NOVEMBER 2019. On the occasion of the 16th Study Tour (October 22-26, 2019), the AIOP Giovani delegation visited Portugal, where it met with local healthcare directors and visited state-of-the-art healthcare facilities in the capital of Lisbon.
The first morning of meetings was dedicated to the presentation of the National Health System (Serviço Nacional de Saúde) by the Secretary General of the Association of Hospital Managers (APAH – Associação Portuguesa de Administradores Hospitalares).
In this sense, it was clarified how Portugal, a country that has about 10 million inhabitants, features a universal healthcare service (Beveridge model), which is for the most part free. It was introduced in 1979, and is financed through a social security system consisting mainly of indirect taxes (60%), for the benefit of the entire population. The amount allocated to support healthcare is approximately 2.75% of gross income, of which 0.8% is paid by the worker, and 1.95% by the employer.
A substantial part of the population then integrates its public coverage with a private expenditure component or with professional insurance schemes. In particular, about 10% of the population participates in supplementary healthcare funds, about 5% resorts to out-of-pocket spending and a further slice of the population, equal to about 25%, benefits from supplementary healthcare coverage from insurance companies and other private healthcare “subsystems” financed by contributions from employers and users. In 2015, public health expenditure amounted to 8.9% of GDP and 71% of total healthcare expenditure, while private spending corresponded to around 29% of the total expenditure.
The ways in which healthcare expenditure is financed have witnessed great changes over the years. In this regard, it is important to remember that with the introduction of the DRGs and the cataloging of health services, starting in 1984, a process of managing hospital costs began which led to the abandonment of the criterion of financing the hospitals based on global budgets, adjusted from year to year and, starting in 1990, saw the introduction, first, of a financing criterion based on historical expenditure and then, starting in 2002, of the contract budget criterion assigned according to prospective activity and according to the DRGs.
Currently, the subdivision of the budget allocated to the healthcare sector starts with the central government making an allocation to the Ministry of Health. The latter allocates the said budget among the various regions which, in turn, then divide the amount received among the healthcare and assistance facilities on the basis of the agreements stipulated. Alongside of the public component, there is an active private, profit-oriented sector, whose activities are largely subsidized by the National Health System through agreements that are stipulated to deal with the emergency of the waiting lists and, therefore, to provide citizens with healthcare services within the time limits required by national legislation.
With this mechanism, about one-third of the financial resources of the National Health System are directed to the private sector.
The country’s continental hospital network is divided into 68 groupings of healthcare centers (ACES – Agrupamentos de Centros de Saúde) organized in 5 regional health authorities (ARS – Administração Regional de Saúde) which are entrusted with the task of managing the healthcare system on a regional level and, more precisely:
- coordinate, guide and evaluate the implementation of national health policy;
- implement and verify the provision of healthcare services by primary care centers and hospitals;
- coordinate the provision of healthcare services with the private sector and other non-profit organizations;
- monitor the quality of the healthcare services provided.
The administration of individual hospitals, on the other hand, falls under the authority of the respective executive branches. The exception to this are the autonomous regions of the Azores and Madeira which enjoy greater managerial autonomy of healthcare services, though remaining under the control of the central government.
Therefore, it is a national health service that is regulated, programmed and managed at the central level, which means, however, that the control and coordination of service provision and territorial assistance are delegated to the regional level. In this regard, it is possible to identify the organizational methods and the roles of the different operators active in the local area for each level of care.
Primary care, fully covered by the public sector, is provided through the USF (Unidades de Saúde Familiares), established in 2006 as functional units of the ACES (Agrupamentos de Centros de Saúde). In 2015, 289 USFs were active in the country: multi-disciplinary teams with functional and technical autonomy composed of general practitioners and nurses, who provide primary care on the basis of a contractual framework stipulated with the regional health administration, with the objectives of accessibility, effectiveness, efficiency and quality. Remuneration of the USFs involves a mixed composition of budgets and incentives linked to the achievement of set objectives. In this sense, the role played by the USFs, which currently assist 52% of the population, in taking charge of chronic patients is becoming increasingly important.
Acute care is provided in hospitals. There are five categories of hospitals in Portugal:
- Hospitais EPE (Empresas Publicas Empresariais): entirely publicly funded hospital facilities subject to direct control by the Ministry of Finance and Health.
- Hospitais SPA (Sector Público Administrativo): public hospitals subject to supervision and monitoring by the Ministry of Health, managed with a business approach and an organizational structure that is divided into management and cost centers.
- Hospitals based on public-private partnerships. This category of facilities stems from the need to find resources for the sustainability and improvement of the National Health System. It is interesting to note that, since the early 2000s, the Portuguese health sector has been a pioneer in creating a highly regulated legal framework in the field of public-private partnerships (PPPs). Under the guidance of the Ministry of Health, interventions were undertaken to renew and reorganize the Serviço Nacional de Saúde network, which led to the establishment of partnerships aimed at promoting innovative ways of sharing healthcare risk, starting with new private management experiences for public facilities and the participation of the private sector in all phases of the commissioning of a hospital: planning, construction, financing and management of hospital units of the National Health System. Although the investment and operation of these units are private, access to clinical services is the same as that available for other hospital units in the public sector: users therefore retain the rights and duties envisaged for accessing the National Health Service. As regards the Property Management Authority, payments by the State are based on the clinical production actually carried out by the main lines of activity (e.g. inpatient and outpatient consultations) and on the availability of the Emergency Service. In turn, the remuneration of the building management body is based on the availability of the infrastructure and the support services provided.
- Public hospitals managed by non-profit organizations.
- Private for-profit and non-profit hospitals.
The Serviço Nacional de Saúde therefore integrates all healthcare services that can be provided in the State: from prevention to diagnosis, from therapy to medical and social rehabilitation. In this regard, Portugal’s healthcare policy, with the aim of responding to an ever-increasing demand for health and reducing the occurrence of acute events, and with the consequent overcrowding of Emergency Rooms, is moving to increase prevention activities and take care of patients at the primary care level.
In addition to this, the demographic trend of the population, with an increasing number of elderly and chronic patients, is leading to the creation of solutions for taking charge of these categories of “fragile subjects” that is witnessing an increasingly active role of the private and the social sector, with a view to full integration and support to the public provider. With the intent, therefore, to reorganize assistance on the basis of integrated networks of hospital services for acute care, intermediate facilities and territorial services for chronic illness, rehabilitation and non-self-sufficiency, private operators are taking on an increasingly important role in the panorama of Portugal’s healthcare services. This is being achieved thanks to the healthcare policies of a State that allows the complementarity and coordination of functions/services with the public sector and uses the benefits in terms of operational efficiencies, clinical outcomes and speed of response to the citizens’ healthcare demand with a flexible supply system and in line with the needs expressed by the territory.