Essay Series: Healthcare Systems –

The Portuguese Healthcare System: Successes and Challenges

By Jorge Simões, President of the Portuguese Health Regulation Authority (Entidade Reguladora da Saúde)

The Portuguese healthcare system’s roots general taxation. The health subsys- 10 percent of the Portuguese GDP is go back to 1946, when the first social tems, which provide healthcare coverage devoted to health expenditure, which security law was enacted. However, it to between 20 and 25 percent of the puts Portugal among the countries with was only after the revolution of 1974 population, are funded mainly through the highest level of health spending that the restructuring of health services employee and employer contributions within the European Union (EU) and the began – a process that culminated in (including contributions from the state as Organization for Economic Cooperation the establishment of the National Health the employer of public servants).1 Close and Development (OECD). Since the Service (NHS) in 1979. to 20 percent of the population is covered mid-1990s, the trend in Currently, the Portuguese healthcare by private voluntary .2 expenditure has been of steady and fast system is characterized by three coexist- About 30 percent of total expenditure growth, with private expenditure remain- ing, overlapping systems: the NHS, a on healthcare is private, mainly in the ing constant, relative to GDP.4 universal, tax-financed system; public form of out-of-pocket payments (both and private insurance schemes for cer- copayments and direct payments by the Primary Healthcare tain professions (which are called health patient), and to a lesser extent, in the A mix of public and private health pro- subsystems); and private voluntary form of premiums to private insurance viders delivers primary healthcare in Por- health insurance. Thus, this system has schemes and mutual institutions.3 tugal. These include primary care a mix of public and private funding. Financial resources dedicated to health- integrated in the NHS, which are called The NHS, which provides universal cov- care have reached a high level relative “health centers,” private sector primary erage, is predominantly funded through to the country’s wealth. Approximately care providers (both not-for-profit and

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for-profit), and professionals or groups Overall, the number of physicians per of professionals in a liberal system with 1,000 population is currently above the which the NHS contracts or develops EU average, but there is a relative scarcity cooperation agreements. Despite the of physicians. The relative number of public/private mix, primary care is mainly nurses in Portugal is well below that of delivered in NHS health centers. Data other countries, which implies that the from the 2005–2006 National Health ratio of nurses to physicians is also much Survey show that in 2005, only 17.1 per- lower than in most countries. cent of primary care consultations were delivered by private providers. Administrative Management In 2009, Portugal had 186 Planning and regulation of the health (86 of which are of private nature) with system takes place at the central level by a total capacity of 35,593 beds (26,077 the Ministry of Health and its institutions. in public hospitals). Almost half of the The management of the NHS takes place private hospitals belong to for-profit orga- at the regional level. In each of the five nizations.5 Trends in numbers regions of Portuguese mainland territory, have been similar to those in other Euro- a Regional Health Administration (RHA) pean countries. There has been a signifi- that is accountable to the Ministry of cant decrease in the number of public Health is responsible for strategic man- hospitals over the decades, from 634 in agement of population health, super- 1970 to 186 in 2009, and also a not-so- vision and control of hospitals, manage- pronounced decrease in the number of ment of primary care/NHS primary care available beds.6 centers, and implementation of national Publicly funded long-term care is mainly health policy objectives. They are also delivered by not-for-profit and for-profit responsible for contracting services with private providers, with which the NHS hospitals and private sector providers for contracts. The recently formed national NHS patients. Financial responsibilities of RHA’s are limited to primary care, since hospital budgets are defined and allo- cated centrally. All hospitals belonging to “Health human resources in the NHS are under the jurisdiction of the Ministry of Health. Private sector hospi- Portugal have been characterized tals, both not-for-profit and for-profit, have their own management arrangements. by a high emphasis on specialist The regulation of the healthcare system hospital care.” in Portugal is carried out by several insti- tutions, the most important of these being the Portuguese Health Regulation Jorge Simões, President, Portuguese Health Regulation Authority Authority (Entidade Reguladora da Saúde (Entidade Reguladora da Saúde) – ERS), the independent organization responsible for regulating the activity of healthcare providers; Infarmed, IP (the network of integrated long-term care National Authority of Medicines and combines teams providing long-term care, Health Products), which is responsible social support and palliative care with for the regulation of pharmaceuticals its origins in communitarian services, and medical equipment; and the profes- covering hospitals, primary care centers, sional associations (physicians, nurses, local and district social security services, dentists, psychologists, and pharmacists), and municipalities. which assure professional self-regulation Health human resources in Portugal have relating to issues of negligence and been characterized by a higher emphasis deontology. than most other countries on specialist ERS was established in 2003 and its hospital care. In 2009, there were 166 responsibilities, organization, and func- specialist physicians for 100 non-special- tioning were restructured in 2009. Its ist physicians (general practitioners).7 scope of regulation includes all health-

