Vol. 9 No. 5 2007
Pedro Pita Barros Jorge de Almeida Simões
Editors: Sara Allin • Elias Mossialos
Health Systems in Transition
Portugal Health system review
The European Observatory on Health Systems and Policies is a partnership between the World Health Organization Regional Office for Europe, the Governments of Belgium, Finland, Greece, Norway, Slovenia, Spain and Sweden, the Veneto Region of Italy, the European Investment Bank, the Open Society Institute, the World Bank, the London School of Economics and Political Science, and the London School of Hygiene & Tropical Medicine.
2007
Health Systems in Transition
Written by Pedro Pita Barros, Department of Economics, Universidade Nova de Lisboa
Jorge de Almeida Simões, Autonomous Section for Health Sciences, Universidade de Aveiro
Edited by Sara Allin, European Observatory on Health Systems and Policies
Elias Mossialos, European Observatory on Health Systems and Policies
The HiT for Portugal has been produced to coincide with the Portuguese presidency of the European Union.
Portugal: Health System Review
© World Health Organization 2007, on behalf of the European Observatory on Health Systems and Policies All rights reserved. The European Observatory on Health Systems and Policies welcomes requests for permission to reproduce or translate its publications, in part or in full.
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Keywords: DELIVERY OF HEALTH CARE
EVALUATION STUDIES
FINANCING, HEALTH
HEALTH CARE REFORM
HEALTH SYSTEM PLANS – organization and administration
PORTUGAL
ISSN 1817-6127 Vol. 9 No. 5
Suggested citation: Barros P, de Almeida Simões J. Portugal: Health system review. Health Systems in Transition, 2007; 9(5): 1–140.
Printed and bound in the United Kingdom by TJ International, Padstow, Cornwall.
http://www.euro.who.int/PubRequest
Editorial Board
Editor in chief Elias Mossialos, London School of Economics and Political Science, United Kingdom and European Observatory on Health Systems and Policies
Editors Reinhard Busse, Berlin Technical University, Germany Josep Figueras, European Observatory on Health Systems and Policies Martin McKee, London School of Hygiene and Tropical Medicine, United Kingdom and European Observatory on Health Systems and Policies Richard Saltman, Emory University, United States
Editorial team Sara Allin, European Observatory on Health Systems and Policies Olga Avdeeva, European Observatory on Health Systems and Policies Anna Maresso, European Observatory on Health Systems and Policies David McDaid, European Observatory on Health Systems and Policies Sherry Merkur, European Observatory on Health Systems and Policies Bernd Rechel, European Observatory on Health Systems and Policies Erica Richardson, European Observatory on Health Systems and Policies Sarah Thomson, European Observatory on Health Systems and Policies
International advisory board Tit Albreht, Institute of Public Health, Slovenia Carlos Alvarez-Dardet Díaz, University of Alicante, Spain Rifat Atun, Imperial College London, United Kingdom Johan Calltorp, Swedish Association of Local Authorities and Regions, Sweden Armin Fidler, The World Bank Colleen Flood, University of Toronto, Canada Péter Gaál, Semmelweis University, Hungary Unto Häkkinen, Centre for Health Economics at Stakes, Finland William Hsiao, Harvard University, United States Alan Krasnik, University of Copenhagen, Denmark Joseph Kutzin, World Health Organization Regional Office for Europe Soonman Kwon, Seoul National University, Korea John Lavis, McMaster University, Canada Vivien Lin, La Trobe University, Australia Greg Marchildon, University of Regina, Canada Alan Maynard, University of York, United Kingdom Nata Menabde, World Health Organization Regional Office for Europe Ellen Nolte, London School of Hygiene and Tropical Medicine, United Kingdom Charles Normand, University of Dublin, Ireland Robin Osborn, The Commonwealth Fund, United States Dominique Polton, National Health Insurance Fund for Salaried Staff (CNAMTS), France Sophia Schlette, Health Policy Monitor, Germany Igor Sheiman, Higher School of Economics, Russia Peter C. Smith, University of York, United Kingdom Wynand P.M.M. van de Ven, Erasmus University, The Netherlands Witold Zatonski, Marie Sklodowska-Curie Memorial Cancer Centre, Poland
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Contents
Preface ............................................................................................................ v Acknowledgements ......................................................................................vii List of abbreviations ..................................................................................... ix List of tables and figures ...............................................................................xi Abstract .......................................................................................................xiii Executive summary ...................................................................................... xv 1. Introduction ................................................................................................ 1 1.1 Geography and sociodemography ................................................. 1 1.2 Economic context .......................................................................... 3 1.3 Political context ............................................................................. 5 1.4 Health status ................................................................................... 5 2. Organizational structure ........................................................................... 13 2.1 Overview of the health system .................................................... 13 2.2 Historical background .................................................................. 14 2.3 Organizational overview .............................................................. 21 2.4 Decentralization and centralization ............................................. 29 2.5 Patient empowerment .................................................................. 30 3. Financing ................................................................................................. 35 3.1 Health expenditure ....................................................................... 36 3.2 Population coverage and basis for entitlement ............................ 41 3.3 Revenue collection/sources of funds ........................................... 44 3.4 Pooling of funds ........................................................................... 51 3.5 Purchasing and purchaser–provider relations .............................. 52 3.6 Payment mechanisms ................................................................... 53 4. Regulation and planning .......................................................................... 63 4.1 Regulation .................................................................................... 63 4.2 Planning and health information management ............................ 68 5. Physical and human resources ................................................................. 73 5.1 Physical resources ........................................................................ 73 5.2 Human resources ......................................................................... 78
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6. Provision of Services ............................................................................... 89 6.1 Public health ................................................................................ 89 6.2 Patient pathways .......................................................................... 92 6.3 Ambulatory care ........................................................................... 93 6.4 Inpatient care ............................................................................... 98 6.5 Emergency care .......................................................................... 100 6.6 Pharmaceutical care ................................................................... 101 6.7 Long-term care ........................................................................... 107 6.8 Palliative care ............................................................................. 110 6.9 Mental health care ...................................................................... 111 6.10 Dental care ............................................................................... 112 6.11 Complementary and alternative medicine ............................... 113 7. Principal health care reforms ................................................................. 115 7.1 Analysis of recent reforms ......................................................... 115 7.2 Future developments .................................................................. 120 8. Assessment of the health system ............................................................ 121 8.1 The stated objectives of the health system ................................. 121 8.2 The distribution of the health system’s costs and benefits across the population ................................................................ 121 8.3 Efficiency of resource allocation in health care ......................... 124 8.4 Technical efficiency in the production of health care ................ 125 8.5 Quality of care ........................................................................... 125 8.6 The contribution of the health system to health improvement .. 126 9. Conclusions ............................................................................................ 127 10. Appendices ........................................................................................... 131 10.1 References and further reading ................................................ 131 10.2 Principal legislation ................................................................. 137 10.3 Useful web sites ....................................................................... 138 10.4 HiT methodology and production process ............................... 138 10.5 About the authors ..................................................................... 140
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Preface
The Health Systems in Transition (HiT) profiles are country-based reports that provide a detailed description of a health system and of reform and policy initiatives in progress or under development in a specific
country. Each profile is produced by country experts in collaboration with the Observatory’s research directors and staff. In order to facilitate comparisons between countries, the profiles are based on a template, which is revised periodically. The template provides detailed guidelines and specific questions, definitions and examples needed to compile a profile.
HiT profiles seek to provide relevant information to support policy-makers and analysts in the development of health systems in Europe. They are building blocks that can be used:
to learn in detail about different approaches to the organization, financing • and delivery of health services and the role of the main actors in health systems;
to describe the institutional framework, the process, content and • implementation of health care reform programmes;
to highlight challenges and areas that require more in-depth analysis; •
to provide a tool for the dissemination of information on health systems and • the exchange of experiences of reform strategies between policy-makers and analysts in different countries.
Compiling the profiles poses a number of methodological problems. In many countries, there is relatively little information available on the health system and the impact of reforms. Due to the lack of a uniform data source, quantitative data on health services are based on a number of different sources, including the World Health Organization (WHO) Regional Office for Europe European Health for All database, national statistical offices, Eurostat, the
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Organisation for Economic Co-operation and Development (OECD) Health Data, the International Monetary Fund (IMF), the World Bank, and any other relevant sources considered useful by the authors. Data collection methods and definitions sometimes vary, but typically are consistent within each separate series.
A standardized profile has certain disadvantages because the financing and delivery of health care differ across countries. However, it also offers advantages, because it raises similar issues and questions. The HiT profiles can be used to inform policy-makers about experiences in other countries that may be relevant to their own national situation. They can also be used to inform comparative analysis of health systems. This series is an ongoing initiative and material is updated at regular intervals.
Comments and suggestions for the further development and improvement of the HiT series are most welcome and can be sent to: info@obs.euro.who.int.
HiT profiles and HiT summaries are available on the Observatory’s web site at www.euro.who.int/observatory. A glossary of terms used in the profiles can be found at the following web page: www.euro.who.int/observatory/glossary/ toppage.
mailto:info@obs.euro.who.int http://www.euro.who.int/observatory http://www.euro.who.int/observatory/glossary/toppage
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Acknowledgements
The Health Systems in Transition (HiT) profile on Portugal was written by Pedro Pita Barros (Universidade Nova de Lisboa) and Jorge de Almeida Simões (Universidade de Aveiro). It was edited by Sara Allin
and Elias Mossialos (European Observatory on Health Systems and Policies, London hub).
This HiT draws upon an earlier version (2004) written by Margarida Bentes, Carlos Matias Dias, Constantino Sakellarides and Vaida Bankauskaite.
