State of Health in the EU Portugal PT Country Health Profile 2019 The Country Health Profile series Contents
The State of Health in the EU’s Country Health Profiles 1. HIGHLIGHTS 3 provide a concise and policy-relevant overview of 2. HEALTH IN PORTUGAL 4 health and health systems in the EU/European Economic 3. RISK FACTORS 7 Area. They emphasise the particular characteristics and challenges in each country against a backdrop of cross- 4. THE HEALTH SYSTEM 9 country comparisons. The aim is to support policymakers 5. PERFORMANCE OF THE HEALTH SYSTEM 12 and influencers with a means for mutual learning and 5.1. Effectiveness 12 voluntary exchange. 5.2. Accessibility 15 The profiles are the joint work of the OECD and the 5.3. Resilience 18 European Observatory on Health Systems and Policies, 6. KEY FINDINGS 22 in cooperation with the European Commission. The team is grateful for the valuable comments and suggestions provided by the Health Systems and Policy Monitor network, the OECD Health Committee and the EU Expert Group on Health Information.
Data and information sources The calculated EU averages are weighted averages of the 28 Member States unless otherwise noted. These EU The data and information in the Country Health Profiles averages do not include Iceland and Norway. are based mainly on national official statistics provided to Eurostat and the OECD, which were validated to This profile was completed in August 2019, based on ensure the highest standards of data comparability. data available in July 2019. The sources and methods underlying these data are To download the Excel spreadsheet matching all the available in the Eurostat Database and the OECD health tables and graphs in this profile, just type the following database. Some additional data also come from the URL into your Internet browser: http://www.oecd.org/ Institute for Health Metrics and Evaluation (IHME), the health/Country-Health-Profiles-2019-Portugal.xls European Centre for Disease Prevention and Control (ECDC), the Health Behaviour in School-Aged Children (HBSC) surveys and the World Health Organization (WHO), as well as other national sources.
Demographic and socioeconomic context in Portugal, 2017
Demographic factors Portugal EU Population size (mid-year estimates) 10 300 000 511 876 000 Share of population over age 65 (%) 21.1 19.4 Fertility rate¹ 1.4 1.6 Socioeconomic factors GDP per capita (EUR PPP²) 23 000 30 000 Relative poverty rate³ (%) 18.3 16.9 Unemployment rate (%) 9.0 7.6
1. Number of children born per woman aged 15-49. 2. Purchasing power parity (PPP) is defined as the rate of currency conversion that equalises the purchasing power of different currencies by eliminating the differences in price levels between countries. 3. Percentage of persons living with less than 60 % of median equivalised disposable income. Source: Eurostat Database.
Disclaimer: The opinions expressed and arguments employed herein are solely those of the authors and do not necessarily reflect the official views of the OECD or of its member countries, or of the European Observatory on Health Systems and Policies or any of its Partners. The views expressed herein can in no way be taken to reflect the official opinion of the European Union.
This document, as well as any data and map included herein, are without prejudice to the status of or sovereignty over any territory, to the delimitation of international frontiers and boundaries and to the name of any territory, city or area.
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© OECD and World Health Organization (acting as the host organisation for, and secretariat of, the European Observatory on Health Systems and Policies) 2019
2 State of Health in the EU · Portugal · Country Health Profile 2019 82 000000 75 000000 79 666667 77 333333 EUR 2000 Life expectancy at birth,years EUR 3000 % of adults services. effectiveness of primary care rates indicatethe general Very low avoidable hospitalisation are now below theEUaverages. and treatable causesinPortugal Mortality from both preventable Effectiveness Per capita spending(EURPPP) care andtackling shortages inthehealth workforce. primary care asafirst step towards greater decentralisation. Other reforms have focusedonimproving accessto than halfofthe population isexempt. InJanuary 2019, somemunicipalities tookover new competencies in There iscost-sharing, with out-of-pocket expenditure being higheroverall thantheEUaverage, althoughmore Portugal’s tax-fundedNationalHealthService(NHS) provides universal coverage andabroad range ofbenefits. 1 per 100000population, 2016 Age-standardised mortality rate EUR 1000 Prevent ble Obest Bne drnn Smon 76 8 PT PT PT PT 77 3 mort lt mort lt Tre t ble Highlights 2000 Bne drnn EU EU EU 2005 Smon 17 Obest 21 22 93 89 140 2011 157 PT PT 10 % 15 15 2017 17 EU % 19 20 80 9 81 6 % 2017 % reporting unmet medical needs, 2017 EU PT municipalities a greater role in primary care planning andmanagement. (GPs) intotheNHS, boost patient registrations with GPs, and give care, the government istaking actiontobring more general practitioners 27.5 %oftotalhealthexpenditure. As part ofeffortstostrengthen primary payments have grown tobethesecondlargest source ofrevenue, reaching is aboutonethird lessthanthe EUaverage (EUR2884). Out-of-pocket Portugal spentEUR2029 per capita onhealthcare (9%ofGDP), which Although spending hasrecovered sincetheeconomiccrisis, in2017 Health system overweight orobesein2013–14. among teenagers are growing, with nearly oneinfive 15-year-olds being is around theaverage across theEU, at15.4%in2017. However, rates drinking, which isconsiderably below theEUaverage (20%). Adult obesity aregularadults (17%)isstill smoker. Some10%ofadultsreport binge consumption. Although smoking rates have since2000, fallen oneinsix behavioural factors, mainly poor diet, smoking andexcessive alcohol More thanonethird deathsinPortugal ofall to canbeattributed Risk factors with chronic diseasesanddisabilities. disease are theleading still causesofdeath. People live longer butoften from Alzheimer’s diseaseis growing, althoughstroke andischaemic heart between those with thehighestandlowest levels ofeducation. Mortality prevalent, with around asix-year gap between women andmen However, inequalitiesby gender andby socioeconomicstatusare reaching 81.6in2017, which isslightly higherthantheEUaverage. Life expectancy inPortugal hasincreased continuously since2000, Health status relatively high. out-of-pocket spending remains for medicalcare alsohave fallen, and self-reported unmetneed primary care have decreased, Although barrierstoaccessing Accessibility %01 0% Hh ncome Countr EU Countr EU %01 State of Healthin the EU ·Portugal ·Country Health Profile 2019 EU Countr All 3% Low ncome 6% the NHS. of the financialsustainability that persist andundermine have accumulated large arrears levels. However, public hospitals in thehealthsystem’s activity have increased value formoney of care delivery boost theefficiency Concerted effortsto Resilience 3
PORTUGAL 2 Health in Portugal PORTUGAL Life expectancy has increased women in Portugal is well above the EU average, over the last decade for men it is in line with the average. As in other EU countries, the gender gap in life expectancy is Life expectancy in Portugal increased by nearly five substantial, with women living 6.2 years longer than years between 2000 and 2017 and is now slightly men in 2017, which is more than the EU average higher than in the EU as a whole. However, it still (5.2 years). lies about two years below the best performing EU countries (Figure 1). While the life expectancy of
Figure 1. Life expectancy in Portugal is higher than the EU average, but the gender gap is large
Ye rs 2017 2000 90 –
Gender gap: Portugal: 6.2 years 85 – 834
831 EU: 5.2 years 827 827 826 825 824 822 822 821 818 817 817 816 816 814 813 812 811 811 809
80 – 791 784 78 7 78 773 76 758 753 749 748 75 –
70 –
65 – EU Sp n It l Fr nce M lt CprusIrel nd Greece Pol nd L tv Norw Icel ndSweden Austr F nl ndBel um Czech Eston Cro t Bul r Portu l Sloven Germ nDenm r Slov Hun rL thu n Rom n Luxembour Netherl nds Un ted n dom
Source: Eurostat Database.