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Number of Nurses per 10,000 Male Life Expectancy Resident Population (2010): at Birth (2009)(2009):76.5 59

Female Life Expectancy Total Expenditure on Health $$ at Birth (2009): per Capita (2008): US$ 2,508 82.6 Total Expenditure on Health as % of GDP (2008): 10.1

Government Expenditure on Health as % of Total Expenditure on Health (2008): 65.1

Population in Thousands (2011) 10,5621 bbbbb Number of Hospital Beds per 10,000 Resident bbbbbb Population (2009): 33

Number of Physician per 10,000 Population (2010): 39

Source: 1 INE – National Statistics Institute Medical AllSolutions other data: · April 2012 · www.siemens.com/healthcare-magazine 4 OECD Health Statistics database Essay Series: Healthcare Systems – Portugal

The National System of Health Quality Assessment – SINAS

According to its legal framework, ERS is responsible (43 public, 20 private for-profit, and 10 private not-for- for implementing a system for assessing healthcare profit). It should be noted that the inclusion of providers providers in terms of global quality of services. in the project is voluntary. Additionally, as a measure to help achieve efficiency The first ratings of Clinical Excellence – which covers and effectiveness improvements in hospital services, procedures in the areas of orthopaedics, gynecology, the Memorandum of Understanding on the external , , acute myocardial infarction, financial assistance from the European Union (EU) and stroke, and ambulatory surgery – were published on the International Monetary Fund (IMF) requires Portugal the website www.websinas.com in September 2010. to set up a system for comparing hospital performance The model of assessment of Clinical Excellence was (benchmarking) on the basis of a comprehensive set developed and implemented for ERS by a consortium of indicators and produce regular annual reports. between Siemens and the Joint Commission Interna- To fulfill this obligation, ERS is developing the National tional (JCI). System of Health Quality Assessment (Sistema Nacional For each clinical area, assessment of Clinical Excellence de Avaliação em Saúde – SINAS). is based on a comprehensive set of JCI performance The SINAS framework for assessing global quality measures, adjusted to the Portuguese healthcare set- considers several distinct dimensions of quality. This ting, thereby complying with the highest international framework is specifically implemented and adapted standards. Complex and robust statistical models were to the assessment of different types of healthcare pro- developed for estimating a rating for each hospital and viders (the SINAS modules). The results of the assess- each clinical area, assessing compliance with clinical ments produced within SINAS are presented to the guidelines and expected outcomes. Both outcome public in the form of ratings of the assessed providers. and process measures were included, focusing simul- With such assessments, ERS intends not only to inform taneously on a patient’s health status and the process patients about the quality of healthcare services, but of care. also to encourage continuous improvement in the A key value of the SINAS project is the belief that health- quality of these services. care quality assessment strongly contributes to improv- The SINAS module applied to hospitals (SINAS@Hospitais) ing efficiency in the delivery of care, while simultane- assesses hospitals in five quality dimensions: Clinical ously increasing transparency. With SINAS, ERS aims to Excellence, Patient Safety, Adequacy and Comfort of induce an unprecedented change in the way hospital Facilities, Patient Satisfaction, and Patient Focus. At the managers, health professionals, and healthcare users present time, SINAS@Hospitais involves 73 hospitals think about the quality of .