The European Observatory on Health Systems and Policies is grateful to Miguel Gouveia (Universidade Católica Portuguesa) for his useful comments and review of the report, and to José Pereira Miguel for reviewing the report on behalf of the Portuguese Ministry of Health. The authors would like to acknowledge the superb research assistance provided by Sara Ribeirinho Machado and Ana Maria Simões, Faculdade de Economia, Universidade Nova de Lisboa.
The current series of HiT profiles has been prepared by the research directors and staff of the European Observatory on Health Systems and Policies. The European Observatory on Health Systems and Policies is a partnership between the WHO Regional Office for Europe, the Governments of Belgium, Finland, Greece, Norway, Slovenia, Spain and Sweden, the Veneto Region of Italy, the European Investment Bank, the Open Society Institute, the World Bank, the London School of Economics and Political Science, and the London School of Hygiene & Tropical Medicine.
The Observatory team is led by Josep Figueras, Director, and Elias Mossialos, Co-director, and by Martin McKee, Richard Saltman and Reinhard Busse, heads of the research hubs.
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Giovanna Ceroni and Jonathan North managed the production and copy- editing, with the support of Shirley and Johannes Frederiksen (layout), Nicole Satterley (copy-editing) and Aki Hedigan (proofreading).
Special thanks are also due to national statistical offices that have provided data. Special thanks are extended to the WHO Regional Office for Europe Health for All database, from which data on health services were extracted; to the Organisation for Economic Co-operation and Development (OECD) for the data on health services in western Europe; and to the World Bank for the data on health expenditure in central and eastern European countries.
The data used in this report are based on information available in May 2007.
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List of abbreviations
English term
ACS High Commissariat for Health
ACSS Central Administration of the Health System
ADFA Health subsystem for the Air Force
ADMA Health subsystem for the Navy
ADME Health subsystem for the Army
ADSE Health subsystem for civil servants
ANPC National Authority for Civil Protection
APIFARMA Association of Pharmaceutical Companies
ASST Authority for Blood and Transplantation Services
CAS NHS Call Centre
CIAV Anti-poison Information Centre
CIS Commonwealth of Independent States
CNS National Health Council
CODU Urgent patients orientation centre
CODU-Mar Urgent patients orientation centre for situations occurred at sea
CT Computerized (axial) tomography
CTT Health subsystem for the Portuguese postal services
DALE Disability-adjusted life expectancy
DGIES Directorate-General for Health Premises and Equipment
DRG Diagnosis-related group
EC European Commission
English term
ERDF European Regional Development Fund
EU European Union
EU15 European Union Member States before May 2004
EU25 European Union Member States before January 2007
EUROPEP Internationally standardized instrument to evaluate general/family practice
FNAM National Medical Federation
GDH General Directorate of Health
GDP Gross domestic product
GMP Good Manufacturing Practice
GP General practitioner
HFA Health for All (WHO Regional Office for Europe database)
HIV/AIDS Human immunodeficiency virus/Acquired immune deficiency syndrome
HRA Health Regulatory Agency
ICD International common designation
IDT National Institute of Drug Addiction
IGAS General Inspectorate of Health-related Activities
IGIF Institute for Financial Management and Informatics
IMF International Monetary Fund
INE National Statistics Institute
INEM National Institute for Medical Emergencies
INFARMED National Authority on Drugs and Health Products
INN International Nonproprietary Name
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INSA National Institute of Health, Dr Ricardo Jorge
IPS Portuguese Blood Institute
IQS Institute for Health Quality
IT Information technology
LCU Local currency unit
MRI Magnetic resonance imaging
NGO Nongovernmental organization
NHS National Health Service
NUTS Nomenclature of Territorial Units for Statistics
OECD Organisation for Economic Co-operation and Development
OMCL Official Medicines Control Laboratory
OMD Medical Dentists Federation
ONSA National Health Observatory
OOP Out-of-pocket (payments)
OPSS Portuguese Health System Observatory
OTC Over-the-counter (pharmaceuticals)
PALOP African countries with Portuguese as official language
PCC Primary care centre
PEC Stability and Growth Programme
PET Positron emission tomography
PFI Project Finance Initiative (English NHS)
PIDDAC Central Administration’s Investment and Development Plan
PPP Purchasing power parity
PPPs Public–private partnerships
PRACE Governmental Programme for Public Administration Restructure
PT-ACS Health subsystem for workers of Portugal Telecom
R&D Research and development
RHA Regional Health Administration
RMP Regional master plans
SAD GNR Health subsystem for National Republican Guards
SAD PSP Health subsystem for Police Agents
SAMS Health subsystem for employees of the banking sector
SARA Rapid Alert and Response System
SG General Secretariat of Health
SIGIC System for management of (waiting list) patients waiting for surgery
SIM Independent Medical Union
SSMJ Health subsystem for employees of the Ministry of Justice
TB Tuberculosis
THE Total health expenditure
USF Family Health Units
VAT Value-added tax
VHI Voluntary health insurance
WHO World Health Organization
WPU Weighted production units
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List of tables and figures
Tables
Table 1.1 Population/demographic indicators, 1970, 1980, 1990, 2000, 2004 3
Table 1.2 Macroeconomic indicators, latest available year 4
Table 1.3 Mortality and health indicators, 1980, 1990, 2000, 2004, 2005 6
Table 1.4 Infant mortality rates (per 1000 live births), by region 7
Table 1.5 Main causes of death (standardized mortality rates), 1995, 2000, 2003, 2004, 2015 (forecast)
7
Table 1.6 Disability-adjusted life expectancy, by gender, 1999–2002 8
Table 1.7 Factors affecting health status, 1990, 1995, 2000–2003 9
Table 1.8 WHO Health for All immunization categories (percentage of children under 3 years)
10
Table 1.9 Maternal and child health indicators, 1980, 1985, 1990, 1995, 2000, 2004
10
Table 2.1 The health care system: historical background and recent reform trends – timeline
18
Table 3.1 Funding mix for the health system (in percentages) 36
Table 3.2 Trends in health expenditure, 1990 to latest available year 39
Table 3.3 Mean annual growth rates, 1990–1995, 1995–2000, 2000–2004 41
Table 5.1 Items of functioning diagnostic imaging technology per million population, 2003
77
Table 5.2 Health care personnel per 1000 population, 1990, 1995, 2000–2004 79
Table 5.3 NHS health workforce by health region, 2005 83
Table 5.4 NHS health workforce by health region per 1000 inhabitants, 2005 83
Table 6.1 NHS co-insurance (percentage paid by the NHS) 103
Table 7.1 Major policy measures, 2000–2006 116
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Figures
Fig. 1.1 Levels of immunization for measles in the European Union and selected countries, 2005
11
Fig. 2.1 Overview chart of the health system 14
Fig. 2.2 Organizational chart of the Ministry of Health 22
Fig. 3.1 Financing flow chart 37
Fig. 3.2 Health expenditure as a share (%) of GDP in the European Union and selected countries, 2004, WHO estimates
38
Fig. 3.3 Trends in health expenditure as a share (%) of GDP in Portugal, selected countries and EU average, 1998–2004, WHO estimates
39
Fig. 3.4 Health expenditure in US$ PPP per capita in the European Union and selected countries, 2004, WHO estimates
40
Fig. 3.5 Health expenditure from public sources as a percentage of total health expenditure in the European Union and selected countries, 2004, WHO estimates
42
Fig. 3.6 Total expenditure on health (in percentage) by source of revenue, 2004 45
Fig. 5.1 Beds in acute care hospitals, psychiatric hospitals and long-term care institutions per 1000 population, 2005
74
Fig. 5.2 Beds in acute hospitals per 1000 population in Portugal, selected countries and EU average, 1990 to latest available year
75
Fig. 5.3 Number of physicians per 1000 population in Portugal, selected countries and EU average, 1990 to latest available year
79
Fig. 5.4 Number of nurses per 1000 population in Portugal, selected countries and EU average, 1990 to latest available year
80
Fig. 5.5 Number of physicians and nurses per 1000 inhabitants in the European Union and selected countries, 2005 or latest available year (in parentheses)
81
Fig. 5.6 Number of dentists per 1000 population in Portugal, selected countries and EU average, 1990 to latest available year
82
Fig. 5.7 Number of pharmacists per 1000 population in Portugal, selected countries and EU average, 1990 to latest available year
87
Fig. 6.1 Outpatient contacts per person in the European Union and selected countries, 2005 or latest available year (in parentheses)
94
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Abstract
The Health Systems in Transition (HiT) profiles are country-based reports that provide a detailed description of a health system and of policy initiatives in progress or under development. HiTs examine different
approaches to the organization, financing and delivery of health services and the role of the main actors in health systems; describe the institutional framework, process, content and implementation of health and health care policies; and highlight challenges and areas that require more in-depth analysis.
The Portuguese population enjoys good health and increasing life expectancy, though at lower levels than other western European countries. All residents in Portugal have access to health care provided by the National Health Service (NHS), financed mainly through taxation. Co-payments have been increasing over time, and co-insurance is higher for pharmaceutical products. Approximately a quarter of the population enjoys a second (or more) layer of health insurance coverage through health subsystems and voluntary health insurance (VHI). Health care delivery is based on both public and private providers. Public provision is particularly present in primary care and hospital care, with a gatekeeping system in place for the former. Pharmaceutical products, diagnostic technologies and private practice by physicians constitute the bulk of private health care provision.
