Chapter 7. Health professions

This chapter analyses the regulation of pharmacists and nutritionists. It focuses mainly on an important issue arising from the Draft-Law 34/XIII text, still pending in parliament, which aims to reserve acts for nutritionists and pharmacists. The provision of healthcare services is heavily regulated throughout the European Union and elsewhere to ensure the health and public safety of consumers overall, considering the positive externalities arising from healthcare services. In 2015, actively practising nutritionists were distributed mainly through clinical nutritionist services (51.97%) and hospitals (19.01%), among others. The majority of practising pharmacists in Portugal work in local community pharmacies (75%), followed by hospital pharmacies (13%). The regulatory barriers analysed here include reserved acts and exclusivity of functions.


7.1. Introduction

The provision of healthcare services is heavily regulated throughout the European Union. The main reason is the need to ensure health and safety for consumers and the community in general, considering the externalities arising from healthcare services.

The European Commission has defined the key challenges of EU health policy: to prevent disease, to promote healthier lifestyles, well-being and access to healthcare, to improve patient safety, to support dynamic health systems and new technologies, among others. Also the Standing Committee of European Doctors, the Pharmaceutical Group of the European Union (PGEU) and the Council of European Dentists have called on the European Commission to take into account the need for professional regulation for patient safety and, in a joint statement published with European dentists and pharmacists, they asked the Commission to exclude the health professions from the future proportionality test for new regulation that is being discussed by the Council and the Commission.1 In fact, the healthcare sector is excluded from the application of the Services Directive 2006/123/EC.

The need to regulate health professions must however not lead to an excess of overly restrictive rules, which lead to an anticompetitive legal environment among operators. Regulations should always remain proportional and adequate to their purpose.

The self-regulated healthcare professions in Portugal are those regulated by a public professional association, in accordance with Law 2/2013, and include the professions of: doctors, veterinarians, pharmacists, nurses, dentists, nutritionists, biologists and psychologists. In October 2017, Parliament also approved the creation of the Professional Association of Physiotherapists. In this report, we focus on two of the health professions: nutritionists and pharmacists.2 The nutritionists in Portugal typically apply and develop principles derived from nutrition science, food, communication and management, to attain and maintain the health status of individuals.

This chapter is divided into three subsections. Section 7.1. discusses the particular case of regulation of pharmacists and nutritionists, provides an economic overview of such services, and describes each of the self-regulated regimes. The specific regulatory barriers to competition in these professions are analysed next (Section 7.2), namely the exclusivity of pharmacists functions and the reserved activities proposed in Draft-Law 34/XIII (Section 7.3).

7.1.1. Economic overview

At the end of 2017, there were 3 748 nutritionists registered within the Portuguese professional association of nutritionists.3

In 2015, more than 50% were working within the area of clinical nutrition (51.97%) and almost 20% within the collective nutrition and hospitality (Figure 7.1).4

Figure 7.1. Number of nutritionists distributed per area of practice in Portugal, 2015

Source: Study by the Centre for Research in Higher Education Policies, published in the Professional Association of Nutritionists website (2015),

The number of nutritionists working as employees is significantly higher (72.1% of effective members and 64.3% of interns) than the number of self-employed professionals, the number of independent workers or the number of employers. Also, 65.1% of the employed members have one paid job and 34.9% have more than one paid job (the average is 2.8 jobs), and 22% of interns have multiple jobs.5

Regarding pharmacists, in October 2016, there were 14 088 pharmacists registered in the respective professional association.6

Pharmacists are distributed by practice as follows: clinical analysis (901), pharmaceutical distribution (700), teaching (263), community pharmacy (9 669), hospital pharmacy (1 400), pharmaceutical industry (809), research (95), not exercising the profession (390), not indicated (1 219) and other areas (1 012) (see Figure 7.2). The total of active professionals resulting from the sum of the indicated numbers is superior to the total of active members registered in the Professional Association of Pharmacists because some members accumulate more than one activity, according to the Professional Association of Pharmacists. When compared with the world’s average, it has also been verified that the majority of actively practising pharmacists work in community pharmacy (75%), followed by hospital pharmacy (13%) and other areas (12%).7

