher quality service, with the creation of family health units, with more supply of nursing, more differentiated and more responsive to people’s needs. During the economic crisis what happened was that there were major blockages in relation to staff hires. For example, in ACES there is a very serious nursing shortage. We have been losing many doctors because the medical population is very old and is retiring and USF created were not enough. Every year we have been losing doctors, as we have fewer nurses than doctors.”

▪ [translated quote] Primary care expert (ID10)

▪ “The hospitals are not designed to provide care of elderly people. They were […] mainly designed to […] to acute services […].The issue is now that most of our patients are elderly and most with chronic conditions. […] So in Portugal we have a low income from the elderly people, […] they are less educated than the rest of the population. […] If the population has low education they are not prepared to use our services […] we have a problem of usage and knowledge about these benefits.”

▪ Hospital manager (ID8)

▪ “We don’t have a real [sic] network, a really working network that provides care and so and when we talk about the integration between hospitals and Primary care, that’s a really important issue in Portugal. And actually there are lots of barriers in terms of communicating between hospital and Primary care.”

▪ Hospital manager (ID8)

Availability

▪ “The problem is that in many Primary care centers, there are not enough family physicians. […] This means that people have to go to the Primary care centers during the emergency hours […] so this is really a problem in terms of access, ok? In terms of waiting times […] they have no possibility to be regularly followed at the Primary care centre at the same person. The have to wait longer, they have to take the emergency hours. And this is a big issue, in Lisbon […]. This is an issue of access-- it’s not only accessing the care but access to high quality of care. Access to follow up of care […] It’s much more expensive for the system, because you are paying highly specialized people at the hospital, while you could treat the people at the Primary care centre. So it’s an incomplete inefficiency of the system. […] Primary care physicians decided to retire and to retire earlier. And they were not substituted […].”

▪ Health Economist (ID2)

▪ “I think it would be important to invest more in home support and respect on health in nursing and continuing care. I think the lack of nurses have much impact on care for the elderly.”

▪ [translated quote] Healthcare staff (ID11)

▪ “It’s important to have the conscience that sometimes we need residential structures to elderly that can solve the problems of isolation, better life quality […]“

▪ [translated quote] Municipality authority (ID2)

▪ “In Lisbon 30% of people would have 55 year olds, would have lots of difficulties walking or going instead. […] if you have accessibility issues [ehm] this is important, really important in Lisbon. Them we have this difficult situation with mostly in the older part of the town, with the small sidewalks.”

▪ Public Health expert (ID4)

▪ “I would say the problem of transportation was a big big issue, really. […]There was a subsidisation for the state, from the state for the transportation of urgent cases, ok? And these remained the same. […] For non-urgent cases it was restricted to the patients for who they was a clear indications of need in clinical terms and below a given amount of income, so it was a strong restriction.”

▪ Health Economist (ID2)

▪ “[…] indirectly has to do with housing conditions then also money […] heating for instance, isolation of the housing, is really bad and we don’t have the central heating […] not having money to use heating […] Humidity and mold and things inside the house […] People with […] this kind of long contract. But that also meant, landlords didn’t do anything about the houses, They did no renovation or whatsoever […]”

▪ Public Health expert (ID4)

Appropriateness

▪ “A part of a deficit in a hospital is the waiting list.[…] However, for an extra production there is some fixed costs that you have to put it. So enlarging waiting lists and time was one of the techniques and that had, because there is no money, you enlarge our waiting times.”

▪ Public health expert (ID1)

▪ “[…] a questionnaire to the nurses, the National Questionnaire […] asking them if the care that they are proving them was friendly to elderly people. And mostly I can share with you the data they say that the services are not designed to them. And actually they are unfriendly to elderly people.”

▪ Hospital manager (ID8)