Inequalities in life expectancy follow internet and the health-related information available a socioeconomic gradient online, which may be difficult to access for the older population as well as those with a lower educational Inequalities in life expectancy exist not only by level. gender, but also by socioeconomic status. In 2016, the life expectancy of Portuguese men with the lowest Deaths from circulatory diseases are falling, level of education at age 30 was approximately five but diabetes mortality is above the EU average and a half years lower than for those with the highest level of education. For Portuguese women, this Since 2000, increases in life expectancy in Portugal education gap was less than three years (Figure 2). have been driven mainly by reductions in mortality Although these differences are less pronounced than rates for circulatory diseases, notably stroke and the EU averages, the life expectancy gap by education ischaemic heart disease (Figure 3). Nonetheless, these can be explained, at least partly by differences in remain as the leading causes of death in Portugal. income that stem from educational background as Mortality rates for diabetes also continue to be very well as by differences in exposure to various risk high in Portugal – with a death rate of 38.7 per 100 000 factors and lifestyles. Individuals on low incomes population compared to 22.2 in the EU on average in in Portugal face a greater challenge in paying for 2016, although there has been a notable improvement pharmaceuticals and in accessing health services not over the last five years. Lung cancer and colorectal covered by the NHS, such as dental care. Differences cancer are the most frequent causes of cancer death in health literacy may also have an impact, although in Portugal, with mortality rates for both having this is overlaid with issues around access to the increased since 2000.
4 State of Health in the EU · Portugal · Country Health Profile 2019 -100 Source: Eurostat Database. Note: Thesize of thebubbles isproportional to themortality rates in2016. Figure 3. Althoughrates are decreasing, circulatory diseases are still themaincauses of mortality Source: Eurostat Database (data refer to 2016). education (ISCED0-2). education isdefined aspeople whohave not completed theirsecondary people whohave completed atertiary education (ISCED5-8) whereas low Note: Data refer to life expectancy at age30. Higheducation isdefined as education 3 to 6years longer thanthose withalow level of Figure 2.Highlyeducated Portuguese peoplelive 100 educated % c EU21: 4.1 years Portugal: 2.8 years Education gap inlife expectancy at age 30: -50 women 50 Lower ers 54 2 0 hn Prostte cncer e 2000-16(orner Brest cncer Stomch cncer educated women Higher ers 57 Colorectl cncer 20 est
er) Chronc obstructvepulmonr dsese educated EU21: 7.6 years Portugal: 5.6 years Lower ers men 47 7 Lun cncer Dbetes
educated Higher ers men 53 3 State of Healthin the EU ·Portugal ·Country Health Profile 2019 Pneumon 60 and 61.2%, respectively). income quintile, farbelow theEUaverages (80.4% health compared toonly about39%inthelowest considerincome quintile themselves tobein good substantial. About 61%ofPortuguese inthehighest in self-reported healthacross income groups are health (Figure 4). As inothercountries, disparities of the population inPortugal reports being in good be either good or very good. Incontrast, lessthanhalf than two thirds ofadultsintheEUrate theirhealthto cultural factors affectresponses. Nonetheless, more can bedifficulttointerpret becausesocialand Cross-country differences in perceived healthstatus rich and the poorfeelabout their health There aremarked differencesinhow the Isc hemc hertdsese Ae-stndrdsed mortlt rteper100000populton,2016 80 Str oe 100 120 5
PORTUGAL Most additional years of life Figure 4. The Portuguese rate their health lower are spent with disability than most other EU citizens Low ncome Totl populton H h ncome
PORTUGAL Due to the steep increase in life expectancy in Irelnd Portugal over the past few decades, the share of Cprus people aged 65 and over is growing steadily. In 2017, Norw Itl more than one in five people (21 %) were aged 65 Sweden and over, up from one in six (16 %) in 2000 and one Netherlnds Icelnd in nine (11 %) in 1980. In 2017, Portuguese people at Mlt Unted n dom the age of 65 could expect to live another 20 years, Bel um Spn the same as in the EU as a whole (Figure 5). However, Greece about 13 out of these 20 years were likely to be lived Denmr 1 Luxembour with some disability. Although the gender gap in life Romn Austr expectancy at age 65 is almost four years in favour Fnlnd of women, men have a higher number of healthy life EU Frnce years because women tend to live a greater proportion Slov of their lives after 65 with health problems. Bul r Germn Sloven Around half of people aged 65 and over in Portugal Czech Crot (53 %) report having at least one chronic disease, Hun r Polnd with many of them reporting two or more chronic Eston conditions – a situation similar to the EU average. Portu l Ltv Some 17 % of the population over 65 report some Lthun limitations in basic activities of daily living (ADL), 0 20 40 60 80 100 such as dressing and showering, which again is % of dults who report ben n ood helth
similar to EU levels (Figure 5). Note: 1. The shares for the total population and the population on low incomes are roughly the same. Source: Eurostat Database, based on EU-SILC (data refer to 2017).
Figure 5. Just over half of people over 65 report having at least one chronic disease
Lfe expectnc t e 65
Portul EU
7.3 20 4 19 9 10 99 ers ers 13.1
Yers wthout Yers wth dsblt dsblt
% of people ed 65+ reportn chronc dseses % of people ed 65+ reportn lmttons n ctvtes of dl lvn (ADL) Portul EU25 Portul EU25
17% 20% 17% 18%
47% 46%
36% 34% 83% 82%
No chronc One chronc At lest two No lmtton At lest one dsese dsese chronc dseses n ADL lmtton n ADL
Note: 1. Chronic diseases include heart attack, high blood pressure, high blood cholesterol, stroke, diabetes, Parkinson disease, Alzheimer’s disease, rheumatoid arthritis and osteoarthritis. 2. Basic activities of daily living include dressing, walking across a room, bathing or showering, eating, getting in or out of bed and using the toilet. Sources: Eurostat Database for life expectancy and healthy life years (data refer to 2017); SHARE survey for other indicators (data refers to 2017).
1: These are measured in ‘Healthy life years’, which are the number of years that people can expect to live free of disability at different ages.