According to the International Pharmaceutical Federation (IPF),8 in 74 countries representing 76% of the world’s population, there are a total of 4 067 718 licensed or registered pharmacists, of whom 2 824 984 are actively practising. The average number of pharmacists per 10 000 inhabitants is 5.09 out of the total of countries analysed by the IPF, the average in Europe being 8.28. In Portugal, the number of pharmacists practising per 10 000 inhabitants is higher (around 15). In Spain, Italy, Ireland, Australia and Japan there are around 12 pharmacists per 10 000 population. In 73 out of 79 countries9 it is mandatory to register in order to practise the profession.10

Figure 7.2. Number of pharmacists distributed per area of practice in Portugal, 2017

Notes: 1. Data include not only pharmacists providing direct services to patients, but also those working in the health sector as researchers, for pharmaceutical companies, etc. 2. Data refer to all pharmacists licensed to practise.

Source: Professional Association of Pharmacists, available at

7.1.2. Methodology for competition assessment

The Project analysed 45 Portuguese laws and regulations11 applicable to the health professions. Among these, the Project identified 37 provisions as potentially harmful to competition and 35 recommendations were made (see Table 7.1)

Table 7.1. Summary of analysed provisions applicable to the health professions





Pieces of legislation analysed




Provisions identified as potentially harmful to competition




Recommendations formulated




The legislation identified by the Project team as harmful to competition in relation to nutritionists and pharmacists stems mostly from the bylaws of the respective professional associations and their internal regulations on access requirements.

In some cases, the regulatory barriers to competition across different professions, including the health professions, are similar in scope. Therefore, those regulations were jointly analysed in Chapter 3.

The following sections analyse the restrictions found in the regulations for the various health professions that were specific only to these professions.

7.1.3. Regulation of nutritionists and pharmacists

The Professional Association of Nutritionists was created by Law 51/2010 with the mission to regulate access to and the exercise of the profession, to elaborate technical and ethical rules, to ensure compliance with the legal and regulatory framework and to exercise disciplinary powers over its members.12

This regime regulates both the professions of nutritionist and dietitian. These were historically two different professions, but the new bylaws, approved by Law 51/2010, amended by Law 126/2015, created a transitional regime for dietitians to converge into the Professional Association of Nutritionists within a three-year period. Currently, both professional titles are integrated and newcomers are registered as nutritionists.

Considering the profession of nutritionist and dietician, in EU-28, 24 Member States regulate the profession, including Portugal. Iceland, Liechtenstein, Norway and Switzerland also regulate the profession. The profession is not regulated in Belgium, Croatia, Estonia or Romania. The regulation may consist of protecting at least one of the professional titles (nutritionist or dietician) and/or reserved activities.13

The profession is also regulated in other countries, which are members of the International Confederation of Dietetic Associations (ICDA), such as Argentina, Brazil, Canada, Japan, South Korea and the United States. In some other cases, the professional title is not protected but the national professional association issues the professional title (in countries such as Singapore, India and Mexico).14

On pharmacists, the corresponding professional association regulates access to and the exercise of the profession in Portugal. The registration of pharmaceutical professionals operating in the national territory, the issuance of the professional title of pharmacist and the titles of specialists, the recognition of foreign qualifications, the application of disciplinary sanctions, among other regulatory powers are described in Professional Association of Pharmacists Bylaws (Decree-law 288/2001, as amended by Law 131/2015), in accordance with Law 2/2013.

Registration as a member of the Professional Association of Pharmacists is mandatory to exercise the profession.

According to the European Commission database, within the EU-28, nine Member States report that the regulation of the profession includes the protection of the professional title (or titles) and reserved activities; in nine Member States there are reserved activities but the title is not protected; in two Member States the title is protected without reserved activities; in two Member States there are multiple types of regulation and five Member States have not submitted information. Within the EFTA countries, Iceland establishes reserves of activities and protected title; Norway only establishes a protection of title and Liechtenstein and Switzerland did not submit information.15 Hence, the majority of the Single Market countries regulate the profession to some degree. In some of these countries, there is more than one professional title, mostly in cases where there is a disaggregation of titles through specialisation.