The Portuguese health system has not undergone any major changes on the financing side since the early 1990s, despite the steady growth of public health expenditure. On the other hand, many measures have been adopted to improve the performance of the health system. Measures since 2002 have included: public–private partnerships (PPPs) for new hospitals; a change in NHS hospital management rules towards a more entrepreneurial approach and a more effective purchaser–provider split; promoting generic substitution of pharmaceuticals;
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liberalization of prices and entry onto the over-the-counter (OTC) market; administrative price reductions for pharmaceutical products; introduction of a reference pricing mechanism for pharmaceuticals facing competition from generics; regular updates of the co-payments for public health care services; reorganization of the public network of services (closure of delivery rooms in some hospitals, reshuffling of emergency departments, mergers of hospital management teams); definition of a national health plan; reform of primary care (creation of Family Health Units (USFs, Unidades de Saúde Familiar)); and creation of long-term care networks. Some of these measures have faced opposition from the (local) population, namely those related to the closure of health care facilities. There is an overall awareness, and concern, about the rise in health care expenditure in Portugal. Most of the reforms that have come into effect have done so too recently to measure any effects at the time of writing.
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Executive summary
Portugal is a republic located in part of the Iberian Peninsula in the south- west of Europe, also comprising two Atlantic archipelagos (Azores and Madeira). The Portuguese population reached 10.57 million in 2005. In
2004, life expectancy at birth was 81.4 for females and 74.9 for males. The main causes of death in Portugal are cardiovascular disorders and malignant neoplasms.
The Portuguese health system is organized around an NHS, with some responsibilities delegated to regional bodies. The NHS is managed by the Ministry of Health. The internal organization of the Ministry is being restructured, in the context of a general reform of civil service in the country. Overlapping with the NHS are certain special public and private insurance schemes for certain professions (termed “health subsystems”), which are compulsory for groups of employees, and private VHI.
Total health expenditure (THE) in 2004, as a percentage of gross domestic product (GDP) was approximately 10%, which is above the European Union (EU) average. Health care expenditure expressed in US$ purchasing power parity (PPP) per capita was 1813 in 2004, which is below the EU average of 2269. The contrast between the values relative to GDP and THE per capita reflect the relatively low GDP level of Portugal within the EU. Public health expenditure has grown since the early 1990s, although its growth has halted during 2005 and 2006. The Portuguese health system is primarily funded through taxation. Public sector funding as a percentage of total expenditure on health care fluctuates around 72%.
The Portuguese NHS establishes the right of all citizens to health protection; a guaranteed universal right to health care (mostly free at the point of use) through the NHS and access to the NHS for all citizens regardless of economic
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and social background. In the Portuguese Constitution the NHS is defined as “universal, comprehensive and approximately free of charge”.
Since the mid-1990s, there have been several attempts to shift from retrospective to prospective payments for providers. Although the NHS health care units are paid according to yearly budgets, mid-year financial reinforcements made the payment system closer to historical cost budgeting and cost reimbursement than prospective budgeting. Since 2003, with the transformation of many NHS hospitals into (state-owned) corporate entities, the purchaser–provider split and the use of explicit contracts based on prospective payments have gained momentum. The contractual approach to hospital payments has also been recently extended to the remaining purely state-owned hospitals.
Patients in Portugal participate in health care financing via co-payments and co-insurance. For certain health care services delivered by NHS facilities the patient pays a certain fixed amount per use. For pharmaceutical products, a co- insurance scheme exists, for which the patient pays a certain fixed proportion of the cost of the pharmaceutical. These systems work as third-party payer systems.
The number of all types of health care professionals has increased continuously since the mid-1980s. The growth was slower in physicians, due to tight controls on admissions to medical schools. This has actually created an undersupply of physicians, which will likely lead to shortages in the medium term (5–10 years). Besides this, certain areas of the country face shortages of physicians due to an uneven distribution across the country. Recently, two new schools of medicine have opened, and numerus clausus constraints have been relaxed in existing ones. For other health professions, namely health ancillary technicians, training has occurred at a faster pace.
Health professionals working in the NHS are paid on a salaried basis. In some hospitals, incentive mechanisms such as performance-related pay are being introduced. Primary care reforms, with the creation of USFs, are also introducing activity-related payments. Private practices of physicians and other health care services are paid for on a fee-for-service basis. Many, if not most, involve explicit agreements with the NHS.
Pharmaceutical products are distributed through community and hospital pharmacies. Only physicians can prescribe pharmaceuticals. The co-insurance rate varies depending on the therapeutic importance of the pharmaceutical product. For therapeutic groups with a generic equivalent, cost sharing has evolved to a reference pricing scheme. The reference price is set equal to the highest generic price for the pharmaceutical that has the same form and dosage,
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which must, nonetheless, be 35% below the price of the original branded product.
The Portuguese health system has not undergone any major changes in terms of financing, despite the steady growth of public health expenditure since the early 1990s. On the other hand, many measures have been adopted to improve the performance of the health system. Measures since 2002 have included: PPPs for new hospitals; a change in NHS hospital management rules towards a more entrepreneurial approach and a more effective purchaser–provider split; promoting generic substitution of pharmaceuticals; liberalization of prices and entry onto the OTC market; administrative price reductions for pharmaceutical products; introduction of a reference pricing mechanism for pharmaceuticals facing competition from generics; regular updates of the co-payments for public health care services; reorganization of the public network of services (closure of delivery rooms in some hospitals, reshuffling of emergency departments, mergers of hospital management teams); definition of a national health plan; reform of primary care (creation of USFs); and creation of long-term care networks. Some of these measures have faced opposition from the (local) population, namely those related to the closure of health care facilities. There is an overall awareness, and concern, about the rise in health care expenditure in Portugal. Most of the reforms that have come into effect have done so too recently to measure any effects at the time of writing.
The Portuguese health system has been under the political spotlight in recent years. Despite improvements to population health, growing concern about spending levels and an increasing awareness that there is a fair amount of waste in terms of resource utilization have motivated many policy measures. Although controlling costs has been an important driver behind some of the government interventions, other measures were actually taken without careful and detailed analysis of the cost implications.
Moreover, health care reform has been widespread, touching all areas of the system to differing degrees, including: public health, primary care, hospital care, long-term care, pharmaceutical market, PPPs, regulation, human resources and new investments in capacity.
In terms of the health of the population, the National Health Plan is a major landmark, as a guide for public action aimed at obtaining health gains for the population. The National Health Plan covers the period 2004–2010, and implementation is currently under way. However, the pace seems to be slower than anticipated. A major challenge for the Portuguese health system is, therefore, to implement the National Health Plan and to monitor the achievements made in terms of health gains.
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Primary care was also subject to a major change, with the ongoing implementation of USFs – multidisciplinary teams formed voluntarily – aimed at providing better care to the population.
The main challenges in hospital care are the reduction of waste without harming quality of care, and redefinition of the role of hospitals in the health system in conjunction with the recent developments in primary and long-term care.
Traditionally, long-term care has seen little public sector involvement. Policy measures since 2005 were designed to change this picture. Taking advantage of existing institutions, many non-profit-making and private, the development of a network of integrated long-term care is envisaged. It aims at reducing costly acute hospital care episodes and admissions by substitution for care that is of lower cost and closer to the community. Given that such policies have only been enacted recently, it is too early to assess the situation in full.
Other policies, such as PPPs and regulation by the Health Regulatory Agency (HRA), have so far produced few results (but lots of “noise”). The clarification of their role remains an issue.
For many of the reforms, the two main points of import are: (a) they mostly aim at improving efficiency of the health system, namely public provision; and (b) the jury is still out, as they have been implemented too recently for a fair appraisal to be carried out. The legal changes that have occurred are yet to materialize in actual changes in the health system. As has happened in the past, there is a risk that many of them may not translate into actual changes, and that unanticipated effects may emerge.
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1.1 Geography and sociodemography
Portugal is part of the Iberian Peninsula in the south-west of Europe. The archipelagos of Azores (nine islands) and Madeira (two main islands and a natural reserve of two uninhabited islands) in the Atlantic Ocean
are also part of Portugal. The mainland is 91 900 km² (maximum 960 km from north to south and 220 km from east to west), with 832 km of Atlantic coastline and a 1215 km inland border with Spain.
The River Tagus, which rises in the Central Iberic Peninsula, divides the country into two distinct geographical areas. The northern and central regions are characterized by rivers, valleys, forests and mountains. The highest range on the continent is the Serra da Estrela, peaking at Torre (1993 m), while the Pico, in the Azores Islands, is the highest mountain overall, at 2100 m. The south, apart from the rocky backdrop of the Algarve, is much flatter, drier and less populated.
Portugal has a temperate climate influenced by the Atlantic Ocean, with considerable variations. The southern region of the Algarve can experience extremely high temperatures in midsummer. In winter the north receives plenty of rain and temperatures can be chilly, with snowfall common in the mountains, particularly the Serra da Estrela range. As a result, the natural flora is varied, with species typical of both western Europe and the Mediterranean.
According to the latest estimates, the total resident population of Portugal was 10.57 million at the end of 2005. This represents a 5.26% increase since the mid-1990s. It also represents a 2.26% increase since the last census in 2001 (INE, 2001). Population density is 114.78 per km2, similar to Slovakia, Hungary and France.
1 Introduction
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Recent legal and illegal immigration from Brazil and central and eastern Europe, together with the more traditional immigration from Africa, are presenting some challenges to the Portuguese health care system. The challenges result both from illegal immigrants having difficulty accessing health care providers (exacerbating health inequalities in the population) and from the prevalence of tropical diseases particular to these groups (GDH, 2004). The National Health Service (NHS) works with nongovernmental organizations (NGOs) due to both the better knowledge NGOs have about the social, economic and cultural context of illegal immigrants and the absence of the official constraints associated with governmental institutions.