6 State of Health in the EU · Portugal · Country Health Profile 2019 2015) anddecreased forboys (22%). EU, with therate having for stabilised (18.2%in girls drinking among teenagers isamong thelowest inthe higher inmen(18%)than women (3%). Binge to a20%average inthe EU), with rates being much 3: Basedondatameasuringtheactual weightandheightofpeople, theobesityrate ismuch amongadults higher-29%in2015. 2: Bingedrinkingisdefinedasconsuming sixormorealcoholicdrinksonasingleoccasion foradults, andfiveormorealcoholdrinksfor children. drinking litres. However, thenumber ofadultsreporting binge litres per person ishigherthantheEUaverage of9.9 decreased steadily over thelastdecade, butat10.7 Alcohol consumption among adultsinPortugal has (Figure 7). remains nonethelessanimportant public healthissue share islower thaninmany otherEUcountries, it smoked cigarettes inthe past month: this while 16-year-olds inPortugal reported thatthey had (see Section5.1). In2015, nearly onefifthof15-to smoking cessationmay leadtofurtherdecreases of 19.2%inthat year. Recenteffortstosupport to oneinsix2014(17%), below theEUaverage declined from aboutoneinfive adultsin2000(21%) The proportion ofadults who smoke every day has consumption isover the EUaverage Smoking rates have declined but alcohol Source: IHME(2018), GlobalHealth Data Exchange (estimates refer to 2017). beverage andsaltconsumption. can beattributed to more thanonefactor. Dietary risksinclude14components, suchaslow fruitandvegetable consumption andhighsugar-sweetened Note: Theoverall numberof deaths related to these riskfactors (39 000) islower thanthesumof each taken individually(45 000) because thesamedeath Figure 6. Around onethird of alldeaths inPortugal canbeattributed to behavioural riskfactors Some 14%ofdeathsinPortugal were linked todietary compared toaround 39%across theEU(Figure 6). tobehavioural2017 canbeattributed riskfactors, (see Section5.1), around onethird deathsin ofall Despite recent measures toaddress behavioural risks inPortugalimpact onmortality Behavioural riskfactorshave aconsiderable 3 EU 18% Portul 14% D etr r ss Riskfactors 2 isthefifthlowest intheEU(10%compared EU 17% Portul 12% Tobcco State of Healthin the EU ·Portugal ·Country Health Profile 2019 rate of6%. alcohol consumption, nearly twicetheEUaverage contrast, about11%ofdeaths were associated with deaths 12 %ofall which isbelow theEUaverage. In (both direct andsecond-hand smoking) was linked to high sugarandsaltconsumption tobaccouse while risks, including low fruitand vegetable intake, and among 15-year-old boys (18%). every day in2013–14. The proportion was much higher reported doing atleastmoderate physical activity teenage onlygirls: 5%of15-year-old inPortugalgirls also relatively low. This is particularly thecaseamong of Portuguese teenagers who report exercising daily is other EUcountries(EUaverage is64%). The proportion physical exercise, alower proportion thaninmost adults reported engaging inatleastmoderate weekly low physical activity. In2014, only 57% ofPortuguese One factorcontributing totheselevels ofobesity is of adults were obesein2017 the EUaverage. Basedonself-reported data, 15.4% Obesity rates among Portuguese adultsare around health issueacross age all groups Obesity isanincreasingly pressing public tackling thistrend (Section5.1). measures to promote healthy eating are aimedat proportion thaninmostotherEUcountries. Recent olds were overweight orobesein2013–14, a greater the lasttwo decadesandnearly oneinfive 15-year- among adolescentshave increased inPortugal over average of14.9%. Overweight andobesityrates Portul 3% Low phs clct v t EU 6% Portul 11% Alcohol 3 , compared totheEU EU 3% 7
PORTUGAL Figure 7. Lack of physical activity is worrying given increases in overweight and obesity rates
PORTUGAL Smon (chldren)
6 Ph scl ctvt (dults) Smon (dults)
Ph scl ctvt (chldren) Bn e drnn (chldren)
Obest (dults) Bn e drnn (dults)
Overwe ht nd obest (chldren) Alcohol consumpton (dults)
Note: The closer the dot is to the centre, the better the country performs compared to other EU countries. No country is in the white ‘target area’ as there is room for progress in all countries in all areas. Source: OECD calculations based on ESPAD survey 2015 and HBSC survey 2013–14 for children indicators; and EU-SILC 2017, EHIS 2014 and OECD Health Statistics 2019 for adults’ indicators. Select dots + Effect > Trnsform scle 130%
Obesity, unlike many other risk behaviours, is strongly linked to income
People with lower education or income tend to be more exposed to behavioural risk factors, but only obesity shows really striking inequalities in Portugal. In 2017, almost one fifth (18 %) of people without a secondary education were obese, compared to only 9 % among those with a higher education. In contrast, more than one in six adults (17 %) in the lowest income quintile smoked daily (in 2014), but this only fell to 15 % among those in the highest income quintile, suggesting a cultural acceptance of smoking across all income groups.
8 State of Health in the EU · Portugal · Country Health Profile 2019 4 000 Source: OECD Health Statistics 2019 (data refer to 2017). 3 percentage points (from 69.8%to66.4%). Portugal government spending onhealthdecreased by around a share ofGDPby nearly one percentage point, while Between 2010and2017, healthspending decreased as which ledtoadecrease intotalhealthexpenditure. The EAPrequired fiscalconsolidation measures health spending has turned around After several years, the negative trend in reforms (Box 1). Portuguese healthsystemhasundergone important banking sectorrespectively). Over thelastdecade, the sector (e.g. thescheme forcivil servants andthe professions orsectors, eitherinthe public or private schemes that provide coverage for particular ‘health subsystems’ - special healthinsurance NHS atthelocallevel. The NHSalsocoexists with five healthadministrationsregional manage the most planning andregulation centrally, the while (see Section2). The Ministry ofHealthconcentrates they experiencesomebarrierstoaccessing care health servicessince2001, althoughin practice Irregular migrants have beenentitledtostate socioeconomic, employment orlegalstatus. system covering residents, all regardless oftheir Portugal’s NHSisauniversal tax-financed structure andisfinancedmainly by generaltax The National HealthServicehasaregional 4 Figure 8. Healthspendingperperson isincreasing, butremains below theEU average EUR PPPperc pt 2 000 5 000 3 000 1 000 Government &compulsor nsur nce 0 Norw Thehealthsystem
Germ n
Austr
Sweden Netherl nds
Denm r
LuxembourFr nce
Belum
Irel nd Volunt r schemes &household out-of-pocet p ments
Icel nd Unted ndom Fnl nd State of Healthin the EU ·Portugal ·Country Health Profile 2019
EU
M lt
It l is 30%below theEUaverage ofEUR2884(Figure 8). (adjusted fordifferences in purchasing power), which now spendsEUR2029 per capita onhealthcare Sp n health interventions (Section 5.1). reforms have focused onstrengthening public towards decentralisation. further Otherrecent primary care planningandmanagement asastep municipalities took over new competencies in because of budgetary constraints. InJanuary 2019, Health Units, althoughinpractice few opened in GPpatient lists (Section 5.3) andto create Family included aprimarycare reform to expand enrolment stagnated duringtheeconomic downturn. These The EAPalso gave new impetus to reforms that had health professionals andincreasing co-payments. pharmaceutical spending,cuttingthesalaries of sector reforms. TheEAPmeasures includedreducing to theeconomic recession andprompted health put inplace between 2011 and2014, responded and aEUR 78 billioninternational loan agreement, Portugal’s Economic Adjustment Programme (EAP) over thelast decade Box 1.Portugal haspursued awiderange of reforms
Czech interventions (Section 5.1). have focused onstrengthening publichealth decentralisation.further Otherrecent reforms planning andmanagement asastep towards took over new competencies inprimary care constraints. InJanuary 2019, municipalities practice few openedbecause of budgetary to create Family HealthUnits, althoughin to expand enrolment inGPpatient lists and downturn. These includedaprimarycare reform reforms that had stagnated duringtheeconomic co-payments. TheEAPalso gave new impetus to salaries of healthprofessionals andincreasing reducing pharmaceutical spending,cuttingthe sector reforms. TheEAPmeasures included to theeconomic recession andprompted health put inplace between 2011 and2014, responded and aEUR 78 billioninternational loan agreement, Portugal’s Economic Adjustment Programme (EAP) reforms over thelast decade Box 1.Portugal haspursued awiderange of
Sloven
Portu l
Cprus
Greece
Slov
Lthu n
Eston
Pol nd
Hun r
Bul r
Cro t
L tv Sh re of GDP Rom n % of GDP 00 25 50 5 7 100 125 9
PORTUGAL The largest share of health care spending in Portugal over the last few years to increase health system is on outpatient care, and at EUR 994 per person efficiency and contain costs. Portugal also spends less in 2017 it was well above the EU average (EUR 858) than many other European countries on preventive
PORTUGAL (Figure 9). In contrast, expenditure on inpatient care care with some EUR 36 per person (1.8 % of total (EUR 520) and pharmaceutical care (EUR 382) were health spending compared to 3.2 % in the EU) spent in considerably below the EU averages (EUR 835 and EUR 2017. 522, respectively). This reflects concerted efforts made
Figure 9. Portugal spends almost half of its health budget on outpatient care
EUR PPP per cp t Portu l EU
1 200 49% of totl spend n 1 000 994
800 858 835 26% 600 of totl spend n 19% 520 of totl 522 400 spend n 471 382
200 3% 2% of totl of totl spend n spend n 6 89 0 5454 336 Outpt ent0 cre Inpt ent0 cre Phrmceut cls0 Lon -term0 cre Prevent on0 nd med cl dev ces
Notes: Administration costs are not included. 1. Includes home care; 2. Includes curative-rehabilitative care in hospital and other settings; 3. Includes only the outpatient market; 4. Includes only the health component. Sources: OECD Health Statistics 2019; Eurostat Database (data refer to 2017).