In the case of Portugal, according to the information submitted to the European Commission, there are the following titles: pharmacist, pharmacist specialised in hospital pharmacy, pharmacist specialised in clinical analysis, pharmacist specialised in the pharmaceutical industry and pharmacist specialised in regulatory affairs.16

Box 7.1. Reforms of regulation of pharmacies in Portugal

In 2006, the AdC recommended legislative reforms to liberalise access to the market in order to promote greater competition in this sector, such as eliminating restrictions on ownership of pharmacies, price and discounts regulation, advertising and others. In fact, the regulation of pharmacies before 2006 was conditioned by several restrictions on business organisation and licensing. For instance, the ownership of pharmacies was limited to graduates in pharmaceutical sciences and each could only own one licence.

Over the last decade certain reforms regarding the regulation of pharmacies and the distribution of medicines were implemented in Portugal. The government approved the new legal regime of community pharmacies through Decree-Law 307/2007, as well as other related regulations such as Ordinance 1430/2007. Important regulatory changes were adopted to liberalise the sector based on proportional adequacy of the regulation to new methods and business structures, including opening the ownership of community pharmacies to non-pharmacists. Also, advertising is now allowed.

The licensing requirements were also modified, depending on the quality of the owner of the pharmacy and the promotion of fair and equitable sharing of permits, based on the lowest ownership of establishments per competitor, within the limit of four pharmacies per owner.

Certain restrictions related to transmission and relocation of pharmacies were also eliminated, even though the transmission of the licence can only be done five years after the tender and should be opened to the public, except in some specific cases.

Several empirical studies demonstrated that the abolishment of such restrictions has a positive consequence on prices and increases the demand for pharmacists. The liberalisation of the distribution of over-the-counter drugs is likely to have a positive impact on new entrants into the market and to reduce the prices of these medicines for consumers.

However, some restrictions are still in force in the law, such as the one of four pharmacies per owner. The aim of this restriction is to balance free access to property and avoid concentration, through a proportional and adequate limitation to four pharmacies. The establishment of new pharmacies is still done through a public tender. Regulation of licensing is subject to a legal regime, in which the rules of capitation and distance have been adapted to the needs of the users in access to medicines.

Some incompatibilities are also still in force. Healthcare professionals prescribing medicines, associations representing pharmacies, distribution companies and medicinal product or pharmaceutical companies, or their respective workers, wholesale distributors of medicines, companies in the pharmaceutical industry, private health care companies, or subsystems that share in the price of medicines cannot hold or exercise, directly or indirectly, the ownership, operation or management of pharmacies.

Sources: (i) Portuguese Competition Authority (2006), “Medidas de reforma do quadro regulamentar da actividade das farmácias, com vista à promoção da concorrência no sector”, Recommendation 1/2006, (ii) Centro de Estudos de Gestão e Economia Aplicada of Universidade Católica Portuguesa (2005), “A situação Concorrencial no sector das farmácias”; and (iii) Pagliero, M. (2015) “The effects of recent reforms liberalizing regulated professions in Italy”, University of Turin & Carlo Alberto College.

7.2. Exclusivity of functions for pharmacists

7.2.1. Description of the barrier

The pharmacist may only carry out another activity under a regime of accumulation, in cases and situations clearly established by the law.17

The pharmacist is prohibited from collaborating with any natural person or legal entity, public or private, if such collaboration may result in the violation of the laws and regulations governing the exercise and legitimate interests of the pharmaceutical profession.18

7.2.2. Harm to competition

This provision sets a general rule that the activity of pharmacist is incompatible with any other activity. It prevents pharmacists from carrying out other professional activities, which could be financially profitable.