According to 2005 estimates, the legal immigrant population represents 2.61% of the resident Portuguese population (INE, 2007). A vast majority of these immigrants (52%) live in the Lisbon area. Approximately 78% of them are in the active age groups (15–64 years old), confirming the strong economic reasons for migrating to Portugal. Immigrants from eastern European countries have become more numerous since the mid-1990s. A distinctive feature of this group relative to other immigrants is its higher literacy and higher degree of professional qualifications. For example, the Fundação Calouste Gulbenkian promoted the professional recognition and adaptation of 105 physicians originating from eastern Europe who were working in construction or in low- end services (e.g. cleaning services).
While in 1970 only 25.9% of the population lived in urban areas, this rose to 29.4% in 1980, 46.7% in 1990, 53.0% by 2000, and 55.1% by 2004, according to the latest data available (Table 1.1). This is clearly below average for the European Union (EU) Member States prior to May 2004 (EU15), which is approximately 70% (WHO Regional Office for Europe, 2007). The two main metropolitan areas are greater Lisbon (resident population 2.013 million in 2005) and greater Oporto (population 1.276 million in 2005). The migration of the population from the interior to the coastal cities has been a constant feature of the Portuguese mainland, but increased after the 1974 revolution. Large suburban areas were built to accommodate the influx of internal and external immigrants. The rapid growth of these suburban neighbourhoods without an accompanying expansion of the public transport network is posing great traffic pressure on city centres.
The number of births has been declining steadily since 1970 (20.0 live births per 1000 population), and in 1990 the crude birth rate for Portugal was 11.80 live births per 1000 population (Table 1.1), below the EU15 average of 12.02 for the first time since 1970 (WHO Regional Office for Europe, 2007). By 2004 the number of births per 1000 population had declined to 10.4 (see Table 1.1).
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The median age of the population has been steadily rising. From 1986 to 1996, it rose by 5 years, from 31 to 36. By 2005, it had settled at approximately 40 years of age. The dependency ratio fell from 0.57 in 1980 to 0.49 in 2004 (based on the relation of those under 15 and over 65 years of age to the remainder of the population) (see Table 1.1). Demographic changes seem to have followed a global improvement in socioeconomic conditions similar to those in other countries in the past. Recent projections show that the Portuguese population may still show a slight increase during the next decade but will decline from 2010 onwards. The increase in the proportion of people over 65 years old and the decrease of the population under 15 years of age will result in a “double ageing” effect. A scenario approach to these estimates seems to confirm that a decrease of the Portuguese population is almost inevitable, even considering important increases in the immigrant population (INE, 2003).
1.2 Economic context
Over the past few years, the Portuguese economy has faced a period of very low and even negative growth. In fact, in 2003 the country was in recession.
Table 1.1 Population/demographic indicators, 1970, 1980, 1990, 2000, 2004
1970 1980 1990 2000 2004 Age dependency ratio (dependants to working-age population)
0.61 0.57 0.51 0.48 0.49
Birth rate, crude (per 1000 people)
20.00 16.20 11.80 11.60 10.40
Death rate, crude (per 1000 people)
10.30 9.70 10.40 10.50 9.70
Fertility rate, total (births per woman)
2.76 2.19 1.43 1.52 1.42
Population ages 0–14 (% of total)
28.80 25.90 20.40 16.20 15.90
Population ages 15–64 (% of total)
62.00 63.60 66.20 67.60 67.20
Population ages 65 and above (% of total)
9.20 10.50 13.40 16.10 16.90
Population density (people per km2)
98.80 107.00 108.00 112.00 115.00
Population growth (annual %) -0.58 1.08 -0.41 0.51 0.58
Population, female (% of total) 52.60 51.60 51.80 51.80 51.70
Population, total (thousand) 9 040 9 770 9 900 10 200 10 500
Urban population (% of total) 25.90 29.40 46.70 53.00 55.10
Source: World Bank, 2006.
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Health systems in transition Portugal
Since 2002, a number of macroeconomic disequilibria have existed, with the most visible effect being the increase in the government budget deficit, as well as a rise in unemployment levels. Table 1.2 shows the main macroeconomic indicators for the latest available year. Inflation settled at approximately 3.0% in 2006, which was approximately 1 percentage point above the Euro Area inflation rate. In 2005, gross domestic product (GDP) growth rate was 0.4%. The most recent data from the Portuguese Central Bank estimate 2006 GDP growth to be approximately 1.2%. In 2002, GDP per capita was €12 376, and in 2005 it increased to €13 549. Unemployment levels have increased yearly since 2002, from 6.1% in 2002 to 8.2% by the end of 2006.
2006 was the first year of a recovery that is expected to boost the Portuguese economy to reach average EU growth levels. This recovery has been sustained by an increase in exports, as well as by the strong measures and reforms being implemented by the Government in order to correct the main macroeconomic disequilibria, such as the government budget deficit and unemployment. The main policy measures included a value-added tax (VAT) increase in 2005, several spending cuts and a global reform of civil service rulings (still under way).
Table 1.2 Macroeconomic indicators, latest available year
Year GDP (constant LCU) (million €) 143 564.9 2005
GDP per capita, PPP (constant 2000 international $) 18 000 2004
GDP per capita (constant LCU) 13 549 2005
GDP, PPP (constant 2000 international $, billion €) 189 2004
GDP growth (last 10 years average %) 6.07 2005
GINI index 38.50 1997
Overall general government balance, excluding temporary measures (% GDP)
–3.4 2006
Agriculture, value added (% of GDP) 3.67 2004
Industry, value added (% of GDP) 26.70 2004
Manufacturing, value added (% of GDP) 16.90 2003
Current account balance (% of GDP) -9.5 2005
Labour force, total 5 544 900 2005
Unemployment, total (% of total labour force) 8.2 2006
Official exchange rate (US$, €, period average) 1.24 2005
Nominal short-run interest rate (%) 2.2 2005
Nominal long-run interest rate (%) 3.4 2005
Inflation rate 3.0 2006
Sources: Government of the Republic of Portugal, 2006; World Bank, 2006; OECD, 2006; Portuguese Central Bank, 2006; INE, 2005a.
Notes: PPP: Purchasing power parity; LCU: Local currency unit; GDP: Gross domestic product.
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1.3 Political context
Portugal has been a constitutional democratic republic since 1974, when the revolution put an end to the 48-year dictatorship of the Salazar–Caetano regime. The main institutions of the State are the President of the Republic, the Parliament, the Government and the courts. Both the President and the Parliament are directly elected by means of universal suffrage, through national elections.
The Parliament is made up of 230 members elected according to a system of proportional representation and the highest average method (Hondt method). The Prime Minister is appointed by the President on the basis of the election results and after consultation with the political parties. The President also appoints the other members of government on the recommendation of the Prime Minister.
The administrative system comprises five regions (North, Centre, Lisbon and Vale do Tejo, Alentejo and Algarve), 18 districts and 2 autonomous regions (the Azores and Madeira). The districts are further divided into municipalities (concelhos), which have their own level of elected government and boroughs (freguesias). The islands have their own political and administrative structures. The President appoints a State Representative (Representante do Estado) to represent the Republic in each of the autonomous regions, following a proposal by the national Government.
In December 1999 China resumed sovereignty over the territory of Macao, which had been under Portuguese sovereignty since 1887. Angola, Mozambique, Guinea-Bissau, Cape Verde, and São Tomé and Principe all became independent after the 1974 revolution, which ended the 48-year dictatorship lead by Salazar (and Marcello Caetano in the final years of the regime) and 13 years of war in the African colonies.
Since the 2005 general elections, the Government is formed by the Socialist Party, which enjoys a majority of seats in the Parliament.
1.4 Health status
Portuguese life expectancy at birth practically doubled during the 20th century, both in women (40.0 years in 1920, 79.7 years in 2000) and in men (35.8 years in 1920, 72.6 years in 2000). This trend has continued to develop since the mid- 1980s (see Table 1.3), making life expectancy in Portugal converge with the EU average. In 2005 average life expectancy at birth in Portugal was 78.2 years,
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Health systems in transition Portugal
while the EU15 average was 78.8 years (OECD, 2006). There is a remarkable difference between estimates of life expectancy for men and for women in Portugal: the 2005 figures were 81.4 years for women and 74.9 years for men (Table 1.3).
Child health indicators, although improving since the early 1960s, have suffered dramatic reductions since the 1974 revolution and are currently near the average European level. The infant mortality rate decreased fivefold between 1970 and 1990, and decreased from 10.8 per 1000 in 1991 to 3.5 per 1000 in 2005, below the average infant mortality rate for EU15 Member States (4.1 per 1000 live births in 2004).
Infant mortality has also declined, as mentioned above (see also Table 1.3). The perinatal mortality rate dropped from 12.1 per 1000 in 1991 to 5.6 per 1000 in the year 2000 and further to 4.4 per 1000 in 2004 (Table 1.3). From 1990 to 2004 the neonatal mortality rate decreased from 6.9 to 2.6 per 1000. Although there has been a positive evolution of infant mortality indicators, there are still some regional disparities of concern (see Table 1.4). In the Azores, the infant mortality rate in 2005 was 6.3 per 1000, twice the mortality rate in the Centro region (2.8 per 1000 live births, Nomenclature of Units for Territorial Statistics (NUTS) II level) (INE, 2005c). The successful evolution of infant mortality, to the point where the level in Portugal is lower than the EU average, may, as well as economic growth and social development (especially after accession to the European Communities in 1986), stem from more than 30 years of well- defined policies, strategies, programmes and selective investments in perinatal, maternal and child care, in spite of political changes and discontinuities (see Section 6.1 “Public health”).