The Portuguese health system has legislation introduced in September 2019 has high out-of-pocket spending abolished user charges for primary care and for all health care prescribed within the NHS (Section 5.2). In 2017, the public share of health expenditure was 66.3 % of total health financing, considerably lower Doctor and nurse numbers have risen and efforts than the EU average of 79.3 %. This partly reflects are focussed on recruiting general practitioners the decrease in public health sector funding during the EAP. OOP spending has grown by just over three The number of doctors and nurses in Portugal has percentage points since 2010 and is the second largest increased steadily since 2000, with the number of source of health system revenue at 27.5 %, well above licensed doctors reaching 5 per 1 000 inhabitants in the EU average of 15.8 %. Private Voluntary Health 2017. This figure appears high compared to the EU Insurance (VHI) in Portugal has a supplementary role average of 3.6, but includes all licensed doctors, even and accounts for just 5.2 % of health financing. It those who no longer practise (Figure 10). The nursing facilitates access to private hospital treatment and workforce (6.7 per 1 000) is below the EU average (8.4), ambulatory consultations. despite numbers rising over the last decade. In 2016, an initiative to increase the number of NHS GPs was Recent legislation has abolished user charges launched, linked to efforts to increase the number of people enrolled on a GP patient list (Section 5.2). At Until recently, most services, including emergency the start of the initiative 1.2 million NHS users (11.6 % care, GP visits and consultations with specialists of the population) were not registered with a GP and required the payment of flat-rate user charges, this has fallen to 600 000 in early 2019 (5.8 %). varying according to the service, in addition to co-payments that are also levied on services. There were always exemptions to these user charges, and in 2016, the criteria were expanded so that 6.1 million NHS users (roughly 60 % of the population were exempted from paying them. Most recently,
10 State of Health in the EU · Portugal · Country Health Profile 2019 Prctcn nurses per1000populton (Section 5.2). interior areas having more limited access toGPs those two cities, with the population inrural and metropolitan areas as well asalong thecoastbetween mostly concentrated intheGreat LisbonandPorto provided by the private sector. Private providers are haemodialysis andrehabilitation are mostcommonly offices. Dentalconsultations, diagnostic services, not-for-profit)and andgroup practices inprivate care units, private sectorclinics (bothfor profit private sectors. Providers include NHS primary Primary care is provided by boththe public and providers deliver primarycare andprivateA mixofpublic Source: Eurostat Database (data refer to 2017 orthenearest year). around 30%inPortugal). InAustria andGreece, thenumberof nurses isunderestimated asitonlyincludes those workinginhospital. Note: InPortugal andGreece, data refer to alldoctors licensed to practice, resulting inalarge overestimation of thenumberof practising doctors (e.g. of Figure 10. Portugal hasarelatively highnumberof doctors butfew nurses Promoting mentalhealth patients’ integration into and thestrengthening ofthelong-term care network. last decade, partly duetoanincrease inday surgery number ofinpatient hospitalbedshasdeclined inthe low (3.4)compared totheEUaverage (5.1). The total The number ofbeds per 1000 population isrelatively over time, particularly formental healthcare The number ofhospital beds has decreased 20 10 18 14 16 12 0 8 4 6 2 2 Nurses Low Doctors Low Nurses H h Doctors Low 25 PL RO LU U SI 3 LV HU IE BE FR FI HR S EE 35 CZ NL EU EU ver e 36 State of Healthin the EU ·Portugal ·Country Health Profile 2019 CY ES IS 4 MT IT D SE (Section 5.2). specialist care concentrated inthemaincities in care provision, with specialistsandambulatory is envisaged. There remain some geographical gaps renovated andtheconstructionoffournew hospitals improved incrementally: primary care unitshave been of psychiatric beds. Older infrastructure isbeing communities has alsohelpedtoreduce thenumber and thenationalnetwork forlong-term care. andcontinuityto acuteillness across primary care responses aimtoensure asafeandadequateresponse have beenencouraged since2017. These integrated and NHShomehospitalisation initiatives which staffed by multi-professional teams(Box 2, Section5.3) Family Health Units(establishedin2007), which are the same geographic area. Otherexamples include i.e., hospitalnetworks comprising institutions within hospital level, with thecreation of ‘Hospital Centres’, as gatekeepers. Furtherintegration canbeseenat are alsoexpectedtosupportintegration andtoact units within asingle provider organisation. GPs integration ofhospitalsand primary healthcare units (UnidadesLocaisdeSaúde), which allow the care hasbeen promoted since1999by localhealth The vertical integration ofdifferent levels ofhealth process to supportintegrated care The Portuguese NHShasinitiated a BG DE 45 LT NO PT 5 Prctcn doctors per1000populton AT 55 EU ver e 85 Doctors H h Doctors H h 6 Nurses H h Nurses Low
EL 65 11
PORTUGAL 5 Performance of the health system PORTUGAL 5.1. Effectiveness
Preventive services have been effective and are now being brought closer to local communities
Portugal reports a lower rate of preventable mortality decentralised some competencies to the municipal than the EU average (Figure 11), with 140 per 100 000 level. Local health councils are expected to have a population in 2016, down from 149 in 2011. This result primary role in defining local health policy, developing reflects government efforts to improve preventive responsive health promotion programmes and services. In January 2019, the government promoting cooperation between all relevant bodies.
Figure 11. Portugal performs better than the EU average on preventable and treatable causes of mortality
Preventble cuses of mortlt Tretble cuses of mortlt
Cprus 100 Icelnd 62 Itl 110 Norw 62 Mlt 115 Frnce 63 Spn 118 Itl 67 Sweden 121 Spn 67 Norw 129 Sweden 68 Frnce 133 Netherlnds 69 Netherlnds 134 Luxembour 71 Irelnd 138 Cprus 71 Icelnd 139 Belum 71 Luxembour 140 Denmr 76 Portul 140 Fnlnd 77 Greece 141 Austr 78 Unted ndom 154 Sloven 80 Belum 155 Irelnd 80 Germn 158 Germn 87 Denmr 161 Mlt 87 Austr 161 Portul 89 EU 161 Unted ndom 90 Fnlnd 166 EU 93 Sloven 184 Greece 95 Czech 195 Czech 128 Polnd 218 Polnd 130 Crot 232 Crot 140 Bulr 232 Eston 143 Slov 244 Slov 168 Eston 262 Hunr 176 Romn 310 Bulr 194 Hunr 325 Ltv 203 Ltv 332 Lthun 206 Lthun 336 Romn 208 0 50 100 150 200 250 300 350 0 50 100 150 200 250 Ae-stndrdsed mortlt rtes per 100 000 populton Ae-stndrdsed mortlt rtes per 100 000 populton
Lun cncer Alcohol-relted dseses Colorectl cncer Brest cncer
Accdents (trnsport nd others) Stroe Ischemc hert dseses Pneumon Ischemc hert dseses Others Stroe Others
Note: Preventable mortality is defined as death that can be mainly avoided through public health and primary prevention interventions. Treatable (or amenable) mortality is defined as death that can be mainly avoided through health care interventions, including screening and treatment. Both indicators refer to premature mortality (under age 75). The data are based on the revised OECD/Eurostat lists. Source: Eurostat Database (data refer to 2016).