By limiting the accumulation with other functions, this rule may discourage suppliers from entering the market. Potential newcomers may face fewer incentives to join the profession if there is a high level of restrictiveness of conduct or exercise regulation. Fewer suppliers in the market for the same services lead to higher prices and to less innovative solutions from the offer.

Strictly enforced incompatibilities of exercise without a full assessment of whether they are proportional or necessary to protect public interest restrict the exercise of the activity and investment in small and medium-size businesses. The activity of a pharmacist may be incompatible with some related business or activity, but not necessarily with all other economic sectors.

7.2.3. Recommendations

We recommend abolishing this rule.

The legislator must consider the introduction of the principle of compatibility of the profession of pharmacist with other activities. In case of a specific need based on public interest, a reason for the establishment of legal incompatibility must be stated. The law must expressly indicate the activities or functions considered as incompatible with the activity of pharmacist.

7.3. Draft-Law 34/XIII: Reserved activities for healthcare professionals

Draft-Law 34/XIII on the definition and regulation of the acts of the biologist, nurse, pharmacist, doctor, dentist, nutritionist and psychologist is currently pending in the national parliament. This project was submitted to the parliament on 14 October 201619 and a final date for discussion and voting had not been confirmed by the time of writing this report.

This Draft-Law determines the academic qualifications necessary for professionals to become members of their corresponding professional association. Those minimum academic requirements are already established in the bylaws of both professional associations, for nutritionists and pharmacists (see Section 3.2.4).20

Art. 11 of Draft-Law 34/XIII establishes that the exercise of pharmacist’s acts is dependent on registration in the Professional Association of Pharmacists. Similarly, the registration in the Professional Association of Nutritionists is a condition for attribution of the professional title.21 Compulsory registration in the professional association is also established as an access requirement in Art. 24 paragraph 1 of Law 2/2013.

The act of registration is not necessarily harmful as such. The problem is the direct relation between access to the professional title and the possible existence of reserved activities. Protection of the professional title results in being harmful to competition as it is associated with strong access requirements and reserved activities.22

No additional training is needed to become a full member of the professional association, except if applying for the title of specialist pharmacist. In that case an internship and final test are required, unless the professional association exempts the candidate from doing the internship, considering his professional experience.23

The draft-law aims to promote greater synergy between the different professionals providing health services. Arguably, the definition of reserved activities for health professions guarantees the quality of these services, especially considering the risks for public health and safety.

Discussing whether reserved activity on healthcare services should be allowed, and the degree of restrictiveness, is neither recent, nor consensual.

The list of reserved activities of pharmacists is already established in the Professional Association of Pharmacists bylaws (Law 131/2015). In contrast, there are no provisions in force establishing reserved activities for nutritionists.

The analyses hereafter focus on the proposed reserved activities presented by the draft-law.

7.3.1. On nutritionists

Description of the barrier

Draft-Law 34/XIII proposes a definition of the acts of nutritionists and their corresponding reserved activities.24

Art. 7 of the same draft-law introduces a dual definition of the nutritionist’s act.

Harm to competition

The provision of reserved activities bans other qualified professionals from the practice of the acts in question. In fact, neither doctors nor nurses, for instance, seem to be allowed to practice the acts listed as reserved activities for nutritionists (or for pharmacists) in this draft-law. As a consequence, it prevents entry into the market of other well-qualified professionals who do not hold the professional title of nutritionist. This will lead to less innovation and higher prices since there will be fewer professionals providing these activities.

Taking into account that other health professionals, with full knowledge and full capacity to give nutrition advice, have done it so far and have not brought any danger to public health, it is difficult to identify the need to protect public interest in the case for which it is intended ̶ to grant exclusive acts to "nutritionists".