care providers located in the mainland and healthcare regulation, (ii) separa- territory of Portugal – whether of public, tion between healthcare regulation private-for-profit and not-for-profit own- and healthcare provision, (iii) regulation ership, and regardless of their individual of the entire sector, (iv) independence or collective nature. As an independent from interest groups, and (v) public con- regulator, the intervention of ERS is fidence. focused mainly on safeguarding the interests of healthcare users. Such inde- Future Outlook pendence, both from the government The recent past has been characterized and from healthcare providers, allows by the introduction of a number of reform for (i) separation between health policy initiatives. There are broadly five different

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areas of intervention that have been in a Memorandum of Understanding. As under the spotlight: health promotion, part of this Memorandum, Portugal will long-term care, primary and ambulatory have to make significant budget cuts care, hospital management and inpatient and undergo structural reforms in several “The objectives care, and the pharmaceutical market. areas in the years to come. The chapter are to improve The sequence of the several reforms is dedicated to the healthcare system is one far from being coherent, due to changes of the most ambitious: In general terms, effi ciency and in the Portuguese government, but the the objectives are to improve efficiency most difficult challenge felt by the suc- and effectiveness in the healthcare sys- effectiveness in cessive administrations in terms of health tem, inducing a more rational use of ser- policy has been to impose cost-control vices and control of expenditures, and the healthcare measures, which (almost) consensually to generate additional savings in the are considered indispensible to assure the areas of pharmaceuticals and hospital system and to sustainability of the NHS in the years to operating costs. And with that, the Por- generate savings come. tuguese healthcare system faces difficult Since the beginning of the global finan- challenges in the near future. in the areas of cial turmoil in 2007, the Portuguese financial and economic situation has pharmaceuticals deteriorated greatly. This culminated in 1 Barros P., Machado S., Simões J., 2011, Portugal: Health system review, Health Systems in and hospital Portugal asking for the external financial Transition, 13(4):1–156. assistance of the European Union and 2 APS (Portuguese Insurers Association), 2009, operating costs.” the International Monetary Fund (IMF), Health Insurance Statistics, . 3 INE (National Statistics Institute), 2010, which occurred in May 2011. The dis- Health Satellite Account 2000-2008, Lisbon. bursements of the assistance are subject 4 OECD, 2011, OECD Health Data: Health expenditure Jorge Simões, President, to the compliance with a number of eco- and financing, OECD Health Statistics database. Portuguese Health Regulation Authority 5 OECD, 2011, OECD Health Data: resources, (Entidade Reguladora da Saúde) nomic policy conditions that were agreed OECD Health Statistics database. to by the Portuguese government, the 6 Campos A.C., Simões J., 2011, O Percurso da Saúde: Portugal na Europa, Almedina, Lisbon. European Commission, the European Cen- 7 INE (National Statistics Institute), 2010, tral Bank, and the IMF, and are detailed Statistical Yearbook of Portugal 2009, Lisbon.

Jorge Simões is the current President of the Portuguese Health Regula- tion Authority (Entidade Reguladora da Saúde). He holds a PhD in Health Sciences and is currently a professor at several Portuguese Universities, such as the University of Aveiro, the University of , the Portu- guese Catholic University, the University of Minho, and the Institute of Hygiene and Tropical Medicine at the University “Nova” of Lisbon. In 2009 and 2010, he coordinated the new Portuguese National Health Plan for 2011-2016. In 2008 and 2009, he coordinated the working group that performed the strategic review of the process of creation of public- private partnerships in hospitals, and in 2006 and 2007 he was the Chair- man of the Committee for the Financial Sustainability of National Health Service, both projects being commissioned by the Ministry of Health. He has published four books, coordinated the editing of six other books, published eighteen book chapters and dozens of essays in journals. Between 1996 and 2006, he served as direct advisor to President Jorge Sampaio on health matters. In 2006, he was honored by the President of the Republic with the Grand Cross of the Infante D. Henrique Order.

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