12 State of Health in the EU · Portugal · Country Health Profile 2019 under 16. the advertising of unhealthy food products tochildren approved changes tothe Advertising Coderestricting healthy eating. More recently, in2019 parliament as NHS facilities part ofa wider strategy to promote banning sweets in cafeteriasand vending machines in In thesame year, areform was alsointroduced cents per bottleinabid toreduce theirconsumption. sugar orsweeteners, increasing their prices by 15to30 In 2017, the government drinks taxedall with added per year. NHS-subsidised programme isaboutEUR1.3million cessation medication. The estimatedcostofthis for thefirsttime, cover 37%ofthe priceofsmoking announcing inJanuary 2017thattheNHS would, also financially supporting peopletoquitsmoking, holiday camps or playgrounds. The government is used by children, including outdoor venues, such as have beenextendedfurthertosmoking in public places health facilities. From January 2018, these restrictions on public transport, andinschools, universities and back as2007, banning smoking indoorsin workplaces, Tobacco control measures were introduced asfar consumption andobesityare being strengthened measures totackleExisting tobacco and 93%in agedgirls 9to13. vaccine hasachieved immunisation rates between 85% (HPV) isa good example: introduced in2008, the emerge. The vaccine against human papillomavirus combinations of vaccines introduced ashealththreats reviewed andupdatedrapidly with new ornew The NationalImmunisation Programme isregularly McKee, 2018). anti-vaccination messages (Rechel, Richardson & media campaigns that encourage uptake andaddress units. They alsoreflect active annual outreach and vaccinations are readily available inlocal primary care free for people over 65andotheratrisk groups; and are free NHSusers;theinfluenza forall vaccine is access: vaccines included inthenational programme (75 %). These positive results are linked toeaseof average (61%)butremains below the WHO target vaccination for older people isalsoabove theEU even surpassing the WHO target of95%. Influenza reached 99%, substantially above theEUaverage and diphtheria, tetanus and pertussis (DTP)andmeasles mandatory. In2018, child vaccination coverage rates for (Figure 12)despite thefactthat vaccinations are not Immunisation levels are very highinPortugal achieved highimmunisation rates nature of vaccinations, Portugal has Notwithstandingthe voluntary State of Healthin the EU ·Portugal ·Country Health Profile 2019 year). Database for people aged 65 andover (data refer to 2017 orthenearest children (data refer to 2018); OECD Health Statistics 2019 andEurostat Source: WHO/UNICEF GlobalHealth Observatory Data Repository for hepatitis B, andthefirst dose for measles. Note: Data refer to thethird dose for diphtheria, tetanus, pertussis and the EU average Figure 12.Immunisation rates are highcompared to EU (around 30). that for women (75), totheaverage similar gap inthe mortality rate formen(106)being much higherthan there asignificant isstill gender gap, withthetreatable than therespective EUaverages in2016. However, colorectal cancerand pneumonia were slightly higher cancer were comparable totheEUaverage. Stroke, were alsobelow theEUaverage rateswhile forbreast Treatable mortalityrates forischaemic heartdiseases EU average forbothmen and women. 100 000 population in2016(Figure 11), andisbelow the been decreasing steadily over time, reaching 89 per appropriate andtimely healthcare interventions) has (i.e. deathsthatcould have beenavoided through The mortalityrate from treatable causesinPortugal overcontinuesdecrease time to fromMortality treatable causes Amon peopleed65ndover Influenz Amon chldrened2 Hept t s B Amon chldrened2 Mesles Amon chldrened2 D phther , tetnus,pertuss s 98 99 99 61 % % % % Portul EU 44 % 93 % 94 % 94 % 13
PORTUGAL Participation in cancer screening programmes Figure 13. Five-year net survival rates for some is increasing, and there are early signs treatable cancers are higher than EU averages of improved 5-year survival rates
PORTUGAL Lun cncer Screening rates in Portugal are above the EU average Portu l 16 % Prostte cncer EU26 15 % for breast cancer (84 % rather than 61 %) and cervical Portu l 91 % cancer (71 % compared to 66 %), with participation EU26 87 % rates for both programmes having increased Brest cncer substantially since 2004. GPs are in charge of breast Portu l 88 % and cervical cancer screening and facilitate access to Colon cncer EU26 83 % these services in the primary care setting, which may Portu l 61 % explain the high uptake. Colorectal cancer screening EU26 60 % rates are in line with the EU average, with about half Note: Data refer to people diagnosed between 2010 and 2014. of 50- to 74-year-olds in 2014 reporting that they have Source: CONCORD programme, London School of Hygiene and Tropical undergone screening. Medicine.
Portugal has experienced advances in diagnosis and treatment of cancer, including improved surgical Primary care is managing chronic conditions techniques, radiation therapy and combined well as part of wider quality improvements chemotherapy along with increased access. Five-year Portugal reports some of the lowest avoidable hospital survival rates for some treatable cancers improved admission rates due to asthma, chronic obstructive in Portugal between 2000–04 and 2010–14 and are pulmonary disease and congestive heart failure in the generally just above the EU average (Figure 13), EU (Figure 14) indicating that these chronic conditions especially for breast and prostate cancers. The are being effectively managed at the primary and colorectal cancer five-year survival rate in 2010–14 outpatient secondary care levels. Quality of care was 61 %, so in line with the EU average, reflecting has been bolstered at all levels in the NHS by the the introduction of innovations in diagnosis and National Strategy for Quality in Health 2015–20. The treatment, as well as increased screening rates. Strategy defines a large number of priorities, and aims to improve the quality of organisational and clinical practice and increase the adoption of clinical guidelines. It also stresses the importance of local interventions and strengthening patient safety, all of which are supported by the continuous monitoring of quality and safety that the Strategy encourages.
Figure 14. Very low avoidable hospitalisation rates suggest effective primary care
Asthm nd COPD Conestve hert flure Dbetes Ae-stndrdsed rte of vodble dmssons per 100 000 populton ed 15+ 1 000
800
600
400
200
0
Itl Spn EU21 Irelnd Frnce Mlt Polnd Icelnd Eston Sweden Norw Fnlnd Belum Austr Czech Portul Sloven Denmr GermnSlov HunrLthun Netherlnds Unted ndom
Source: OECD Health Statistics 2019 (data refer to 2017 or nearest year).
14 State of Health in the EU · Portugal · Country Health Profile 2019 Source: Eurostat Database based onEU-SILC (data refer to 2017). comparing thedata across countries asthere are somevariations inthesurvey instrument used. Note: Data refer to unmet needs for amedical anddental examination ortreatment dueto costs, distance to travel orwaitingtimes. Caution isrequired in Figure 15. Unmet needsfor dentalcare are higherthanfor medicalcare 2.3 %ofthePortuguese population reported unmet groups, particularly inrural areas (Box 2). In2017, there are someaccessbarriersforcertain population and comprehensive healthcare, althoughin practice The Portuguese NHSisdesignedto provide universal sizable gaps betweenincome groups Barriers to accessaredecreasing but with 5.2. Accessibility Agriculture introduced anaction plan toreduce the prevention andcontrol of AMR andtheMinistryof Ministry ofHealthimplemented a programme onthe as asignificant public healthissue. In2013, the Portugal recognises antimicrobial resistance (AMR) health priority but with limitedsuccess Tackling antimicrobial isapublic resistance Unted n dom Slov Republc Czech Republc Luxembour Netherlnds H h ncome Lthun Germn Denmr Romn Hun r Portu l Sloven Bul r Bel um Norw Sweden Eston Fnlnd Crot Icelnd Austr Polnd Cprus Irelnd Greece Frnce Ltv Mlt Spn Itl EU Unmet needsformedclcre 0 Totl populton 5 % reportn unmet medclneeds 10 Low ncome 15 State of Healthin the EU ·Portugal ·Country Health Profile 2019 20 compared to2.3%). the share was doubletheEUaverage in2017(4.6% the lowest between incomequintile 2014and2017, needs duetofinancialbarriersamong peoplein barriers, and, despiteadecrease intherate ofunmet Most oftheseunmetneeds were driven by financial and high-income groups were sizeable(Figure 15). reported differences inunmetneedsbetween low- but remained above theEUaverage (1.8%). Moreover, waiting times. Unmetneedsdecreased from 2014, needs formedicalcare duetocost, distanceor EU. points from 2016(5.2 %), theseventh highestinthe 2018), anincrease ofmore thanthree percentage to treat bacterial infections), was 8.6%in2017(ECDC, to carbapenems (a potent last-lineclass ofantibiotics infections causedby Klebsiella pneumoniae resistant Despite thesesteps, the percentage ofbloodstream inanimalsconsumedbyuse ofantibiotics humans. Unted n dom Czech Republc Luxembour Netherlnds H h ncome Lthun Germn Denmr Romn Hun r Portu l Sloven Slov Bul r Bel um Norw Sweden Eston Fnlnd Crot Icelnd Austr Polnd Cprus Irelnd Greece Frnce Ltv Mlt Spn Itl EU Unmet needsfordentlcre 0 Totl populton 5 10 % reportn unmet dentlneeds 15 Low ncome 20 25 30 15