This draft-law creates exclusive (monopoly) rights by reserving activities with no flexibility. For example, it is difficult to understand why health promotion, prevention and treatment of the disease by evaluation, diagnosis, prescription and intervention and nutritional support to individuals are exclusive activities, as these can also be performed by qualified nurses, school nurses and general medical practitioners. Although activities may typically be performed by a category of professionals, they do not necessarily justify the need to attribute exclusive rights, because that would mean the exclusion of other well-qualified professionals from the possibility of exercising those activities. It also means that consumers are not able to choose between nutritionists and other professionals, e.g. physicians, with regard to those acts, or to consult with only one professional (who could provide a plethora of services) instead of having to pay for more than one practitioner.

This goes against the idea of the Centre for Nutrition Advocacy (CAN) that “nutrition affects all systems and functions of the body. Therefore, many professionals appropriately serve their patients and clients by incorporating nutrition advice into their professional practice” (p. 4). Those professionals can include medical doctors and nurses, but also acupuncturists and health coaches. Additionally, there is “scant evidence of harm linked to nutrition care delivered by either those with or without state credentials” (p. 13).

Furthermore, by segmenting healthcare services by profession, this proposal does not allow consumers to benefit from receiving services by the same professional in a set of related activities. This would, in turn, reduce consumers’ costs and time and would create a stronger competitive environment between suppliers to increase innovative ways of providing complementary health services. It may also drive consumers to make more use of less monitored Internet services where, for instance, nutritionist advice is available from other jurisdictions or in other languages, as these will appear more accessible than a very closed and restrictive profession.

Moreover, although nutritionists are allowed to associate themselves with other professionals in corporative structures, this proposal would not allow them to provide other health services themselves, neither would it allow other professionals to provide services listed as reserved work for nutritionists.


For nutritionists, we recommend that the legal provision establishing reserved activities in the draft-law should be changed in such a way that the "act of nutritionist" is not exclusive to nutritionists, given that other health professionals with the academic knowledge and professional skills to provide nutritional advice do it as well. Allowing this restriction would be detrimental to the very substance of providing sound health advice by doctors and nurses.

7.3.2. On pharmacists

Description of the barrier

Draft-Law 34/XIII proposes the definition of the acts of pharmacist and reserved activities.25 Art. 4 also presents a definition of the pharmacist’s act with dual criteria.

Harm to competition

Unlike other self-regulated health professions, the bylaws of the Professional Association of Pharmacists already define the reserved activities attributed to pharmacists. Hence, the proposal for this Art. 4 seems to be an unnecessary duplication of regulation.

On the one hand, according to Art. 4, pharmacists acts consists of the activity of manufacture, registration, quality assurance, acquisition, distribution and dispensing of medicines, validation of the prescription within the scope of dispensing and in the preparation and control of masterly formulas and with respect for the ethical and deontological values of the pharmaceutical profession (paragraph 1 of Art. 4).

On the other hand, the following activities, when practised by pharmacists, must also be considered as pharmacists’ acts: (a) evaluation and pharmaceutical indication in self-limited pathologies, monitoring and surveillance of the use of medicines, information, promotion and implementation of the rational use of medicinal products, medical and other health technologies and the manufacture, registration, quality assurance and management-integrated circuit of medical devices and other health technologies, as well as the preparation, implementation, interpretation and validation of clinical analyses and biological, toxicological, hydrological, bromatological, genetic and environmental factors; and (b) the technical and scientific activities of research, education, training, education, regulation and organisation for health promotion and disease prevention (paragraph 2 of Art. 4).

For pharmacists, the wording of Art. 4 para. 2 is not very clear but it can be interpreted as a creation of a list of reserved activities, which limits competition by determining exclusive rights to a certain category of supplier. The adoption of exclusive rights for the practice of economic activities closes the market to potential operators who do not meet certain criteria or standards, banning other qualified professionals from the practice of the acts in question.

Similarly as explain for nutritionists, the creation of a list of reserved activities restricts competition by determining exclusive rights to a certain category of supplier. The adoption of exclusive rights hampers competition, confining the access to the market to a limited group of professionals.


We recommend revisiting the scope of reserved activities for pharmacists (including the proposed draft-law) with a view to opening them up to other healthcare professionals, except in cases where public health might be at risk. This will allow for more entry into the market.