Improvements in the health status of the Portuguese population seem to be associated with increases in human, material and financial resources devoted to
Table 1.3 Mortality and health indicators, 1980, 1990, 2000, 2004, 2005
1980 1990 2000 2004 2005 Life expectancy at birth, female (years) 74.6 77.6 80.3 81.6 81.4
Life expectancy at birth, male (years) 67.5 70.6 73.2 74.9 74.9
Life expectancy at birth, total (years) 71.2 74.1 76.8 78.3 78.2
Mortality rate (per 1000 female adults) 8.7 9.6 9.5 9.0 –
Mortality rate (per 1000 male adults) 10.6 11.1 11.2 10.5 –
Mortality rate, crude (per 1000) – – – – 10.2
Infant deaths per 1000 live births 24.3 11.0 5.5 3.9 3.5
Probability of dying before age 5 years
(per 1000 live births) 29.2 14.0 7.3 5.2 –
Sources: WHO Regional Office for Europe, 2007; OECD, 2006c; INE, 2005a (for all 2005 data).
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health care, as well as to a general improvement in socioeconomic conditions. Despite the overall improvement in living standards, there are inequalities among the regions (as shown in Table 1.4), and also between social classes. These disparities are evident in the variation of some health indicators such as mortality rates (the average for crude malignant neoplasm mortality rates, over the period 1999–2003, ranged between 1.9 per 1000 in the North region and 3.4 in lower Alentejo) and infant mortality rates (4.6 per 1000 in the Lisbon region and 6.9 in the Alentejo region, over the same period). There are also disparities in the supply ratio of physicians (6.0 per 1000 in Lisbon and Oporto, whereas in lower Alentejo the 2004 figure was only 1.6) and nurses (6.0 per 1000 in
Table 1.4 Infant mortality rates (per 1000 live births), by region
1999 2000 2001 2002 2003 2004 2005 National average 5.6 5.5 5.0 5.0 4.1 3.8 3.5
Continent 5.4 5.3 4.8 4.9 4.1 3.7 3.4
North 6.5 5.8 5.9 5.4 4.2 3.9 3.8
Centre 4.7 4.5 3.9 3.9 3.9 3.2 2.8
Lisbon 4.8 5.0 4.4 5.2 3.6 3.8 3.3
Alentejo 3.9 5.3 3.7 4.4 5.2 3.4 3.5
Algarve 4.9 5.5 4.3 5.1 4.5 4.2 3.6
Azores 9.5 8.1 5.1 6.5 2.9 6.3 6.3
Madeira 5.2 8.1 8.2 5.8 7.9 3.7 3.4
Source: INE, 2005b.
Table 1.5 Main causes of death (standardized mortality rates), 1995, 2000, 2003, 2004, 2015 (forecast)
Cause of death 1995 2000 2003 2004 2015f
Diseases of the circulatory system 332.8 272.1 244.0 217.2 238.6
Cerebrovascular disease 179.6 139.8 113.2 97.6 110.4
Ischaemic heart disease 70.5 61.1 59.6 54.2 57.3
Malignant neoplasms of 169.4 164.2 159.4 154.3 145.8
stomach 24.0 20.1 17.5 16.6 16.1
lung 21.8 22.5 23.2 22.3 24.3
breast 25.2 22.4 21.1 19.1 18.2
prostate 28.6 30.0 25.0 24.5 22.6
Diseases of the respiratory system 61.5 66.8 55.2 49.0 52.6
Diseases of the digestive system 38.9 31.4 32.3 31.6 35.2
Diabetes mellitus 23.1 21.1 27.3 26.1 28.5
Land transport accidents 23.1 12.4 16.7 14.5 14.1
Undefined cause of death 94.9 96.3 66.6 58.6 45.5
All causes 838.3 754.0 700.7 646.9 578.0
Source: Personal communication from the General Directorate of Health (GDH).
Note: f forecast.
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Health systems in transition Portugal
Lisbon and Oporto, while in lower Alentejo in 2004 there were 2.4 nurses per 1000 inhabitants) to population (INE, 2004; INE, 2005a).
The leading causes of death are shown in Table 1.5. Since the mid-1980s, the main causes of death have been diseases of the circulatory system, cerebrovascular disease and malignant neoplasms. These are likely to remain the main causes of death of the Portuguese population for the coming decades, according to a recent General Directorate of Health (GDH (DGS, Direcção- Geral da Saúde)) study (see Table 1.5). One should not underestimate the extremely high level of undefined causes of death, suggesting there might be weaknesses in data collection. Diseases of the circulatory system, together with malignant neoplasms, account for over 50% of deaths in 2004, according to the latest figures provided by the National Statistics Institute (INE, Instituto Nacional de Estatística). The mortality rate of these diseases has been above the EU average over recent decades, despite the clear descending trend. In contrast, Portugal has one of the lowest mortality rates from cardiac ischaemic disease in the EU. The most frequent fatal tumours were gastrointestinal tumours, both among men and women.
Another interesting feature is the analysis of “avoidable deaths”. According to 2001 data, men die from avoidable causes much more than women do, essentially due to cerebrovascular disease and infant mortality. This can be seen in almost every age group, particularly among the older population (Santana, 2005). A large share of premature mortality among men comes from traffic accidents. The mortality rate associated with motor vehicle accidents was 5.1 in 2001, the highest in the EU15 Member States (Santana, 2005). Excessive speed, dangerous manoeuvres and high blood alcohol levels are the main causes of this problem and have been targeted with specific legislation and law-enforcement measures (see Section 6.1 “Public health”).
Disability-adjusted life expectancy (DALE) levels in Portugal are worse than the average for EU15 members, both for men and for women (Table 1.6). The
Table 1.6 Disability-adjusted life expectancy, by gender, 1999–2002a
1999 2000 2001 2002 Countries MF M F MF M F MF M F MF M F Portugal 69 66 73 67 64 69 67 64 69 69 67 72
Spain 73 70 76 71 69 73 71 69 73 73 70 76
United Kingdom 72 70 74 69 68 70 70 68 71 71 69 72
EU15 72 – – 70 – – 70 – – 72 – –
Source: WHO Regional Office for Europe, 2007.
Notes: a Due to relatively large year-to-year fluctuations, the empirical estimates should be regarded with caution, as indicative; EU15: European Union Member States before May 2004.
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trend over the period 1999–2002 has been similar to that observed in Spain and the United Kingdom. Men have a clearly lower DALE than women do.
The number of both total and new tuberculosis (TB) cases has been decreasing over the last decade. In 2004, the incidence rate was down to 35 per 1000 population, from 49 per 1000 population in 1995. However, when compared to the data from EU15 Member States, it is still above average.
Portugal has one of the highest prevalence of human immunodeficiency virus (HIV) infection in Europe (280 per million population in 2004), more than twice the highest rates observed in the other EU countries. The relative size of incidence data is similar (Table 1.7). The High Commissariat for Health (ACS, Alto Comissariado para a Saúde) (through the National Coordinator for HIV/ AIDS (acquired immune deficiency syndrome), which has replaced the National Committee against AIDS in the area of prevention and treatment of AIDS) has identified a set of priority areas for intervention, such as epidemiological information, health education, national counselling and early detection centres,
Table 1.7 Factors affecting health status, 1990, 1995, 2000–2003
1990 1995 2000 2001 2002 2003 HIV incidence per 100 000 – – 40.4 23.7 24.3 21.5
Pure alcohol consumption, litres per capita
12.8 11.9 10.6 10.1 9.5 9.4
Spirits consumed in pure alcohol, litres per capita
1.9 1.6 1.5 1.4 1.4 1.4
Beer consumed in pure alcohol, litres per capita
3.4 3.4 3.1 3.1 2.9 2.9
Pure alcohol consumed, litres per capita, age 15+
16.0 14.4 12.6 12.1 11.3 11.1
Average number of calories available per person per day (kcal)
3 441 3 552 3 741 3 745 3 769 3 746
% of total energy available from fat
32.2 32.1 33.6 33.4 33.7 34.2
% of total energy available from protein
11.8 12.3 12.6 12.8 12.6 12.5
Total fat intake, grams per capita per daya – – – 139 141 142
Total calories intake, calories per capita per daya – – – 3 745 3 769 3 747
Total protein intake, grams per capita per daya – – – 120 119 117
Alcohol consumption, litres per capita, age 15+a – – – 12.3 11.5 11.4
Sources: WHO Regional Office for Europe, 2007; aOECD, 2006.
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and national centres for administration of combined therapy and extra-hospital support activities (see Section 6.1 “Public health”).
Data on immunization in Portugal are reliable and show the high coverage of the population (Table 1.8). Figure 1.1 shows a level of measles vaccination coverage that is comparable to the EU15 average but below the current EU25 (European Union Member States before January 2007) average.
Maternal and child health indicators (Table 1.9) show a marked improvement over the period, leading to a convergence with the EU average. This is one of the success stories in the Portuguese health system since the mid-1970s.
Over recent decades the health status of the Portuguese population has improved. This is due both to more significant progress in 30% of the municipalities and to the diminishing disparities among regions between 1991 and 2001 (Santana, 2005). Both effects are related to social and health factors and behaviours, as can be seen in Table 1.7. However, there is still some concern over regional disparities, particularly between urban-coastal and rural-interior regions. The latter had, and still have, the worst health condition. Rural regions
Table 1.8 WHO Health for All immunization categories (percentage of children under 3 years)
Category % Year Infants vaccinated against: tuberculosis 89 2005
diphtheria 93 2005
tetanus 93 2005
pertussis 93 2005
poliomyelitis 93 2005
hepatitis B 94 2005
mumps 96 2003
rubella 96 2003
Children vaccinated against measles 93 2005
Infants vaccinated against invasive disease due to haemophilius influenza type B
93 2005
Source: WHO Regional Office for Europe, 2007.