PORTUGAL The NHS does not generally cover dental care, which User charges only play a very minor role within OOP is mainly provided privately through direct patient spending. Recent legislation in 2019 abolished user payments or VHI. As a result, reported unmet needs charges for primary care services and other health
PORTUGAL for dental care (due to cost, distance or waiting lists) care prescribed within the NHS (Section 4). Given the are the second highest in the EU and around four small value of user charges and the large exemptions times the EU average (11.6 % compared to 2.9 % in in place, the new legislation is not likely to reduce 2017) (Figure 15). Financial barriers are the dominant Portugal’s high level of out-of-pocket spending. cause for unmet needs for dental care, and 11.5 % of the total population faced unmet needs in dental care An excessive reliance on OOP payments for the health due to financial barriers in 2017, compared to 2.6 % in system’s financing can undermine accessibility and the EU. have an impoverishing effect on households. In Portugal, about 8.1 % of households are estimated Income inequality in unmet needs is much greater to have suffered from catastrophic health spending4 for dental care than for health care in Portugal. in 2016 (Figure 17). Catastrophic spending is much To address this, in 2008 Portugal implemented a higher for households in the poorest income quintile, dental voucher programme as part of the National reaching about 30 % (WHO Regional Office for Europe, Programme for Oral Health Care Promotion, which 2019). has allowed progressive increases in dental care coverage. Currently, Portugal provides free dental Box 2. Some population groups face significant care to pregnant women, school-aged children, older accessBox barriers2. Some inpopulation practice groups face significant people who receive social benefits, people living with access barriers in practice HIV/AIDS (since 2010) and those with oral cancer All immigrants who are in Portugal for more than 90 (since 2014). Plans are also currently underway to All immigrants who are in Portugal for more than days90 havedays haveaccess access to GP to services, GP services, irrespective irrespective of their roll out a pilot project to integrate dentists into 91 legal status. There are no restrictions for pregnant primary care units. women,of their children, legal status. people There with are infectious no restrictions diseases for or pregnantthose needing women, urgent children, care. people While with the infectiousNHS covers The share of out-of-pocket payments is higher than all diseasesresidents or in those Portugal needing there urgent are care.barriers While that, the EU average and mainly driven by co-payments dethe facto, NHS prevent covers allimmigrants residents in from Portugal accessing there NHS services,are barriers including that, delanguage, facto, prevent cultural immigrants differences and OOP payments play a very substantial role in Portugal, administrativefrom accessing hurdles. NHS services, The new including 2019 Basic language, Health representing 27.5 % of total health expenditure Lawcultural enhances differences existing and legislation administrative and grants hurdles. access to the NHS to anyone who needs medical care, (Figure 16), which is substantially higher than the EU The new 2019 Basic Health Law enhances existing including tourists and irregular migrants. average (15.8 %) (Section 4). Some 13 % of total OOP legislation and grants access to the NHS to anyone payments are spent on outpatient care, and 6.4% on who needs medical care, including tourists and pharmaceuticals (compared to EU averages of 3 % irregular migrants. and 5.5 % respectively), mainly due to co-payments.
Figure 16. The Portuguese pay more out of pocket for outpatient care and pharmaceuticals
Overll shre of Dstrbuton of OOP spendn Overll shre of Dstrbuton of OOP spendn helth spendn b tpe of ctvtes helth spendn b tpe of ctvtes
Portu l EU Inp tent 22% Inp tent 14% Outp tent Outp tent medc l c re 31% medc l c re 131% OOP OOP Ph rm ceutc ls 55% 275% 158% Ph rm ceutc ls 64% Dent l c re 25% Lon-term c re 06% Lon-term c re 24% Others 52% Others 09%
Sources: OECD Health Statistics 2019 (data refer to 2017).
4: Catastrophic expenditure is defined as household OOP spending exceeding 40% of total household spending net of subsistence needs (i.e. food, housing and utilities). Others
OOP Lon-term c re Dent l c re 16 State of Health in the EU · Portugal · Country Health Profile 2019 Not OOP OOP ph rm ceutc ls
Outp tent medc l c re
Inp tent patients tochoose treatment with any public or maximum waiting time guarantees with optionsfor hip replacements) were addressed, by combining elective surgery (such ascataract removals and 2010,Until long-standing waiting timesfor aftermaths of the recession but areimproving again Waiting times forelective surgery rose in the (0.5 %), butagain thisisbelow theEUaverage (0.8%). are slightly higherforthelowest income populations EU average (0.2%). Unmet needsdueto waiting lists the population inthe poorest in2017, quintile halfthe care needsrelated todistanceaffectedonly 0.1%of (Figure 18). However, self-reported unmetmedical health care facilities, including primary care units Azores, which are historically underserved by in rural inlandareas as well asMadeira andthe population. These municipalities are concentrated citizens alsohave alower ratio ofdoctors per 1000 that municipalities with ahigher proportion ofelderly orthopaedic specialistsinrural areas. Itisnotable shortages of psychiatric, ophthalmologyand and professionals) (facilities with particular, There ofhealthresources isanunequaldistribution self-reported unmetneedsremainlow Resources areunevenly distributed, but Source: WHORegional Office for Europe 2018; OECD Health Statistics 2019 (data refer to 2017 orthenearest year). Figure 17. Highout-of-pocket payments are associated withhighlevels of catastrophic spending % of households w thc t stroph c spend n 10 14 16 12 0 8 4 6 2 0 5 FR 10 HR SI IE DE 15 CZ U SE S 20 AT State of Healthin the EU ·Portugal ·Country Health Profile 2019 EU18 EE PL 25 www.sns.gov.pt. % of thetotal) by health region inPortugal inMarch 2019, available at Source: Based ondata ontheproportion of primaryhealth care units(in follows thedistribution of thepopulation Figure 18. Thedistribution of primarycare facilities 1 3% Azores 3 6% Mder M rch 2019 he lth c reunts, Proporton ofprm r % of out-of-pocet p ments s sh re of he lthspend n 30 0% -44 9% 15 0% -29 9% 1 0% -14 9% HU PT 30 LT 35 EL Tus Vlle nd the Lsbon 34 0% 40 Alrve Alenteo 6 5% Centre 20 5% 2 0% LV North 32 1% 45 CY 50 17
PORTUGAL private provider. However, the marked successes to Since May 2016, GPs can refer NHS patients to that point have been partly reversed due to decreases hospitals outside their area of residence for in the number of professionals and NHS funding elective procedures or outpatient consultations if
PORTUGAL during the economic crisis, and waiting times have waiting times are shorter. An NHS website provides started to increase again in recent years. Although information on waiting times for outpatient still below their 2006 levels, waiting times for consultations across several specialties. elective surgery such as cataract surgery and knee replacement are now longer than in Spain, the United Kingdom and Netherlands (Figure 19).
Figure 19. There has been a rise in waiting times for elective surgery since 2010
C t r ct surer nee repl cement
Portu l Unted n dom Spn Netherlnds
Men ds Men ds 200 350
300 150 250
200 100 150
100 50 50
0 0 2006 2008 2010 2012 2014 2016 2018 2006 2008 2010 2012 2014 2016 2018
Source: OECD Health Statistics.