Centro de Estudos de Gestão e Economia Aplicada of Universidade Católica Portuguesa (2005), “A situação Concorrencial no sector das farmácias”,

Centre for Nutrition Advocacy (2014), “Identifying and overcoming barriers to competition in nutrition services”.

Centre for Research in Higher Education Policies (2015), “Estudo do Percurso Socioprofissional dos Membros da Ordem dos Nutricionistas”,

European Commission (2006), “Professional qualifications: infringement proceedings against Portugal and Spain”.

European Commission (2013), “The European Union explained: Public Health”, Luxembourg: Publications Office of the European Union, 2013,

International Pharmaceutical Federation (2017), “Pharmacy at a glance - 2015-2017”. The Hague, The Netherlands: International Pharmaceutical Federation,

OECD (2017), Health at a Glance 2017: OECD Indicators, OECD Publishing, Paris.

Pagliero, M. (2015), The effects of recent reforms liberalising regulated professions in Italy, University of Turin & Carlo Alberto College.

Portuguese Competition Authority (2006), “Medidas de reforma do quadro regulamentar da actividade das farmácias, com vista à promoção da concorrência no sector”, Recommendation 1/2006,


← 1. See PGEU press release in

← 2. This decision was ratified by the High-Level Committee at its meeting on 16 November 2016.

← 3. Data provided by the Portuguese Professional Association of Nutritionists, 15 September 2017.

← 4. Centre for Research in Higher Education Policies (2015) study, published in the Professional Association of Nutritionists website.

← 5. Centre for Research in Higher Education Policies (2015) study, published in the Professional Association of Nutritionists website.

← 6.

← 7. International Pharmaceutical Federation (2017), “Pharmacy at a glance - 2015-2017”, as an executive summary of the 2017 report “Pharmacy: A Global Overview – Workforce, medicines distribution, practice, regulation and remuneration 2015-2017”, p2. This data was analysed based on the responses of 58 countries and territories (86% of the population covered by the study),

← 8. International Pharmaceutical Federation (2017), “Pharmacy at a glance - 2015-2017”, as an executive summary of the 2017 report “Pharmacy: A Global Overview – Workforce, medicines distribution, practice, regulation and remuneration 2015-2017”,

← 9. Representing 92% of the total countries analysed in the 2017 study from the International Pharmaceutical Federation “Pharmacy: A Global Overview – Workforce, medicines distribution, practice, regulation and remuneration 2015-2017”.

← 10. International Pharmaceutical Federation (2017), “Pharmacy at a glance - 2015-2017”, as an executive summary of the 2017 report “Pharmacy: A Global Overview – Workforce, medicines distribution, practice, regulation and remuneration 2015-2017”,

← 11. Henceforth called “Pieces of Portuguese legislation”.

← 12. Art. 4 of Law 51/2010 as amended by Law 126/2015.

← 13. European Commission website: and information provided by stakeholders.

← 14. Information provided by stakeholders.

← 15. European Commission website on regulated professions database

← 16. According to information published in the European Commission website, on regulated professions database

← 17. Art. 89 of Law 131/2015.

← 18. Art. 89 of Law 131/2015.

← 19. The Portuguese Parliament website, Parliamentary Activity and Legislative Process,

← 20. Art. 14 establishes the qualifications for the professional title of nutritionist. According to this provision, the exercise of the nutritionist’s acts is dependent on minimum academic qualifications and on registration in the corresponding professional association. These same requirements are already established in the professional association bylaws (Law 51/2010, amended by Law 126/2015), and also in Regulation 308/2016.

← 21. Art. 4 (d) and Art. 61 (1), (5) and (6) of Law 51/2010 as amended by Law 126/2015.

← 22. Art. 5 of Law 131/2015.

← 23. Art. 35 of Law 131/2015.

← 24. Art. 1 (1) and Art. 7 (1) and (2) of Draft-Law 34/XIII.

← 25. Art. 1 (1) and Art. 7 (1) and (2) of Draft-Law 34/XIII.

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