Table 1.9 Maternal and child health indicators, 1980, 1985, 1990, 1995, 2000, 2004
Indicators 1980 1985 1990 1995 2000 2004 Neonatal deaths per 1000 live births
15.50 12.20 7.00 4.74 3.41 –
Perinatal deaths per 1000 births 22.40 17.40 10.50 7.21 5.20 5.64
Maternal deaths per 100 000 live births
19.60 9.96 10.30 8.40 2.50 8.23
Source: WHO Regional Office for Europe, 2007.
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Fig. 1.1 Levels of immunization for measles in the European Union and selected countries, 2005
Percentage
Hungary (2004)
Poland
Slovakia
Lithuania
Finland
Czech Republic (2004)
Spain
Romania
The former Yugoslav Republic of Macedonia
Netherlands
Bulgaria
Estonia
Croatia
Sweden
Luxembourg
Denmark
Latvia
Slovenia (2004)
Germany
Portugal
Turkey
Austria
Norway
Greece (2004)
Belgium
Italy
Cyprus
Malta
France (2004)
Ireland
United Kingdom
Switzerland
Averages
CIS average
EU average
EU15
88.0
90.0
94.0
95.0
95.0
95.4
95.4
95.5
95.9
96.3
96.4
96.7
96.8
96.9
97.0
97.2
98.0
98.2
99.9
93.3
92.6
91.0
91.0
88.0
87.2
86.3
86.0
86.0
84.2
82.1
82.0
98.0
91.3
89.7
96.2
70 80 90 100
Source: WHO Regional Office for Europe, 2007. Notes: CIS: Commonwealth of Independent States; EU: European Union; EU15: EU Member States before May 2004.
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are also the poorest in the country. Health inequalities are associated with economic and social factors, such as income, living conditions, unemployment and health care (coverage, utilization rates, among others). The study led by Santana (2005) shows a wide range of health status among the Portuguese population, based on demographic, social and economic inequalities. Of the 275 municipalities analysed in 1991, 144 (52.3%) showed a health status below the mean. Most of them were located in the countryside. By 2001, although there was an improvement in the overall health status, this regional inequality seemed to have prevailed (Santana, 2005).
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2.1 Overview of the health system
The Portuguese health care system is characterized by three coexisting, overlapping systems: the NHS; special public and private insurance schemes for certain professions (health subsystems); and private
voluntary health insurance (VHI). Figure 2.1 outlines the relationships between the various bodies, organizations and institutions comprising the health care system.
The health system in Portugal is a network of public and private health care providers, each of them connected to the Ministry of Health and to the patients in its own way. The key relationships are shown in Fig. 2.1, with the Ministry of Health coordinating all health care provision and the financing of public health care delivery. Most of the population is entitled to choose among (or can use both) two health care insurers: NHS and VHI. Part of the population, approximately 20–25%, are also covered by a health subsystem, which means that they have a third option for the choice of care, although financing of the health subsystem is compulsory for certain beneficiaries (as it is occupation-based health insurance). The providers can be either public or private, with different agreements with respect to their financing flows, ranging from historically based budgets to purely prospective payments. Out-of-pocket (OOP) payments make for a significant portion of the financial flows. Only capitation payments are, at least for the moment, absent from the financial arrangements.
2 Organizational structure
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Health systems in transition Portugal
Fig. 2.1 Overview chart of the health system
Central Government
Ministry of Health
Regional health
administrations (public
insurers)
Health subsystems
Private insurance
funds
Pharmacies
USFs
Health centres (public)
Public hospitals
Private hospitals
Private ambulatory
care
Population and
companies
Patients
Opting-out payments for some subsystem users
Direct and indirect taxes (compulsory,
income-based contributions)
Historical and activity-based
budget
Moving towards
prospective payment
established by yearly
negotiated contracts
Direct financing
Capital expenditure
Capital expenditure and salary + other payments
Conventioned sector
Service flow
User charges
Out-of-pocket payments
Reimbursement of non-NHS users
V ol
un ta
ry r
is k-
ra te
d pr
em iu
m s
P ay
ro ll
co nt
rib ut
io ns
Regulated prices
DRG-based pricing system
Agreement payments
Fee-for-service
Direct or prospective payments
Contract-based payments or fee-for-service
Service flow
Source: Authors’ compilation.
Notes: DRG: Diagnosis-related group; USFs: Family Health Units; NHS: National Health Service.
2.2 Historical background
In order to understand Portugal’s complex health care system, it is important to examine some of the main historical factors that have influenced its development. Prior to the 18th century, health care was provided only for the poor by the
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hospitals of religious charities called Misericórdias (see “Misericórdias” within Section 2.3), which are still first and foremost religiously affiliated institutions. During the 18th century, the State established a limited number of teaching hospitals and public hospitals to supplement this charitable provision. This was further extended in 1860 with the appointment of salaried municipal doctors who provided curative services to the poor. The development of public health services did not begin until 1901. The first public health legislation act in 1901 enabled the creation of a network of medical officers responsible for public health. A further public health law was introduced in 1945, which established public maternity and child welfare services. It was also under this law that the national programmes for TB, leprosy and mental health, which were already operating, were legally established.
The more recent development of health services can be traced back to 1946 when the first social security law was enacted. Health care provision at this time followed the German Bismarckian model which provided cover for the employed population and their dependants through social security and sickness funds. This social welfare system was financed by compulsory contributions from employees and employers, and provided outpatient curative services, free at the point of use. Cover was limited to industrial workers in the first instance, with other sectors of the workforce and their dependants added through extensions to the system in 1959, 1965 and 1971.
Until 1971, the Government did not assume responsibility for providing health care services to the population. Health care provision therefore consisted of many small independent and uncoordinated subsystems that were used in order to accomplish any kind of health policy objective. By 1971, the right to health of the citizens was recognized. This laid the groundwork for certain measures to be taken after the 1974 revolution. Charity and private institutions are no longer the “owners” of health care delivery to the population. Among the measures taken in 1971 were those regarding health care prevention and promotion. These were issues of great concern in the international community, as can be seen by the resolutions taken in Alma-Ata, seven years later. Despite the efforts made prior to 1979, the following major problems still existed. (For more information on the evolution of the Portuguese health system, see Simões (2004).)
asymmetric geographical distribution of health facilities and human • resources;
poor sanitation;•
population coverage not being universal (although there is no precise estimate • of coverage);
centralized decision-making; •
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Health systems in transition Portugal
no coordination among existing facilities and providers, and little • evaluation;
multiple sources of financing and a disparity in benefits among population • groups;
discrepancy between legislation and policy and the actual provision of • health services;
low remuneration of health professionals. •
The move towards greater public provision of health care and a commitment to universality was embodied in the legislation passed in 1971. This law, although never fully implemented, gave priority to prevention over cure and sought to integrate health policy in the context of wider social policies, that is, to include protection of the family and disabled people and other health-related social welfare activities.
After the revolution of 1974, a process of health services restructuring began, which culminated in the establishment of the NHS in 1979. First, in 1974, district and central hospitals owned by the religious charities were taken over by the Government. Local hospitals followed in 1975 and were integrated with existing health services. Finally, in 1977, the Government assumed ownership and responsibility of over 2000 medical units or health posts situated throughout the country. These had previously been operated under the social welfare system for the exclusive use of social welfare beneficiaries and their families. The principle of citizens’ right to health was embodied in the Portuguese Constitution as early as 1976 and was to be delivered through “a universal, comprehensive and free-of-charge National Health Service”. After the Constitution’s revision (1989), the “free of charge” has been changed to “approximately free of charge”, a term that has been subject to a discussion about its exact meaning (essentially, detailing the legal meaning of the term to make clear that the Constitution did not preclude the existence of co-payments in the NHS). The law enabling the implementation of this principle was not passed until 1979. The 1979 law establishing the NHS laid down the principles of centralized control, but with decentralized management. Central, regional and local bodies were established to this end. The law brought together public health services and the health services provided by the social welfare system, leaving the general social security system to provide cash benefits and other social services (e.g., for older people and children).
So, by 1979, legislation had been introduced to establish the right of all citizens to health protection; a guaranteed right to universal free health care through the NHS; access to the NHS for all citizens regardless of economic and social background; integrated health care including health promotion, disease
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surveillance and prevention; and a tax-financed system of coverage in the form of the NHS. (Only when health care could not be provided through the NHS would outside services be covered.)
Before 1979 and the establishment of the NHS, the Portuguese State had traditionally left the responsibility for paying for health care to the individual patient and her/his family. Care of the poor was the responsibility of charity hospitals and care outside of hospital remained the responsibility of the Department of Social Welfare. The State only took full responsibility for the costs of health care for civil servants. Otherwise the State provided limited preventive care, maternal and child health care, and had some interventions in the control of infectious diseases and mental health.
Despite the development of a unified publicly financed and provided health care system and the incorporation of most of the health facilities previously operated by the social welfare system and religious charities, some aspects of the pre-NHS system persisted. In particular, the health subsystems (from the Portuguese subsistemas) continued to cover a variety of public and private employees. These schemes offered greater choice of provider than would be available under the NHS and a higher reimbursement level when patients resort to private providers. Consequently, the trade unions, which ran and managed some of the funds, forcefully defended them on behalf of their members.
In the autonomous regions of Azores and Madeira, health policy followed the same general constitutional principles of the NHS, but was implemented locally by regional governments who retained some flexibility.