Netherlnds
Spn 5.3. Resilience5 which resulted in the emigration of many younger citizens, including health professionals. The resident Unted n dom Health spending is growing at a moderate population has aged (and has greater life expectancy), Portu l rate following economic adjustment while the proportion of economically active people in Portugal has fallen. Public health expenditure is The EAP that Portugal implemented between 2011 and projected to increase from 5.9 % of GDP in 2016 to 2014 (Section 4) saw the health sector apply measures 8.3 % in 2070 (a 2.4 % increase, well above the 0.9 % to contain costs and improve health system efficiency. projected for the EU). Over the same period public Public financing of health decreased by 5.7 % in real expenditure on long-term care may increase from terms between 2005 and 2012. Since then, current 0.5 % of GDP to 1.4 %; this 0.9 % percentage point health expenditure started to increase in line with increase is below the forecast rate (1.1 %) in the EU GDP growth and in 2015 slightly outstripped GDP (European Commission–EPC, 2018). growth (Figure 20) posing questions about the long-term sustainability of the NHS. In March 2018, Despite substantial capital injections, NHS the government created a Mission Structure for the hospitals have accumulated substantial arrears Sustainability of the Health Budgetary Programme There are also pressing short-term risks to the health specifically to monitor the financial performance of system’s financial sustainability, particularly the debt the NHS and propose measures to enhance resilience accumulated by NHS hospitals. By the end of 2017, and sustainability. the government injected EUR 400 million from general The majority of health system costs are related to revenues into the public hospital sector to clear caring for people with chronic conditions. This reflects part of the accumulated arrears. However, hospital an ageing population, but also the economic crisis, arrears started increasing again in 2018, reaching
5: Resilience refers to health systems’ capacity to adapt effectively to changing environments, sudden shocks or crises.
18 State of Health in the EU · Portugal · Country Health Profile 2019 -10% -8% -4% -6% to increased working hoursandcontracting with reductions inspending) andmore productive (due EU countries:thesystembecame cheaper (dueto Portugal performs relatively well compared toother following the economiccrisis Health systemefficiencyhasincreased GPs, with training places increasing every year. been changes to postgraduate specialisttraining for (and take thestrain offhospitals). There have also train andappoint more GPstoscale-up primary care human resources. Effortsare focusing oninitiatives to Portugal is working tocorrect someimbalancesin needs. as aresult ofinitiatives addressing primary care however, hasincreased over thesame period, in part since 2010. The number of medical graduates, number ofnursing graduates consistently hasfallen be underserved (Section5.2). Most worryingly, the outside great metropolitan areas, which tend to EU. Staffshortages have beenidentified particularly better paid jobsinothersectors orelsewhere inthe doctors, andespecially nurses, toleave theNHSfor low health professional salarieslinked tothecrisisled nurses (Figure 10, Section4). The economiccrisisand relatively highnumbers ofdoctorsandrelatively few When viewed against EUaverages, Portugal has graduates make the healthsystem vulnerable Migration andfalling numbers ofnursing Source: OECD Health Statistics 2019; Eurostat Database. Figure 20. Healthexpenditure growth hasmainlyevolved inparallel withGDPgrowth since 2010 2019). However, persistent challenges inestablishing inDecember2018(Europeanmillion Commission, of 2018helpedtoreduce hospitalarrears toEUR484 capital inthesecondhalf injection ofEUR500million November 2017figure ofEUR1103million). Afurther inNovemberEUR 903million 2018(slightly below the Annul chne nrel terms -2% 8% 0% 4% 6% 2% 2006 2007 2008 2009 2010 State of Healthin the EU ·Portugal ·Country Health Profile 2019 2011 have delivered theefficiency gainsanticipated(Box 3). initiativesalthough notall todevelop primary care specialist hospital-based provision to primary care, health systemhasshiftedthefocusaway from the NHS. To furtherimprove efficiency, the Portuguese raises of concernsaboutthefinancialsustainability mostlikelywill anincrease entail inspending, which limitations, andinthenearfuture productivity gains institutions). This typeofevolution hasnatural Portugal, 2019). causes ofthehospitalarrears (Government of Mission Structure aims toaddress theunderlying hinder progress. A new programme underthe2019 mechanisms in state-owned hospitalscontinue to more effective budgetary planning andcontrol be shared more appropriately. professionals andwere intended to allow duties to GPs, nurses, administrators andother health They consist of multi-professional teams, including care for thelocalpopulation andimprove efficiency. primary care inorder to provide integrated primary restructuring theorganisation of Portuguese Family HealthUnitswere introduced in2007, delivered onefficiency Box 3. Primary care innovations have not always (Wismar, Glinos andSagan, inpress). expand therange of nurses’ tasks withintheunits been resistance to revising thescope of practice to encourage qualityteamwork. However, there has individual andcollective performance and Incentive schemes were designed to reward reflects thesize of the list of patients registered. Each unitwas formed on avoluntary basis and allow duties to beshared more appropriately. other healthprofessionals andwere intended to teams, includingGPs, nurses, administrators and efficiency. They consist of multi-professional primary care for thelocalpopulation andimprove primary care inorder to provide integrated restructuring theorganisation of Portuguese Family HealthUnitswere introduced in2007, always delivered onefficiency Box 3. Primary care innovations have not 2012 2013 2014 GDP 2015 Publc spendn onhelth 2016 2017 19
PORTUGAL Portugal has also continued to develop its capacity New governance arrangements seek to in health technology assessment (HTA). In 2015, the further improve hospital efficiency Ministry of Health launched the SiNATS (the National
PORTUGAL System for Health Technology) initiative. Covering The overall number of hospital beds per 1 000 all public and private institutions that produce or population in Portugal changed little between 2007 use health technologies, SiNATS aims to ensure that and 2016 and is still well below the EU average health investments and technologies employed in the (Figure 21). The number of acute care beds, however, Portuguese health system represent value for money has declined, with a corresponding increase in more rate. SiNATS carries out an economic evaluation cost-effective beds, for example on rehabilitation of all health technologies before new products and long-term care. There was an increase in average are introduced into ambulatory care and hospital length of stay (ALOS) between 2008 and 2012 to nine settings. The capacity of the HTA system is already days, which is one day more than the EU average. well developed with international links through the EUnetHTA Network.
Figure 21. Portugal has a low number of hospital beds, but a relatively high average length of stay
Portul Beds ALOS EU Beds ALOS Beds per 1 000 populton ALOS (ds) 7 12
6 10
5 8 4 6 3 4 2
1 2
0 0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
Source: Eurostat Database.
Day surgery rates for cataract, hernia and and specific training in health care management. tonsillectomy have increased considerably across the By promoting autonomy and the involvement of country over the last decade (Figure 22). This steep NHS professionals in managing resources, integrated increase was prompted by government efforts, which accountability centres are expected to increase in 2008 published clear criteria for the organisation of productivity, efficient management and quality of day surgery to promote efficiency (Lemos, 2011), and care (Portuguese Government, 2019). introduced financial incentives for institutions and patients.