In addition, private provision has always been available, mainly in ambulatory care (although some in hospital care as well). Physicians’ and dentists’ private offices (evolving over time into small clinics), laboratory tests, radiology and imaging, and pharmaceutical products are the main areas of private provision.
At the start of the 21st century the health care system in Portugal continues to face problems such as:
inadequate public ambulatory services, with high use of hospital emergency • departments;
long waiting lists for surgical procedures; •
mixed evidence about satisfaction of consumers and professionals with • public services (some surveys show a high degree of satisfaction with the system, while others indicate the need for change – in these cases, it is important to consider the exact service under analysis, as dissatisfaction is higher about waiting lists and congestion related to access to hospital emergency departments);
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a major increase in health expenditure and difficulties with cost control; •
increased demand for health care from vulnerable groups; and •
difficulty in reducing mortality due to traffic accidents and lifestyle-related • diseases (despite the marked improvement in the last couple of years, there is still room for further reductions).1
The discussion of how these problems are being addressed through further reforms is included in the following chapters of this report. The relevant legislation and reforms are discussed in detail in Chapter 7 “Principal health care reforms”.
1 There were 1629 deaths due to traffic accidents in 2000, whereas in 2006 this number had fallen to 850. The number of severely injured patients dropped from 6918 to 3483 (Ministry of Law and Order, 2006). 2 A more in-depth view of the historical background and reform trends can be found in Viegas, Frada, Miguel (2006).
Table 2.1 The health care system: historical background and recent reform trends – timeline2
1901 The first act of public health legislation was published, whereby a network of medical officers responsible for public health was created. It followed the international trend set by several institutions, which tried to develop the basis of public health movement. This is thought to be the root of “modern sanitarism” (Ricardo Jorge reform).
1940 Establishment of the first (specific) Health Department within the Ministry of Internal Affairs.
1944 The Social Services Statutory Statute was published, comprising a “minimum state intervention” principle in the social arena.
1945 Public maternity and child welfare services were established. Vertically organized national institutes and programmes for TB, leprosy and mental health, which were already operating, were also legally established.
1946 The law that laid the groundwork for hospital organization and the promotion of new hospital buildings, financed by Government funds, but run by Misericórdias. Hospital regionalization was initiated. Hospitals were to reorganize into three levels, municipality, district and region, ensuring technical cooperation among them. A mandatory social health insurance system for a limited number of professions was created, the Caixas de Previdência.
1958 The Ministry of Health and Assistance is created.
1963 Statute of Health and Assistance, according to which the State is obliged to co- finance the installation and functioning of health facilities.
1968 The Hospitals Regulatory Act defined the nature and attributions of hospital care.
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1971 The State was acknowledged to be responsible for health policy and implementation, for the integration of health activities, and for investment in health prevention and promotion. Citizens’ right to health was also recognized. Health centres were created.
1974 The democratic revolution occurred on 25 April, which ended a long period of right- wing political dictatorship. As a result, health services administration was taken from private holders that had been financed mainly by public funds, aiming to give the whole population access to health care, irrespective of ability to pay.
1976 The Portuguese Constitution was approved, which embodied citizens’ right to health care. It recognizes citizens’ right to health care by “the creation of a universal, free- of-charge national health system”.
1979 The National Health Service Law created a universal health system, free at the point of use.
1982 The career of general practitioners (GPs)/family doctors was created.
1988 The Law on Hospital Management established guiding principles for NHS hospitals, including entrepreneurial management, decentralization of decision-making through intermediate responsibility centres and nomination of management boards by the Government.
1989 The first pricing list based on DRGs was issued for third-party payers with respect to NHS hospital inpatient use by their beneficiaries. The Portuguese Constitution was reviewed, and states “national health service is universal and tends to be free-of-charge, taking into account citizens’ social and economic conditions”.
1990 The Law on the Fundamental Principles of Health introduced new principles for the organization and functioning of the health system. Inter alia, an explicit role was assigned to the private profit-making and non-profit-making sectors, through contracting with the NHS; the system’s operation and management was decentralized to the regional level and user charges were introduced for ambulatory services. Private practice was allowed in public hospitals, under certain conditions related to the seniority and position of physicians as well as to the status of exclusive employment in the NHS. Private financing of health care was allowed, and incentives for private health insurance were given. The possibility of creating an alternative health insurance system was also approved.
1993 The Statute of the NHS was published in order to accommodate the changes introduced by the Law of Fundamental Principles of Health in 1990, namely the decentralization of the health system, the integration of health centres and hospitals in health units and the contracting out of NHS services. The new internal organization of the Ministry of Health was published. A Decree on the statutory regulation of private health entities was issued in order to ensure the accomplishment of quality standards. Five regional health administrations (RHAs, Administração Regional de Saúde) were established.
1995 The first attempt at putting an NHS hospital under the management control of a private consortium was initiated with the launch of a public bid for proposals according to a set of predefined terms.
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1997 Contracting Agencies (initially named Accompanying Agencies) were created – one in each RHA – with the overall aim of providing the basis for the payment and provider split within the NHS. The Contracting Agencies should also promote means of citizens’ participation in health decision-making.
1998 An experimental payment system for GPs working at health centres was introduced. The intention was to pay according to capitation and performance, instead of the traditional payment by fixed salary. Adherence to this experimental system was voluntary. A National List of Health Equipment was published for the first time. A law on the principles of mental health policy was published, whereby community care is given priority over institutional care under different arrangements. The law also regulated the compulsory inpatient status of individuals with mental illness.
1999 A National Health Strategy and goals for the period 1998–2002, involving a broad range of social partners, were published as a revised version of a more internal document issued in 1998. Legislation was passed creating local health systems and reforming health centres. Local health systems were integrated into frameworks for hospitals, health centres and other health care provider entities. Primary health care reform was based on financially autonomous health centres, with networks of primary health care teams. This legislation was not implemented. The Local Health Unit of Matosinhos became the first example of effective integration of local hospitals and related health centres into a unique provider entity. A law was approved in Parliament to fund a special programme to reduce waiting lists for surgical procedures at NHS hospitals. The contracting out of non-NHS entities was allowed only after internal capacity was fully used. Responsibility Centres in hospitals were set up as a means of establishing intermediate management levels and promoting decentralization of authority and of responsibility, in order to achieve higher levels of efficiency in the NHS.
2000 The use of an NHS Identity Card became mandatory.
2001 Regulations for the licensing and evaluation of private clinics and dentists’ private practices were published.
2002 A framework for the implementation of PPPs for the building, maintenance and operation of health facilities was created, along with the identification of the basic principles and instruments. A new law on the management of hospitals was issued to enable the changeover of some institutions into public enterprises. A total of 34 hospitals, corresponding to approximately 40% of all NHS hospitals, were transformed into public enterprises. A Decree established NHS drugs prescription using the common international denomination (International Nonproprietary Name, INN) as obligatory, as well as the conditions under which prescribed brands can be substituted by generics when dispensing. Reference prices for pharmaceuticals were introduced to cap state co-payment levels.
2003 The HRA was created, to ensure citizens have access to health care and to guarantee competition among health care providers.
2004 The National Health Plan for 2004–2010 was approved.
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2005 Law that allows the selling of OTC products in other authorized establishments (i.e., outside pharmacies). The number of hospitals transformed into public enterprises was increased. A new legal statute was adopted, to signal that there is no intention of privatization.
2006 USFs were created. The goal is to bring GPs closer to patients. The GP payment system depends on their performance and on the case-mix of their patients.
2007 The values of co-payments were updated. Co-payment was expanded to ambulatory surgery and hospital admission. The prices of pharmaceutical products decreased for the second consecutive year, by administrative ruling.
2.3 Organizational overview
This section describes the administrative structure of the NHS.
Ministry of Health
The central Government, through the Ministry of Health, is responsible for developing health policy and overseeing and evaluating its implementation. Figure 2.2 outlines the organization of the Ministry of Health. Its core function is the regulation, planning and management of the NHS. It is also responsible for the regulation, auditing and inspection of private health services providers, whether they are integrated into the NHS or not.
Many of the planning, regulation and management functions are in the hands of the Minister of Health. The Secretaries of State have responsibility for the first level of coordination, under delegation of the Minister of Health.
The Ministry of Health is made up of several institutions: some of them under direct government (Estado) administration; some integrated under indirect government administration; some having public enterprise status; an HRA and a consultative body. The HRA is formally independent in its actions and decisions, though its budget comes mostly from the Ministry of Health.
The following central services are under the State’s direct administration, which means that they are run by the Ministry of Health (in terms of their hierarchic relation).
Notes: TB: Tuberculosis; GP: General practitioner; NHS: National Health Service; RHA: Regional health administration; DRG: Diagnosis-related group; OTC: Over-the-counter; USF: Family Health Unit; PPPs: Public–private partnerships.
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• The High Commissariat for Health (ACS) The aims of the ACS are to provide technical support on policy development and strategic planning in the health sector; to guarantee the development of vertically integrated health programmes; to assure international relations coordination; to assess policy execution, planning instruments and results; and to elaborate, coordinate and evaluate the National Health Plan.
Fig. 2.2 Organizational chart of the Ministry of Health
Source: Authors’ compilation.
Notes: MoH: Ministry of Health; INFARMED: National Authority on Drugs and Health Products; LVT: Lisbon and Vale do Tejo.
Regional Health Administrations
Minister of Health
High Commissioner for Health
General Inspectorate of Health Activities
General Secretariat of MoH
General Directorate of Health
Authority for Blood and Transplantation Services
Central Administration of the Health System
INFARMED
National Institute for Medical Emergencies
Portuguese Blood Institute
National Institute of Drug Addiction
RHA North RHA Centre RHA LVT RHA Alentejo RHA Algarve
Health centres Central
District
Specialized
Hospitals
National Institute of Health Dr Ricardo Jorge
Indirect administrationDirect administration
National Health Council
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• The General Inspectorate of Health-related Activities (IGAS, Inspecção-Geral das Actividades em Saúde) The IGAS performs the disciplinary and audit function for the NHS and audits NHS institutions and services.
• The General Secretariat of Health (SG, Secretariado-Geral da Saúde) The SG provides technical and administrative support to the other sections of the Ministry, coordinates their work and provides assistance to staff within various government offices. The SG gives support to other institutions, services and bodies not integrated within the NHS, concerning internal resources, legal advice, information and public relations.
• The General Directorate of Health (GDH, Direcção–Geral da Saúde) The GDH plans, regulates, directs, coordinates and supervises all health promotion, dis ease prevention and health care activities, institutions and services, whether or not they are integrated into the NHS.
• The Authority for Blood and Transplantation Services (ASST, Autoridade para os Serviços de Sangue e Transplantação) The ASST guarantees quality and safety regarding donation, analysis, processing, storing and distribution of human blood and blood components, as well as human organs, tissues and cells.
The following central services are under the State’s indirect admini- stration.3
• Central Administration of the Health System (ACSS, Administração Central do Sistema de Saúde) The ACSS is in charge of the management of financial and human resources, facilities and equipment, systems and information technology (IT) of the NHS. It is also responsible for the definition of policy, regulation and planning of health, along with the RHAs, namely in the area of health service contracting.
3 Indirect administration designates activities performed by public institutes or state-owned companies.
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• The National Authority on Drugs and Health Products (INFARMED, Autoridade Nacional do Medicamento e Produtos de Saúde) INFARMED regulates and supervises the pharmaceuticals and health products sector, following the highest standards of public health protection (see Section 6.6. “Pharmaceutical care”).
• The National Institute for Medical Emergencies (INEM, Instituto Nacional de Emergência Médica) The INEM delineates, participates in and assesses the activities and performance of the Integrated System of Medical Emergency, guaranteeing immediate assistance to injured or severely ill patients (see Section 6.5 “Emergency Care”).
• Portuguese Blood Institute (IPS, Instituto Português do Sangue) The IPS regulates, at a national level, the pharmaceuticals related to transfusions and guarantees there is a stock of secure blood and blood components available when needed.
• National Institute of Drug Addiction (IDT, Instituto da Droga e da Toxicodepência) The IDT promotes the reduction of both legal and illegal drugs consumption, as well as the decrease in drug addictions.
• National Institute of Health, Dr Ricardo Jorge (INSA, Instituto Nacional de Saúde Dr Ricardo Jorge) This institute is a state laboratory, the aim of which is to increase gains in the public health sector, along with health monitoring and epidemiological surveillance, either in the field of laboratorial or genetic medicine. It is responsible for conducting, coordinating and promoting health research at the Ministry of Health. It should also produce evidence for policy and action in public health.
• Regional health administrations (RHAs) The NHS, although centrally financed by the Ministry of Health, has had a strong regional structure since 1993 comprising five health administrations: North, Centre, Lisbon and Vale do Tejo, Alentejo and the Algarve. In each region a health administration board, accountable to the Minister of Health, manages the NHS. The management responsibilities of these boards are a
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mix of strategic management of population health, supervision and control of hospitals, and centralized direct management responsibilities for primary care/NHS health centres.
The RHAs are responsible for the regional implementation of national health policy objectives and coordinating all levels of health care. They work in accordance with principles and directives issued in regional plans and by the Ministry of Health. Their main responsibilities are the development of strategic guidelines; coordination of all aspects of health care provision; supervision of management of hospitals and primary health care; establishment of agreements and protocols with private bodies; and liaison with government bodies, Misericórdias, other private non-profit-making bodies, and municipal councils. They are also in charge of the development of a long-term care network.
• National Health Council (CNS, Conselho Nacional de Saúde) The CNS is the consultative body for the Ministry of Health. It is responsible for issuing recommendations and advice on measures to enforce the implementation of health policy objectives. This Council has never actually been put to work, despite its legal existence.
Ministry of Finance
The creation of new posts within the NHS, whether hospital-based or not, requires the approval of the Ministry of Finance. The Ministry of Finance presents a project for inclusion within the state budget, which also includes the NHS budget based on a proposal submitted by the Ministry of Health, for government approval. The state budget is discussed and approved afterwards in Parliament. (See Section 3.4 “Pooling of funds” for more information about this process). The Ministry of Finance also sets the budget for public subsystems.
Ministry of Labour and Social Solidarity
This Ministry is responsible for social benefits such as pensions, unemployment benefits and incapacity benefits. In 1995, 9.5% of GDP was allocated to social security. In 2000 this percentage rose to 12.1% (OECD, 2006). The Ministry’s collaboration with the Ministry of Health has improved in recent years. Joint projects include a review of certification for absence from work, a programme to improve coordination between health and social care services and an initiative to improve continuity of long-term care for older people and people with disabilities. The relations between the two ministries in the long-term care network are described later (see Section 6.7 “Long-term care”).
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Ministry of Science and Higher Education
The Ministry of Science and Higher Education is responsible for undergraduate medical education and for academic degrees. Specialty postgraduate training in medicine, however, is the joint responsibility of the Medical Association (Ordem dos Médicos) and the Ministry of Health.
Local government
Below the RHAs are the municipalities. For the purposes of health care provision, boundaries are based on geographical proximity rather than administrative areas, so the definition for the purposes of the Ministry of Health is not exactly coterminous with administrative boundaries.
There are a number of initiatives being undertaken in cooperation with the municipalities, such as promoting greater traffic and pedestrian safety and encouraging physical exercise. Nutrition is also being promoted in close cooperation with the media, the educational system, sports organizations and local authorities. Overall, however, the role of municipalities in the Portuguese health system is rather marginal. There is no formal evidence on the subject, but it is possible to make a conjecture that the involvement of the municipalities in health promotion and improvement programmes has not expanded beyond a few specific projects, namely in child oral health, environmental health and behavioural orientation of risk groups.
Health subsystems
Almost three decades after the inception of the NHS in Portugal, the historical remnants of the pre-NHS social welfare system still persist in the form of health insurance schemes for which membership is based on professional or occupational category. These are often referred to as health “subsystems” (subsistemas). In addition to the health insurance coverage provided by the NHS, approximately 25% of the population is covered by the health subsystems or VHI. More precisely, approximately 16% of the population are covered by a health subsystem, approximately 10% are covered by VHI and less than 2% have cumulative coverage from both VHI and health subsystems (INSA, 2007). Health care is provided either directly or by contract with private or public providers (and in some cases by a combination of both). Access is generally limited to members of a specific profession and their families.
Until 2005, the main subsystems operating in the public sector were:
ADSE (• Assistência a Doença dos Servidores do Estado), for civil servants;
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SSMJ (• Serviços Sociais do Ministério da Justiça), for employees of the Ministry of Justice;
ADMA (• Assistência na Doença aos Militares da Armada), for the Navy;
ADME (• Assistência na Doença aos Militares do Exercito), for the Army;
ADFA (• Assistência na Doença aos Militares da Forca Aérea), for the Air Force;
SAD PSP (• Assistência na Doença da Polícia de Segurança Pública), for Police Agents;
SAD GNR (• Serviços de Assistência à Doença à GNR), for National Republican Guards.
In 2005, these funds converged into the ADSE, meaning that benefits have been standardized across health subsystems.
In the private sector, the major health subsystems are that of Portugal Telecom (PT-ACS, Associação de Cuidados de Saúde) for the employees of the historic telecommunications operator and for postal service employees, and a health subsystem for banking and associated insurance employees (SAMS, Serviços de Assistência Médico-Social), set up by their respective unions on a regional basis. There are also a few additional smaller funds. Most health subsystems are members of the National Association of Health Subsystems. Some of the funds are associated with and run by trade unions and managed by boards of elected members. PT-ACS was the first fund to sign an opting-out contract with the Ministry of Health. The firm cancelled the contract, effective from January 2007, mainly for financial reasons.
The largest health subsystem, ADSE, which is mandatory for all civil servants, is controlled by the Ministry of Finance. It covers almost 10% of the population (1.36 million enrolled beneficiaries). Private health care providers mainly fulfil a supplementary role to the NHS rather than providing a global alternative to it. Private sector activity continues to prosper despite the establishment of the NHS and now mainly provides diagnostic, therapeutic and dental services as well as some ambulatory consultations, rehabilitation and psychiatric care services. The key agents are private practitioners, Misericórdias, and private hospitals and clinics. The majority of specialist consultations take place in the private sector whereas the public sector provides the overwhelming majority of GP consultations. According to the data obtained from the preliminary information of the 4th National Health Survey (INSA, 2007), the private sector accounts for 31% of all medical consultations in ambulatory care. Most health centres only have GPs, who should act as gatekeepers to access specialists. Almost all appointments with specialists in the NHS have to be carried out in the outpatient departments of hospitals. Patients with less severe conditions and/or with the
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necessary financial means may opt for private practice specialists in ambulatory care, which explains their role and market share.
Misericórdias Misericórdias are independent non-profit-making institutions with a charitable background. The Lisbon Misericórdia is an exception, being a public enterprise with a board nominated jointly by the Ministry of Health and the Ministry of Labour and Social Solidarity rather than elected by members. These institutions currently operate very few ho