A new hospital management regime has been put into place (approved February 2017), specifically to build on improvements in hospital performance. The law establishes that all hospitals with enterprise management status should be organised as ‘integrated accountability centres’ (centros de responsabilidade integrada), which aim to: improve the quality of services; increase productivity; and enhance patient access and accountability. There are also new rules designed to strengthen the capacity of hospital management boards as well as intermediate management structures, and board members are expected to have relevant professional experience
20 State of Health in the EU · Portugal · Country Health Profile 2019 in the policymakingin processand promotehealth alsoaimstoensureCouncil NHSusers’ participation scrutinises policies andmakes recommendations. The consultative body fortheMinistryofHealth, which is theNationalHealthCouncil, anindependent the toolscurrently being usedforitsimplementation and guides planning forthe period 2012-2020. Oneof Portugal’s National HealthPlansetshealth priorities and scrutiny to help strengthen resilience The National HealthPlanisusing transparency Source: OECD Health Statistics 2019. Note: Data refer to theshare of genericsinvolume. Figure 23. Incentives andprofessional contributed support to therapid uptake of generics between 2005and2012, butthetrend haslevelled the EU. The uptake of generics increased atafast pace pharmaceutical expenditure compared to22.9%for as a whole (Figure 23). This represents 19.8%oftotal is inline with Spainandonly slightly below theEU retailof all pharmaceutical sales(by volume), which Between 2016and2017, generics made upnearly half rapidly to reach just below the EUaverage The useof generic medicineshasincreased Source: OECD Health Statistics 2018; Eurostat Database (data refer to 2006 and2016, ornearest year). Figure 22. Day surgery hasgrown rapidly for selected procedures % of d sur eres 100 60% 40% 20% 50% 30% 10% 80 60 90 40 20 50 30 70 10 0% 0 2005 Portul Portu l 2006 Ctrct 2007 Sp n EU 2008 2009 Itl State of Healthin the EU ·Portugal ·Country Health Profile 2019 Portu l 2010 In unl hern EU17 2011 for itemslike medicinesandconsultations. patients, as well asinformationon public expenditure and real-time outpatientconsultationsforNHS publishes waiting times foremergency departments with thelaunch oftheonlineNHSPortal. The portal government hasfurtherincreased transparency system transparency andaccountability. The sales. of generics sold, alsohas played arole inincreasing of aEUR0.35incentive to pharmacies foreach pack below EUR10). Recentmeasures, such asthe payment the reference product (or25%, iftheretail price is price of generics setatleast50%lower thanthatof well asnew prices for generics, with thehighestsale retailers and pharmacies were created in2011, as off over thelastfew years. New trade margins for 2012 EU 2013 2014 Portu l Tonsllectom 2015 2016 2006 EU 2017 2016 21
PORTUGAL 6 Key findings PORTUGAL • Life expectancy in Portugal has increased • Portugal has a strong primary care system, substantially in the last decade (driven by which manages to keep patients out of falling mortality from stroke and ischaemic hospital when appropriate. Since 2016, it heart disease), but the gender gap is above has successfully increased the number the EU average and there are inequalities of general practitioners, creating new by level of education. Notably, lung cancer positions across the country, and increasing has increased, reflecting the legacy of postgraduate training. Nonetheless, some 0.6 past smoking rates. Still, only half of the million NHS users were not registered with population reports being in good health in a general practitioner in early 2019. Current contrast to most of the EU where two thirds of programmes and incentive schemes are also adults rate their health positively. in place to tackle the uneven distribution of health care resources. Notably, new hospitals have been established, and incentive schemes • Levels of physical activity are low compared are in place for health personnel to move to to the EU average. There are concerns about underserved areas. adult alcohol consumption and the rise in overweight and obesity levels, particularly among children. There are multiple efforts • There are two significant challenges to to address these concerns, including taxing the health system’s financial and fiscal all drinks with added sugar or sweeteners. sustainability. The first is the need to care for Around one in six adults are daily smokers, an ageing population with rising health needs although the rate has decreased since 2000. and chronic conditions. The cost-cutting The indoor smoking ban, first introduced in and efficiency measures that followed the 2007, was recently extended to ban smoking economic crisis contributed to the health to protect children outdoors, such as in system delivering better value for money, playgrounds and holiday camps. spending less than the EU average. This has been achieved alongside relatively low levels of mortality from preventable and treatable • The National Health Service provides causes, and a continued focus on further universal coverage to the entire population. opportunities to increase the efficiency of the Until recently, user charges were levied on health system is as relevant as ever. Secondly, almost all services within the National Health the high and steadily growing arrears of NHS Service (NHS), such as general practitioner hospitals are a long-standing and serious or emergency visits, but a large share of problem. A new programme introduced in the population (60 %) was exempted. New 2019 aims to address the underlying causes of legislation in 2019 abolished user charges the hospital arrears and find a more durable for primary care services and other health solution. care prescribed within the NHS. However, given the small value of user charges and the large exemptions in place, this reform is • The Portuguese health system is formally not expected to reduce Portugal’s high level committed to public participation and patient of out-of-pocket spending, which currently empowerment. It has progressively increased makes up 27.5 % of total health expenditure, transparency, mainly through its NHS Portal, significantly higher than the EU average which shares information on spending and (15.9 %). waiting times, and the National Health Council, which strives to engage NHS users in the policymaking process.
22 State of Health in the EU · Portugal · Country Health Profile 2019 Key Sources
Simões J et al. (2017). Portugal: Health System Review. OECD/EU (2018), Health at a Glance: Europe 2018 – Health Systems in Transition, 19(2): 1–184. State of Health in the EU Cycle, OECD Publishing, Paris, https://www.oecd.org/health/health-at-a-glance- europe-23056088.htm
References
ECDC (2018), Surveillance Atlas of Infectious Diseases, Ministry of Health (2013), Programme on Prevention https://atlas.ecdc.europa.eu/public/index.aspx and Control of Infection and Antimicrobial Resistance. Directorate-General of Health, Lisbon. European Commission (2019), Country Report Portugal 2019. 2019 European Semester. Brussels, https:// Rechel B, Richardson E, McKee M, eds. (2018), The ec.europa.eu/info/sites/info/files/file_import/2019- organization and delivery of vaccination services in the european-semester-country-report-portugal_en_0.pdf European Union. European Observatory on Health Systems and Policies and European Commission, European Commission (DG ECFIN)-EPC (AWG) (2018), Brussels, http://www.euro.who.int/__data/assets/pdf_ The 2018 Ageing Report – Economic and budgetary file/0008/386684/vaccination-report-eng.pdf?ua=1 projections for the EU Member States (2016–2070), Institutional Paper 079. May 2018. Brussels. WHO Regional Office for Europe (2019), Can people afford to pay for health care? New evidence on Government of Portugal (2019), Order. Despacho. financial protection in Europe. WHO Regional Office Finanças e Saúde [Financing and Health], Lisbon. for Europe, Copenhagen, https://apps.who.int/iris/ Lemos P (2011), A Huge Increase in Ambulatory Surgery bitstream/handle/10665/311654/9789289054058-eng. Practice in Portugal, Ambulatory Surgery, 17(1), March. pdf?sequence=1&isAllowed=y
Ministry of Agriculture and Sea (2013), National Action Wismar M, Glinos I, Sagan A (in press), Skill mix Plan for the Reduction of Antibiotic Use in Animals. innovations in primary and chronic care. European Food and Veterinary Directorate-General, Porto. Observatory on Health Systems and Policies, Brussels.
Country abbreviations
Austria AT Denmark DK Hungary HU Luxembourg LU Romania RO Belgium BE Estonia EE Iceland IS Malta MT Slovakia SK Bulgaria BG Finland FI Ireland IE Netherlands NL Slovenia SI Croatia HR France FR Italy IT Norway NO Spain ES Cyprus CY Germany DE Latvia LV Poland PL Sweden SE Czechia CZ Greece EL Lithuania LT Portugal PT United Kingdom UK
State of Health in the EU · Portugal · Country Health Profile 2019 23 State of Health in the EU Country Health Profile 2019
The Country Health Profiles are an important step in Each country profile provides a short synthesis of: the European Commission’s ongoing State of Health in the EU cycle of knowledge brokering, produced with the ·· health status in the country financial assistance of the European Union. The profiles ·· the determinants of health, focussing on behavioural are the result of joint work between the Organisation risk factors for Economic Co-operation and Development (OECD) and the European Observatory on Health Systems and ·· the organisation of the health system Policies, in cooperation with the European Commission. ·· the effectiveness, accessibility and resilience of the The concise, policy-relevant profiles are based on health system a transparent, consistent methodology, using both quantitative and qualitative data, yet flexibly adapted The Commission is complementing the key findings of to the context of each EU/EEA country. The aim is these country profiles with a Companion Report. to create a means for mutual learning and voluntary For more information see: ec.europa.eu/health/state exchange that can be used by policymakers and policy influencers alike.
Please cite this publication as: OECD/European Observatory on Health Systems and Policies (2019), Portugal: Country Health Profile 2019, State of Health in the EU, OECD Publishing, Paris/European Observatory on Health Systems and Policies, Brussels.
ISBN 9789264397644 (PDF) Series: State of Health in the EU SSN 25227041 (online)